Factors influencing the risk of repeat termination of pregnancy: A register-based study in Finland.

OBJECTIVE: This study aimed to assess how factors such as sociodemographic characteristics, termination of pregnancy (TOP) related factors and contraception affect the risk of repeat TOP. MATERIALS AND METHOD: This is a nationwide register-based study of 193,741 women who had TOP(s) during 1987-2015, using the Finnish Register of Induced Abortions. The risk of various factors, such as age, marital status, residence, parity, TOP related factors and contraception, was assessed separately for each repeat TOP. Cox proportional hazard model was used to estimate risk of different factors for repeat TOPs. RESULTS: 21% of the women having TOP had repeat TOPs during the years 1987-2015. Among women with repeat TOPs, more than 70% had one repeat TOP and the rest had two or more. Older, married and rural or semi-urban women had reduced risk of repeat TOPs. Adjusted risk for one repeat TOP was higher among parous women (HR 1.67, 95% CI 1.61-1.72). No significant risk for repeat TOP was observed by method in sub-analysis for the recent period after 2006. Women using less reliable (HR 1.14, 95% CI 1.06-1.23) and unreliable (HR 1.33, 95% CI 1.23-1.43) contraception had increased risk of repeat TOP than women using reliable contraception. CONCLUSION: Older age, being married, residing in rural or semi-urban areas and using reliable contraception were found to be protective factors for repeat TOPs whereas, parous women had higher risk for repeat TOPs. Proper counselling regarding contraception and use of reliable contraception immediately after TOP should be encouraged.

A Cohort Study of Mental Health Services Utilization Following a First Pregnancy Abortion or Birth.

Objective: To determine whether exposure to a first pregnancy outcome of induced abortion, compared to a live birth, is associated with an increased risk and likelihood of mental health morbidity. Materials and methods: Participants were continuously eligible Medicaid beneficiaries age 16 in 1999, and assigned to either of two cohorts based upon the first pregnancy outcome, abortion (n = 1331) or birth (n = 3517), and followed through to 2015. Outcomes were mental health outpatient visits, inpatient hospital admissions, and hospital days of stay. Exposure periods before and after the first pregnancy outcome, a total of 17 years, were determined for each cohort. Findings: Women with first pregnancy abortions, compared to women with births, had higher risk and likelihood of experiencing all three mental health outcome events in the transition from pre- to post-pregnancy outcome periods: outpatient visits (RR 2.10, CL 2.08-2.12 and OR 3.36, CL 3.29-3.42); hospital inpatient admissions (RR 2.75, CL 2.38-3.18 and OR 5.67, CL 4.39-7.32); hospital inpatient days of stay (RR 7.38, CL 6.83-7.97 and OR 19.64, CL 17.70-21.78). On average, abortion cohort women experienced shorter exposure time before (6.43 versus 7.80 years), and longer exposure time after (10.57 versus 9.20 years) the first pregnancy outcome than birth cohort women. Utilization rates before the first pregnancy outcome, for all three utilization events, were higher for the birth cohort than for the abortion cohort. Conclusion: A first pregnancy abortion, compared to a birth, is associated with significantly higher subsequent mental health services utilization following the first pregnancy outcome. The risk attributable to abortion is notably higher for inpatient than outpatient mental health services. Higher mental health utilization before the first pregnancy outcome for birth cohort women challenges the explanation that pre-existing mental health history explains mental health problems following abortion, rather than the abortion itself.

Multiple induced abortions - implications for counselling and contraceptive services from a multi-centre cross-sectional study in Sweden.

OBJECTIVES: To investigate factors associated with multiple induced abortions. MATERIALS AND METHODS: A multi-centre cross-sectional survey among abortion-seeking women (n = 623;14-47y) in Sweden, 2021. 'Multiple abortions' was defined as having had ≥2 induced abortions. This group was compared to women with a previous experience of 0-1 induced abortion. Regression analysis was conducted to determine independent factors associated with multiple abortions. RESULTS: 67.4% (n = 420) reported previous experience of 0-1 abortion, and 25.8% (n = 161) ≥2 abortions (42 women chose to not respond). Several factors were associated with multiple abortions, but when adjusted in the regression model, the following factors remained; parity ≥1 (OR = 2.96, 95%CI [1.63, 5.39]), low education (OR = 2.40, 95%CI [1.40, 4.09]), tobacco use (OR = 2.50, 95%CI [1.54, 4.07]) and exposure to violence over the last year (OR = 2.37, 95%CI [1.06, 5.29]). More women in the group who had 0-1 abortion (n = 109/420) believed they could not become pregnant at the time of conception, compared to women who had ≥2 abortions (n = 27/161), p=.038. Mood swings, as a contraceptive side-effect, were more often reported among women with ≥2 abortions (n = 65/161), compared to those with 0-1 abortion (n = 131/420), p=.034. CONCLUSION: Multiple abortions is associated with vulnerability. Sweden provides high quality and accessible comprehensive abortion care; however, counselling must be improved both to achieve contraceptive adherence and identify and address domestic violence.

