Last reviewed: February 15, 2021
Recommendation:
-
· Following vacuum aspiration or dilatation and evacuation (D&E), hormonal and non-hormonal contraception, including intrauterine device (IUD) placement and female sterilization, may be initiated immediately.
-
Hormonal methods, including pills, patches, rings, injectables and implants may be started on the day of the first pill of medical abortion. IUD placement and female sterilization should be performed when it is reasonably certain the woman is no longer pregnant.
-
Male sterilization (vasectomy) is safe and effective and can be performed at any time.
-
Long-acting contraceptive methods have higher continuation rates and lower pregnancy rates compared to short-acting methods.
-
Satisfaction with contraceptive services/uptake amongst medical abortion clients appears to be greater when contraception is initiated at the same time as mifepristone.
-
People, including adolescents, should be able to choose whether to use a contraceptive method, and to select their preferred method, based on accurate contraceptive information and their personal needs and preferences.
Strength of recommendation: Strong
Quality of evidence:
- IUDs and combined oral contraceptives: High
- Implants: Moderate
- Other methods: Low to Moderate
Fertility return
Following induced abortion at less than 13 weeks gestation, women will typically ovulate within three to four weeks; however, women can ovulate in as little as eight days (Boyd & Holmstrom, 1972; Lahteenmaki & Luukkainen, 1978; Schreiber, Sober, Ratcliffe, & Creinin, 2010; Stoddard & Eisenberg, 2011). At least 85% of women will ovulate before their first menses (Boyd & Holmstrom, 1972; Lahteenmaki & Luukkainen, 1978; Cameron & Baird, 1988). There is no difference in time to ovulation following medical abortion compared to vacuum aspiration (Cameron & Baird, 1988).
Data for return to fertility after abortion performed at or after 13 weeks gestation are limited. One study with only nine participants found that 66% ovulated within 21 days (Marrs, Kletzky, Howard, & Mishell, 1979). Given the rapid return to fertility, all women who wish to begin contraception
the time of their abortion. If a woman’s preferred method is not available, she should be provided a referral and, if desired, an interim method (World Health Organization [WHO], 2014b).
Safety and acceptability of postabortion contraception
For adult women, WHO’s 2015 Medical Eligibility Criteria for Contraceptive Use (WHO, 2015) classifies all contraceptive methods as category one, or safe for immediate use, following first-trimester uncomplicated abortion; recommendations do not differ based on the type of abortion. Female sterilization is classified as acceptable after an uncomplicated abortion.
Similarly, the Medical Eligibility Criteria for Contraceptive Use (WHO, 2015) classifies all contraceptive methods as category one, or safe for immediate use, following uncomplicated second-trimester abortion—except IUDs. Due to an increased risk of expulsion when used after abortion at or after 13 weeks gestation, IUDs are classified as category two, meaning the advantages of using the method generally outweigh the risks. Female sterilization is classified as acceptable after an uncomplicated abortion at or after 13 weeks gestation.
Two of these recommendations differ for adolescent women: Depot medroxyprogesterone acetate (DMPA) injection is classified by WHO as a category two for women under 18 years of age, due to concerns about effects on bone mineral density. Sterilization may be performed on young women, but special precautions may need to be taken due to the increased risk of regret (WHO, 2015).
In comparison to short-acting methods, long-acting methods of contraception such as implants and IUDs have higher continuation rates and lower pregnancy and abortion rates (Blumenthal, Wilson, Remsburg, Cullins & Huggins, 1994; Cameron et al., 2012; Kilander et al., 2016; Korjamo, Mentula, & Heikinheimo, 2017; Langston, Joslin-Rohr, & Westhoff, 2014; Peipert, Madden, Allsworth, & Secura, 2012; Pohjoranta, Mentual, Gissler, Suhonen, & Heikinheimo, 2015; Roberts, Silva, & Xu, 2010; Rose, Garrett, & Stanley, 2015). Uptake of long-acting methods is higher after surgical abortion as compared with medical abortion (Laursen, Stumbras, Lewnar, & Haider, 2017; Rocca et al., 2018). A systematic review and meta-analysis of randomized controlled trials has demonstrated significantly higher rates of patient satisfaction with immediate start (day of mifepristone) of implants and injectables compared with a delayed start (Schmidt-Hansen et al., 2020).
