Interpretation
This study explored both efficacy measures of immediate IUD insertion at
17-20 GW, such as expulsion and removal rates, and effectiveness
measures such as how immediate insertion affects continued use. Our
results show that planned immediate insertion of the IUD leads to
significantly more women receiving an IUD compared to planned delayed
insertion. We found that four out of ten women planned for immediate IUD
insertion will either not have the IUD inserted, have the IUD removed,
or expel the IUD. However, if a woman receives the IUD before she leaves
the hospital, it is likely that she will continue to use the original,
or a replacement IUD, if provided with continuity of care, as
demonstrated by a 90% continuation rate at 6 weeks among women who
received immediate insertion. Both groups showed a preference for
immediate insertion despite many women in the immediate group needing
removal and replacement of the original IUD.
Similarly, a systematic review of immediate vs delayed IUD insertion
after abortion in the first- and early second trimester concluded that
immediate insertion was associated with higher expulsion rates but also
with higher rates of continued use.11
Immediate insertion was associated with higher rates of expulsion and
removal due to malposition than delayed insertion. Interestingly, most
women with intracervical IUD placement were asymptomatic which is
concerning as they may be less likely to follow-up. Two Finnish studies
found expulsion/removal rates of 12.5% after early medical abortion,
27.5% after later first trimester abortion and 18.5% after early
second trimester abortion although the study was underpowered for the
second trimester group.15,16 Expulsion and removal
rates have been estimated at 5% and 8.5% after early and late surgical
abortion respectively but these studies accepted self-report of IUD use
which may underestimate malposition rates.17,18 Our
study did not find lower rates of expulsion and removal among women who
had the IUD inserted after vacuum aspiration. It is possible that the
high cumulative doses of misoprostol needed for medical abortion in the
latter part of the second trimester contributed to the relatively high
expulsion/malposition rates. Studies on post-placental IUD insertion
also indicate that insertion within the first 10 minutes of placental
delivery is more effective than insertion at 10min-48 hours, which may
also be true for post-abortion insertion and which this study cannot
evaluate.13
Four out of the 6 women with complete expulsion did not notice the IUD
falling out and thus would be unknowingly unprotected from a repeat
pregnancy had they not come for a check-up. However, women in our
immediate study arm were much more likely to follow-up in-person
compared to women in the delayed arm. If women who receive an IUD before
leaving the hospital are strongly motivated to return, the risk
associated with unnoticed expulsion would be mitigated and they would be
ensured of continued contraception. Pregnancy within the first 6-week
period is not impossible, and in that case an advantage of the copper-
over the levonorgestrel IUD is that a new pregnancy is likely to be
detected early by the absence of a period. Scheduling the first
follow-up visit at 3-4 weeks may be preferable as a replacement IUD
would then act as emergency contraception in case of a pregnancy
occurring within that period.
The low rates of use in the delayed arm were because only one in five
women presented at CHCs for IUD insertion. This was despite several
pre-emptive study measures to facilitate interval insertion at CHCs
compared to standard care. Interval initiation of contraception
post-abortion and postpartum is known to be complicated by low
compliance, which is a main rationale for quick-start contraception
post-abortion and postpartum.9,19 Finally, two women
who followed the delayed protocol became pregnant during the study
period. During the post-pregnancy period women are especially vulnerable
to repeat pregnancy and this must be considered in the risk-benefit
calculation of immediate and delayed IUD insertion
post-abortion.20
Abortion care in South Africa suffers from a scarcity of willing
providers, a high rate of second trimester abortion and an overall low
use of LARC.5 In contrast to this, satisfaction rates
with the IUD were high throughout the study period and most women
predicted that they would use the IUD for the full five years of
recommended use.