Seeking multiple abortions is common in Sweden, and is associated with parity, low education, tobacco use, and exposure to violence. Although Sweden provides high quality and accessible comprehensive abortion care, counselling must be adaptable and address specific needs in vulnerable groups.

The Enduring Association of a First Pregnancy Abortion with Subsequent Pregnancy Outcomes: A Longitudinal Cohort Study.

Introduction: Multiple abortions are consistently associated with adverse health consequences. Prior abortion is a known risk factor for another abortion. Objective: To determine the persistence of the association of a first-pregnancy abortion with the likelihood of subsequent pregnancy outcomes. Methods: Data was extracted for a study population of 5453 continuously eligible Medicaid beneficiaries in states which funded and reported elective abortions 1999-2015. Women age 16 in 1999 were organized into three cohorts based upon the first pregnancy outcome: abortion, birth, natural loss. Results: Women in the abortion cohort are more likely than those in the birth cohort to experience another abortion rather than a birth or natural loss, and less likely to experience a live birth rather than an abortion or natural loss, for every subsequent pregnancy. The tendency toward abortion (OR 2.99, CL 2.02-4.43) and away from birth (OR 0.49, CL 0.39-0.63) peaks at the sixth pregnancy, but persists throughout the reproductive period ages 16-32. The pattern is reversed, but similarly consistent, for women in the birth cohort. They remain likelier to have another birth rather than an abortion or natural loss in subsequent pregnancies. Compared to the birth cohort, the abortion cohort had 1.35 times as many pregnancies: 4.31 times the abortions, 1.53 times the natural losses, but only 0.52 times the births. They were 4.3 and 5.0 times as likely to have 2-plus and 3-plus abortions, but only 0.47 times and 0.31 times as likely to have 2-plus and 3-plus births. Of the abortion cohort, 37.1% had no births. By contrast, 73.6% of the birth cohort had no abortions. Conclusion: The first-pregnancy abortion maintains a strong and persistent association with the likelihood of another abortion in subsequent pregnancies, enabling a cascade of adverse events associated with multiple abortions.

Repeat-induced abortion and associated factors among reproductive-age women seeking abortion services in South Ethiopia.

INTRODUCTION: Despite the advances in modern health care, maternal morbidity and mortality remain major problems in Ethiopia. Repeat-induced abortion is an indispensable contributor to this problem. Even though there are adverse effects on health, a significant proportion of Ethiopian women procure more than one abortion during their reproductive lifetime. This study aimed to determine the prevalence and associated factors of repeat-induced abortion in South Ethiopia, in 2020. METHODS: An institution-based cross-sectional study design and a systematic random sampling technique were used to collect data from 410 samples of women. Data were collected using pre-tested and semi-structured interviewer-administered questionnaires. The data were coded and entered into EpiData version 4.6.2.0 before being exported to Statistical Package for Social Sciences (SPSS) version 26 for analysis. Variables with a p-value of less than 0.05 in binary logistic regressions were exported into multivariate logistic regression analysis. Finally, variables with a p-value of less than 0.05 in the multivariate logistic regression analysis were used to declare statistical significance. RESULT: The prevalence of repeat-induced abortion was found to be 35.4% (95% confidence interval = 30.7-40). Not facing a complication in prior abortion care, having more than two partners in the last 12 preceding months, perceiving abortion procedure as non-painful, having a sexual debut before the age of 18 years, and consuming alcohol have higher odds of repeat-induced abortion when compared with their counterparts. CONCLUSION: The prevalence of repeat-induced abortion in Hawassa city is high compared to studies conducted in other parts of Ethiopia. Not facing complications during previous abortion care, perceiving the abortion procedure as non-painful, alcohol consumption, having multiple sexual partners, and having a sexual debut before the age of 18 years are found to increase the chance of repeat-induced abortion.

Repeat abortion and associated factors among women seeking abortion services in northwestern China: a cross-sectional study.