Contraceptive start
Following vacuum aspiration, D&E or medical abortion where pregnancy expulsion occurs in a facility, all hormonal and nonhormonal contraceptive methods, including IUD insertion and female sterilization, may be initiated immediately (WHO, 2015; WHO, 2018). Fertility awareness-based methods may be initiated once a woman has had at least one postabortion menses. Male sterilization (vasectomy) may be performed at any time.
For medical abortion where pregnancy expulsion is expected to occur at home, most forms of contraception (including pills, injectables and implants) may be started with the first pill of the medical abortion if there are no medical contraindications (WHO, 2015; WHO, 2018). IUDs may be inserted and sterilization performed as soon as it is reasonably certain that a woman is no longer pregnant (WHO, 2014a; WHO, 2018).
Evidence related to specific contraceptive methods
IUDs: See “Postabortion IUD use: Safety and timing.”
Progestin-only subdermal implants: Two randomized non-inferiority trials conducted in women undergoing medical abortion before 13 weeks gestation (Hognert et al., 2016; Raymond et al., 2016b) have demonstrated
that abortion success rates are the same in women receiving a contraceptive implant on the day they receive mifepristone compared to delayed placement. In both studies, insertion rates were higher for women receiving their implant on the day they received mifepristone. One study (Hognert et al., 2016) reported a significantly higher pregnancy rate in the delayed insertion group at follow-up six months after the abortion (3.8% compared to 0.8%). An additional study randomized women undergoing D&E to either delayed or immediate implant insertion (Cowett et al., 2018). Fewer than half of women in the delayed group had their implant inserted, compared to 100% in the immediate group.
Progestin-only injection: A study of 132 women using DMPA immediately after aspiration abortion reported no serious adverse events but low method continuation rates (22%) at one year and high repeat pregnancy rates (Goldberg, Cardenas, Hubbard, & Darney, 2002). One randomized, controlled non-inferiority trial (Raymond et al., 2016a) comparing 220 women undergoing medical abortion up to 75 days gestation who received intramuscular DMPA on the day of mifepristone to 226 women who did not found similar rates of surgical intervention for any reason after medical abortion (6.4% and 5.3%, respectively) and pregnancy rates at six months after the intervention (2.3% and 3.2%, respectively). However, ongoing pregnancy as a reason for medical abortion failure in the DMPA injection group was significantly higher (3.6% vs 0.9%). Smaller retrospective cohort studies have found no differences in medical abortion success rates or ongoing pregnancy rates in women who start progestin-only injections on the same day as mifepristone administration (Douthwaite et al., 2016; Park, Robinson, Wessels, Turner, & Geller, 2016). Women report high satisfaction with same-day administration of progestin-only contraceptives (Raymond et al., 2016a)
Combined oral contraceptives (COCs): A review of seven studies including 1,739 women demonstrated no serious adverse events using COCs immediately after aspiration or medical abortion before 13 weeks gestation (Gaffield, Kapp, & Ravi, 2009). Additionally, women who used COCs immediately demonstrate similar bleeding patterns to women using no contraception, and less bleeding than copper IUD users. Two randomized controlled trials of COCs compared to placebo started immediately after medical abortion up to 49 or 63 days gestation showed that pills do not have a significant effect on the efficacy of medical abortion or the quantity or duration of blood loss (Tang, Gao, Cheng, Lee, & Ho, 1999; Tang, Xu, Cheng, Lee, & Ho, 2002).
Combined vaginal ring: A cohort study of 81 women who placed a vaginal ring one week after aspiration or medical abortion before 13 weeks gestation showed no serious adverse events or infections (Fine, Tryggestad, Meyers, & Sangi-Haghpeykar, 2007).
Combined contraceptive patch: A trial of 298 women randomized to either immediate postabortion start or delayed start the Sunday after an abortion showed no difference in continuation rates at two and six months. In the 53% of women who could be contacted at six months, half had stopped using the contraceptive patch (Steinauer et al., 2014).
Quality of evidence
Because of the demonstrated safety of contraception after vacuum aspiration and medical abortion before 13 weeks, the 2015 Medical Eligibility Criteria for Contraceptive Use categorizes the immediate initiation of hormonal injections, implants, combined hormonal contraception (pills, patches and rings) and progestin-only pills as category one, or safe for use (WHO, 2015).