BACKGROUND: Repeat abortion is a significant public health problem in China. International knowledge about repeat abortion and its associated factors in Chinese women is scarce. This study aimed to analyze the prevalence of repeat abortion among women seeking abortion services with unintended pregnancies in northwestern China and to identify factors associated with the repeat abortion from both two perspectives of abortion seekers themselves and their sexual partners. METHODS: This cross-sectional survey was conducted from May 1st to May 31st, 2020, in 90 medical institutions in Xi'an, the largest city in northwestern China. All women seeking abortions within the first 12 weeks of pregnancy were invited to participate in this survey; however, only those abortion seekers with unintended pregnancies were extracted and included in this study. Pearson's chi-squared tests, Kolmogorov-Smirnov tests, and binary logistic regression analysis were performed. RESULTS: Of 3397 abortion seekers, 56.6% (1924) were undergoing repeat abortions. Participants who were older than 30 years (OR: 1.37, 95% CI: 1.08-1.73 for 31-35 years; 1.82, 1.29-2.57 for ≥36 years), received a low-level education (1.86, 1.42-2.43 for ≤senior high school; 1.46, 1.17-1.83 for junior college), were jobless (2.46, 1.18-5.13), had one child (1.54, 1.10-2.17), had a general (1.60, 1.28-1.98) or no (2.51, 2.02-3.11) cognition of possible adverse health effects of having abortions, and had used contraception at the time of conception, i.e., condoms (1.33, 1.09-1.61), withdrawal (1.43, 1.12-1.84), and emergency measures (1.48, 1.09-1.99) were more likely to undergo a repeat abortion. Besides, participants whose sexual partners were older than 30 years (1.33, 1.06-1.68 for 31-35 years; 2.13, 1.56-2.91 for ≥36 years), attained a low-level education (1.66, 1.28-2.15 for ≤senior high school; 1.38, 1.10-1.74 for junior college), received a high-level monthly income (1.34, 1.08-1.65 for ≥6001 Yuan), and had a weak or very weak willingness to use contraception (6.84, 2.42-19.33) were more likely to have a repeat abortion. CONCLUSIONS: The study findings highlight the problem of repeat abortion in China and suggest the need for government and civil society to increase efforts to reduce the risks of unintended pregnancy and repeat abortion in China. One approach may be to offer better access to reproductive health and contraception knowledge to women and their sexual partners and to promote their correct, consistent, and effective contraception practice.

The level and deriving factors of repeat-induced abortion in Ethiopia: A systematic review and meta-analysis.

BACKGROUND: Despite repeat induced abortion is a growing challenge for both developing as well as developed countries, abortion-related complications are found to be higher among women in developing countries. This systematic review and meta-analysis was intended to assess the level of repeat-induced abortion and its deriving factors in Ethiopia. METHODS: Different data sources such as PubMed, EMBASE, Google Scholar, and University online data bases were used to identify candidate articles for this systematic review and meta-analysis. The article search was conducted from June 10 to 26, 2020. The Newcastle-Ottawa Quality Assessment Scale (NOS) was used to assess the quality of the included studies. Data extraction was performed through a format prepared on Microsoft excel work book and exported to Stata 11 for analysis. The heterogeneity of the studies was tested using Cochran (Q test) and I2 test statistics. Publication bias was assessed by funnel plot and Egger's regression asymmetry test. Subgroup-analysis was conducted based on sample size and study Regions. RESULTS: Five studies with 2000 participants who visited health facilities for abortion services were included in this systematic review and meta-analysis. The pooled level of repeat-induced abortion was found to be 29.93% (95%, CI 23.15%, 36.71%). Urban residence (OR = 5.10, 95%, CI 2.51, 10.33), illiteracy (OR = 4.12, 95%, CI 2.40, 7.07), having multiple sexual partners (OR = 6.28, 95% CI 4.28, 9.22), and early sexual initiation (OR = 3.80, 95%, CI1.76, 8.19) were found to be the deriving factors for experiencing repeat induced abortion. However, there was no significant association between ever use of family planning and repeat induced abortion (OR = 1.03, 95%, CI 0.09, 11.59). CONCLUSION: The level of repeat-induced abortion was found to be high in Ethiopia. High risk of experiencing repeat-induced abortion was reported among participants who were urban residents, illiterate, who had multiple sexual partners, and early sexual initiation. However, a statistically significant association was not found between ever use of family planning and repeat-induced abortion. Health education shall be given about the risk of subsequent abortion and the relevance of avoiding unintended pregnancy, multiple sexual partners, and early sexual initiations through various mechanisms.

Association between contraceptive method chosen after induced abortion and incidence of repeat abortion in Northern Portugal.

OBJECTIVES: In Portugal, a country with strong Catholic roots, elective termination of pregnancy at women's request is still stigmatised, especially if it is a repeat abortion. The objectives of this study were to determine the incidence of repeat abortion, taking into account the contraceptive method chosen after the index abortion event, and characterise the risk factors for repeat abortion. METHODS: This was a retrospective cohort study of 988 women who requested termination of pregnancy during 2015 in a Portuguese tertiary care public hospital. Contraception was given free of charge after the index event. The occurrence of a repeat induced abortion was evaluated during a 24 month follow-up period. RESULTS: Forty-nine (5.0%) of the 988 women had a repeat abortion. Users of long-acting reversible contraception (LARC) had fewer repeat abortions compared with users of non-LARC methods. Overall repeat abortion was 0.8% in subcutaneous contraceptive implant users, 1.5% in intrauterine contraceptive device (IUCD) users, 2.8% in vaginal ring users and 5.8% in oral contraceptives users (p < 0.05). Cox hazards ratio (HR) analysis showed that method choice after abortion correlated significantly with the probability of repeat abortion (p < 0.05). Using women choosing oral contraception as the reference group, the HRs (95% CIs) for repeat abortion were as follows: IUCD 0.282 (0.084, 0.942), contraceptive implant 0.142 (0.019, 1.050), vaginal ring 0.508 (0.175, 1.477). CONCLUSION: Even though highly effective contraceptive methods are freely accessible in Portugal, other challenges must be managed to improve outcomes, such as a timely, patient-centred counselling approach.

Is Repeat Abortion a Public Health Problem among Chinese Adolescents? A Cross-Sectional Survey in 30 Provinces.

The Chinese Family Planning (FP) programme mainly focuses on married couples, and young unmarried women have limited access. This cross-sectional study aims to identify risk factors related to repeat abortions in Chinese adolescents receiving abortions. Data were collected using a questionnaire for all women seeking abortions within 12 weeks of pregnancy during a period of 2 months in 297 participating hospitals randomly selected across 30 provinces of China in 2013. Only the adolescents (younger than the minimum legal married age of 20 years) were included in this study. Of the 2370 adolescents who were receiving abortions, 927 (39%) were undergoing repeat abortions. The primary reason for the current unintended pregnancies was non-use of contraception (68%). Adolescents receiving abortions who had an increased risk of repeat abortions were those who had children (OR 2.57, 95% CI 1.80⁻3.67), those who resided in a middle-developed region (OR 1.81, 95% CI 1.30⁻2.50), those who resided in a relatively poor region (OR 2.40, 95% CI 1.78⁻3.23), and those who had used contraception during the 6 months preceding the survey (OR 1.38, 95% CI 1.12⁻1.71 for condom use). The occupation as a student was a protective factor for adolescents (OR 0.64, 95% CI 0.50⁻0.83). Adolescents should be offered equal access to FP to that of married women in China to reduce unintended pregnancies and repeat abortions. Correct and consistent contraception practice should be promoted.

Risky Sexual Behaviors and Repeat Induced Abortion Among Unmarried Young Women in China: Results from a Large, Nationwide, Population-Based Sample.

Background: Young women are disadvantaged with respect to their ability to access contraception, which puts them at especially high risk of repeat induced abortion. This study aims to estimate the prevalence of repeat induced abortion and to identify its association with risky sexual behaviors among unmarried young women in China. Materials and Methods: Data were obtained from the Survey of Youth Access to Reproductive Health in China and collected using probability proportionate to size sampling. Population numbers and prevalence of repeat induced abortion by characteristics were calculated among 11,076 unmarried young women aged 15-24 years. Univariate logistic regression, multivariate logistic regression, and logistic regression with propensity score-based weighting were used to elucidate the associations of each risky sexual behavior with repeat induced abortion among sexually active young women. Results: The prevalence of repeat induced abortion was 0.8% (95% confidence interval [CI]: 0.7-1.0) among unmarried young women (11,076) and it accounted for 21.3% of those who had ever had induced abortion. Among sexually active young women, the prevalence of abortion was 4.40% (95% CI: 3.6-5.4). Condom nonuse during the first sexual experience (odds ratio = 2.72, 95% CI: 1.55-4.76), sexual activity with multiple partners (9.71, 5.61-16.81), being forced to have sexual intercourse (4.46, 1.44-13.76), casual sex (5.77, 3.28-10.13), commercial sex (4.51, 2.01-10.12), condom nonuse during the most recent sexual encounter (2.01, 1.31-3.08), and having any of the above behaviors (5.68, 2.26-14.28) were associated with repeat abortion. Conclusions: Risky sexual behaviors were associated with repeat abortion among unmarried young women in China. The findings highlight the need for reproductive health promotion programs for unmarried young women in China and other similar settings.

Risk factors and the choice of long-acting reversible contraception following medical abortion: effect on subsequent induced abortion and unwanted pregnancy.

OBJECTIVE: To analyse the post-abortion effect of long-acting reversible contraception (LARC) plans and initiation on the risk of subsequent unwanted pregnancy and abortion. MATERIALS AND METHODS: retrospective cohort study of 666 women who underwent medical abortion between January-May 2013 at Helsinki University Hospital, Finland. Altogether 159 (23.8%) women planning post-abortion use of levonorgestrel-releasing intrauterine system (LNG-IUS) participated in a randomized study and had an opportunity to receive the LNG-IUS free-of-charge from the hospital. The other 507 (76.2%) women planned and obtained their contraception according to clinical routine. Demographics, planned contraception, and LARC initiation at the time of the index abortion were collected. Data on subsequent abortions were retrieved from the Finnish Abortion Register and electronic patient files until the end of 2014. RESULTS: During the 21 months ([median], IQR 20-22) follow-up, 54(8.1%) women requested subsequent abortions. When adjusted for age, previous pregnancies, deliveries, induced abortions and gestational-age, planning LARC for post-abortion contraception failed to prevent subsequent abortion (33 abortions/360 women, 9.2%) compared to other contraceptive plans (21/306, 6.9%) (HR 1.22, 95% CI 0.68-2.17). However, verified LARC initiation decreased the abortion rate (4 abortions/177 women, 2.3%) compared to women with uncertain LARC initiation status (50/489, 10.2%) (HR 0.17, 95% CI 0.06-0.48). When adjusted for LARC initiation status, age <25 years was a risk factor for subsequent abortion (27 abortions/283 women, 9.5%) compared to women ≥25 years (27/383, 7.0%, HR1.95, 95% CI 1.04-3.67). CONCLUSIONS: Initiation of LARC as part of abortion service at the time of medical abortion is an important means to prevent subsequent abortion, especially among young women.

Which Abortion Patients Have Had a Prior Abortion? Findings from the 2014 U.S. Abortion Patient Survey.

BACKGROUND: Updated information about abortion patients who have had a prior abortion could inform patient-centered practices that help women avoid unintended pregnancies in the future. MATERIALS AND METHODS: Data come from a national sample of 8,380 nonhospital U.S. abortion patients accessing services at 87 facilities. The dependent variable was a self-reported measure of prior abortion. Bivariate and multivariable analyses were used to assess associations between a range of demographic and circumstantial characteristics and reports of obtaining a prior abortion. RESULTS: We found that 45% of patients reported having one or more prior abortions. Age was most strongly associated with this outcome, and patients aged 30 and older had more than two times the odds of having had a prior abortion compared with those aged 20-24. Other characteristics associated with an increased likelihood of prior abortion included having one or more children, being black, relying on insurance or financial assistance to pay for the procedure, and exposure to disruptive events in the last 12 months. Characteristics associated with a decreased likelihood of having a prior abortion included having a college degree and living 25 or more miles from the facility where the current abortion was obtained. CONCLUSIONS: Age is the biggest risk factor for having had a prior abortion; the longer a woman has been alive, the longer she is at risk of unintended pregnancy. Some characteristics associated with prior abortion were beyond the control of the individuals experiencing them.

Women's experiences of more than one termination of pregnancy within two years: a mixed-methods study.

OBJECTIVE: To examine the experiences of women seeking more than one termination of pregnancy (TOP) within 2 years. DESIGN: Mixed methods study. SETTING: Six TOP services across Scotland. SAMPLE: Women presenting for TOP between July and December 2015. METHODS: Descriptive and inferential analysis of quantitative survey data, thematic analysis of qualitative interview data and integrative analysis. In quantitative analysis, multinomial logistic regression was used to compare three groups: previous TOP within 2 years, previous TOP beyond 2 years and no previous TOP. MAIN OUTCOME MEASURES: Characteristics and experiences of women seeking TOP. RESULTS: Of 1662 questionnaire respondents, 14.6% (n = 242) and 19.8% (n = 329) reported previous TOP within and beyond 2 years, respectively. The previous TOP within 2 years group was significantly less likely to own their accommodation than the no previous TOP group (adjusted odds ratio [aOR] 0.34, 95% CI: 0.18-0.62) and previous TOP beyond 2 years group (aOR: 0.44, 95% CI: 0.23-0.85); and more likely to report inconsistent (aOR: 1.63, 95% CI: 1.04-2.57; aOR: 1.95, 95% CI: 1.16-3.28) and consistent (aOR: 2.13, 95% CI: 1.39-3.26; aOR: 1.71, 95% CI: 1.07-2.76) contraceptive use than the no previous TOP and previous TOP within 2 years groups, respectively. Twenty-three women from the previous TOP within 2 years group were interviewed. Qualitative and integrative analyses highlight issues relating to contraceptive challenges, intimate partner violence, life aspirations and socio-economic disadvantage. CONCLUSIONS: Women undergoing more than one TOP within 2 years may experience particular challenges and vulnerabilities. Service provision should recognise this and move away from stigmatising discourses of 'repeat abortion'. FUNDING: Scottish Government. TWEETABLE ABSTRACT: Women having two or more terminations of pregnancy in 2 years may face key challenges/vulnerabilities including intimate partner violence and socio-economic disadvantage.

Contraceptive counselling of women seeking abortion - a qualitative interview study of health professionals' experiences.

OBJECTIVES: A substantial proportion of women who undergo an abortion continue afterwards without switching to more effective contraceptive use. Many subsequently have repeat unintended pregnancies. This study, therefore, aimed to identify and describe health professionals experiences of providing contraceptive counselling to women seeking an abortion. METHODS: We interviewed 21 health professionals (HPs), involved in contraceptive counselling of women seeking abortion at three differently sized hospitals in Sweden. The interviews were recorded and transcribed verbatim and analysed using conventional qualitative content analysis. RESULTS: Three clusters were identified: 'Complex counselling', 'Elements of counselling' and 'Finding a method'. HPs often experienced consultations including contraceptive counselling at the time of an abortion as complex, covering both pregnancy termination and contraceptive counselling. Women with vulnerabilities placed even greater demands on the HPs providing counselling. The HPs varied in their approaches when providing contraceptive counselling but also in their knowledge about certain contraception methods. HPs described challenges in finding out if women had found an effective method and in the practicalities of arranging intrauterine device (IUD) insertion post-abortion, when a woman asked for this method. CONCLUSIONS: HPs found it challenging to provide contraceptive counselling at the time of an abortion and to arrange access to IUDs post-abortion. There is a need to improve their counselling, their skills and their knowledge to prevent repeat unintended pregnancies.

Why prevention of repeat abortion is so challenging: psychosocial characteristics of women at risk.

OBJECTIVES: Abortion rates have declined in recent decades; however, the rate of repeat abortion remains high. In order to identify keys to making efficient interventions against repeat abortion, our objectives were: to assess the percentage of repeat abortions in women opting for termination of pregnancy over a period of 1 year; to identify the risk factors for repeat abortion; and to assess the characteristics of women who opted for a further pregnancy termination despite having received standard post-abortion care. METHODS: A retrospective cross-sectional survey was carried out among 362 women who underwent pregnancy termination during a 1-year period. Women with and without repeat abortion were compared with regard to age, nationality, marital status, parity and use of contraception. In a subsample of 160 women who were available for follow-up over 4 years, those who underwent a further pregnancy termination during the observation period were also analysed qualitatively. RESULTS: The rate of repeat abortion was 30.1% in the survey population. Age and immigrant status were identified as risk factors. The use of long-acting reversible contraception (LARC) was significantly higher after repeat abortion than after a first termination of pregnancy. Among women with repeat abortion in the follow-up group, those with psychological problems tended to discontinue contraception and those with partnership conflicts were prone to using unreliable contraceptive methods. CONCLUSION: Aside from promoting LARC methods, strategies to reduce repeat abortion should consider the psychosocial risk factors and characteristics of women at risk identified in this study. An interdisciplinary approach including social care and counselling would be the most appropriate means to enable this.

Likelihood of repeat abortion in a Swedish cohort according to the choice of post-abortion contraception: a longitudinal study.

INTRODUCTION: Despite high access to contraceptive services, 42% of the women who seek an abortion in Sweden have a history of previous abortion(s). The reasons for this high repeat abortion rate remain obscure. The objective of this study was to study the choice of contraceptive method after abortion and related odds of repeat abortions within 3-4 years. MATERIAL AND METHODS: This is a retrospective cohort study based on a medical record review at three hospitals in Sweden. We included 987 women who had an abortion during 2009. We reviewed medical records from the date of the index abortion until the end of 2012 to establish the choice of contraception following the index abortion and the occurrence of repeat abortions. We calculated odds ratios (OR) with 95% CI. RESULTS: While 46% of the women chose oral contraceptives, 34% chose long-acting reversible contraceptives (LARC). LARC was chosen more commonly by women with a previous pregnancy, childbirth and/or abortion. During the follow-up period, 24% of the study population requested one or more repeat abortion(s). Choosing LARC at the time of the index abortion was associated with fewer repeat abortions compared with choosing oral contraceptives (13% vs. 26%, OR 0.36; 95% CI 0.24-0.52). Subdermal implant was as effective as intrauterine device in preventing repeat abortions beyond 3 years. CONCLUSIONS: Choosing LARC was associated with fewer repeat abortions over more than 3 years of follow up.

Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: first-year results of a randomized controlled trial.

STUDY QUESTION: Can the need of subsequent abortion be reduced by providing intrauterine contraception as a part of the abortion service? SUMMARY ANSWER: Provision of intrauterine devices (IUDs) in association with first trimester abortion more than halved the incidence of repeat abortion during the first year of follow-up. WHAT IS KNOWN ALREADY: Following abortion, the incidence of subsequent abortion is high, up to 30-40%. In cohort studies, intrauterine contraception has reduced the need of repeat abortion by 60-70%. STUDY DESIGN, SIZE, DURATION: A randomized controlled trial. The main outcome measure was the incidence of subsequent induced abortions during the follow-up. Altogether 751 women seeking first trimester induced abortion were recruited and randomized into two groups. Randomization was accomplished by computer-assisted permuted-block randomization with random block sizes of four to six. The investigators did not participate in randomization, which was done before commencing the study. The participants were recruited between 18 October 2010 and 21 January 2013. PARTICIPANTS, SETTINGS, METHODS: The inclusion criteria were age ≥18 years, duration of pregnancy ≤12 weeks, accepting intrauterine contraception, residence in Helsinki and signing the informed consent form. Women with contraindications to intrauterine contraception, such as uterine anomaly, acute genital infection or pap-smear change requiring surgical treatment were ineligible to participate.This study was conducted in collaboration between the Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, and Centralized family planning of the City of Helsinki.The intervention group (n = 375) was provided with intrauterine contraception (either the levonorgestrel-releasing intrauterine system or copper-releasing intrauterine device) immediately following surgical abortion (18.1%) or at a follow-up 2-4 weeks after medical abortion (81.9%). Women in the control group were prescribed oral contraceptives and advised to contact their primary healthcare unit for a follow-up visit and further contraceptive services according to national guidelines. The women were followed-up to 28 February 2014 by using the Finnish National Abortion Registry, Helsinki University Hospital electronic database and clinical follow-up visit at 1 year. MAIN RESULTS AND THE ROLE OF CHANCE: The median age of the whole study group was 27 years and 44% had a history of induced abortion(s). During the follow-up year the number of women requesting subsequent abortion was significantly lower in the intervention than in the control group (9/375 [2.4%] versus 20/373 [5.4%], difference -3.0 [95% CI -6.0 to -0.2] percentage points, P = 0.038, according to intention-to-treat analysis and 5/346 [1.4%] versus 20/357 [5.6%], difference -4.2(-7.2 to -1.4) percentage points, P = 0.003, according to per-protocol analysis, respectively). Provision of intrauterine contraception was safe with rate of infection and expulsion similar to those reported previously. LIMITATIONS, REASONS FOR CAUTION: The power calculation was calculated for a 5-year follow-up. However, significant differences between the two groups were already seen after 1 year. The present study was performed in a single clinic, where, ∼15% of all abortions in Finland are performed. WIDER IMPLICATIONS OF THE FINDINGS: In order to decrease the need of subsequent abortions, IUDs should be provided at the time of abortion. TRIAL REGISTRATION: The study was registered at www.clinicaltrials.gov (NCT01223521). TRIAL REGISTRATION DATE: 18 October 2010. DATE OF FIRST PATIENT'S ENROLMENT: 18 October 2010.

Effect of previous induced abortions on postabortion contraception selection.

OBJECTIVE: The objective was to compare contraceptive method selection in women undergoing their first pregnancy termination versus women undergoing repeat pregnancy termination in an urban abortion clinic. We hypothesized that women undergoing repeat abortions will select highly effective contraceptives (intrauterine device, subdermal implant, tubal ligation) more often than patients undergoing their first abortion. STUDY DESIGN: We conducted a retrospective analysis of all women undergoing first-trimester surgical abortion at John H. Stroger, Jr., Hospital of Cook County from October 1, 2009, to October 31, 2011. We compared contraceptive method selection in the postabortion period after receipt of contraceptive counseling for 7466 women, stratifying women by history of no prior abortion versus one or more abortions. RESULTS: Of the 7466 women, 48.6% (3625) had no history of previous abortion. After controlling for age, race and number of living children, women with a history of abortion were more likely to select a highly effective method [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.06-1.33]. Most significantly, having living children was the strongest predictor of a highly effective method with an OR of 3.17 (95% CI 2.69-3.75). CONCLUSIONS: In women having a first-trimester abortion, the factors most predictive of selecting a highly effective method for postabortion contraception include history of previous abortion and having living children. The latter holds true independent of abortion history. IMPLICATIONS: This paper is unique in its ability to demonstrate the high interest in highly effective contraceptive selection in high-risk, low-income women with prior abortion history. Efforts to integrate provision of highly effective methods of contraception for postabortion care are essential for the reduction of future unintended pregnancies.

Expulsion and continuation rates after postabortion insertion of framed IUDs versus frameless IUDs - review of the literature.

BACKGROUND: Early intrauterine device (IUD) discontinuation after insertion immediately following aspiration abortion or after early medical abortion occurs as a consequence of expulsion of the IUD or removal due to side effects. These are often the consequence of the uterine forces impacting on the IUD due to spatial discrepancy with the uterine cavity causing pain, abnormal bleeding, and eventually, removal of the IUD. These women are candidates for repeat pregnancy as they often select less-effective methods or no contraception at all. Repeat abortion could be reduced by giving attention to these factors. STUDY DESIGN: In order to have an indication on the magnitude of the problem of IUD expulsion or discontinuation, we searched the MEDLINE database for clinical trials, randomized controlled trials, and prospective observational studies related to immediate postaspiration termination of pregnancy (TOP) and early medical abortion IUD insertion studies that reported IUD expulsion and IUD continuation rates. RESULTS: The search identified 17 clinical trials that were suitable based on the data they presented. The majority concerned T-shape IUDs, inserted immediately following surgical (aspiration) pregnancy termination. Two studies were conducted after medical TOP, and four studies were conducted with the frameless IUD inserted after surgical (vacuum aspiration) TOP. The results showed expulsion rates between 0.8% and 17.3% at 8 weeks, up to 5 years after insertion, respectively. In four studies with the frameless IUD, totaling 553 insertions, the expulsion rate was 0.0% in three of them. Follow-up in the latter studies varied between 5 weeks and 54 months. Reported continuation rates with conventional (framed) IUDs were between 33.8% and 80% at 1 year for studies providing 1 year rates and between 68% and 94.1% for studies reporting continuation rates at 6 months. Studies utilizing frameless IUDs reported 1 year continuation rate over 95%. CONCLUSION: Frameless IUDs, due to their attachment to the uterine fundus, appear to be better retained by the postabortal uterus when compared with conventional framed IUDs. The absence of a frame ensures compatibility with uterine cavity anatomical dimensions, and may therefore result in improved acceptability and continuation rates in comparison with framed IUDs. Both these characteristics of the frameless IUD could help reduce the number of repeat unwanted pregnancies and subsequent abortions in some cases.

Risk factors for repeat abortion and implications for addressing unintended pregnancy in Vietnam.

OBJECTIVE: To determine predictors of repeat abortion in 3 provinces in Vietnam. METHODS: In a cross-sectional study between August and December 2011, women who underwent abortion were interviewed after the procedure in 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC). Information on sociodemographic factors, contraceptive and reproductive history and intentions, and opinions and experience of abortion services was collected. The primary outcome was repeat (≥2) abortions. RESULTS: Overall, 1224 women were interviewed: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. The mean age and parity of the respondents were 29 years and 1.8, respectively, and 79.6% were married. Approximately half of the respondents were not using contraception before pregnancy. The prevalence of repeat abortion was 31.7%. In multivariate models, significant predictors of repeat abortion included living in Hanoi, higher parity, age 35 years or older, and having 2 or more daughters (versus 1) or no sons (versus 1) after controlling for parity (all P < 0.05). CONCLUSION: Repeat abortion remains high in Vietnam, fueled partly by inadequate contraceptive use. Son preference seems to be an important predictor of repeat abortion. Strengthening post-abortion contraceptive counseling and promoting long-acting contraceptive methods are essential to reduce repeat abortion.