With the exception of IUD use following D&E, the immediate use of most methods of contraception have not been adequately studied following D&E or medical abortion at or after 13 weeks gestation. The 2015 Medical
Eligibility Criteria for Contraceptive Use recommendations do not differ based on type of abortion performed, whether medical or D&E. A woman’s immediate need for reliable contraception after abortion, coupled with the reduced uptake of contraception when provision is delayed, strongly supports the recommendation to start contraceptive methods immediately.
Informed decision making
WHO recommends that sexual and reproductive health services, including contraceptive services, be delivered in a way that ensures fully informed decision-making, respects dignity, autonomy, privacy and confidentiality, and is sensitive to individuals’ needs and perspectives (WHO, 2014b). People should be able to choose or refuse contraception based on their personal needs and preferences. Evidence-based, comprehensive contraceptive information, non-directive contraceptive counseling and support should be accessible for all people, including adolescents, so that patients are able to make an informed decision. In one US study, a majority of women preferred not to discuss contraception in depth at the time of their abortion visit, most commonly because they already knew what postabortion contraceptive method they wanted (Cansino et al., 2018). Ideally a range of contraceptive methods should be available, appropriate referrals for methods not available on site should be offered, and these services should be integrated with abortion and postabortion care (Baynes et al., 2019; WHO, 2014b). When contraception is delivered at the time of abortion and a wide range of contraceptive commodities is available, contraceptive uptake in postabortion patients can be as high as 73%, including among young women (Benson, Andersen, Healy, & Brahmi, 2017; Benson et al., 2016).
References
Baynes, C., Kahwa, J., Lusiola, G., Mwanga, F., Bantambya, J., Ngosso, L., & Hiza, M. (2019). What contraception do women use after experiencing complications from abortion? An analysis of cohort records of 18,688 postabortion care clients in Tanzania. BMC Women’s Health, 19(1), 22.
Benson, J., Andersen, K., Healy, J., & Brahmi, D. (2017). What factors contribute to postabortion contraceptive uptake by young women? A program evaluationprogram evaluation in 10 Countries in Asia and sub-Saharan Africa. Global Health: Science and Practice, 5(4), 644-657.
Benson, J., Andersen, K., Brahmi, D., Healy, J., Mark, A., Ajode, A., & Griffin, R. (2018). What contraception do women use after abortion? An analysis of 319,385 cases from eight countries. Global Public Health, 13(1), 35-50.
Blumenthal, P. D., Wilson, L. E., Remsburg, R. E., Cullins, V. E., & Huggins, G. R. (1994). Contraceptive outcomes among post-partum and post-abortal adolescents. Contraception, 50(5), 451-460.
Boyd Jr, E. F., & Holmstrom, E. G. (1972). Ovulation following therapeutic abortion. American Journal of Obstetrics & Gynecology, 113(4), 469.
Cameron, I. T., & Baird, D. T. (1988). The return to ovulation following early abortion: A comparison between vacuum aspiration and prostaglandin. Acta Endocrinologica (Copenhagen) 118, 161-167.
Cameron, S., Glasier, A., Chen, Z., Johnstone, A., Dunlop, C., & Heller, R. (2012). Effect of contraception provided at termination of pregnancy and incidence of subsequent termination of pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology, 119(9), 1074-1080.
Cansino, C., Lichtenberg, E. S., Perriera, L. K., Hou, M. Y., Melo, J., & Creinin, M. D. (2018). Do women want to talk about birth control at the time of a first-trimester abortion? Contraception, 98(6), 535-540.
Cowett, A. A., Ali, R., Cooper, M. A., Evans, M., Conzuelo, G., & Cremer, M. (2018). Timing of etonogestrel implant insertion after dilation and evacuation: A randomized controlled trial. Obstetric s & Gynecology, 131(5), 856-862.
Douthwaite, M., Candelas, J. A., Reichwein, B., Eckhardt, C., Ngo, T. D., & Dominguez, A. (2016). Efficacy of early induced medical abortion with mifepristone when beginning progestin-only contraception on the same day. International Journal of Gynaecology & Obstetrics, 133 (3), 329-333.
Fine, P. M., Tryggestad, J., Meyers, N. J., & Sangi-Haghpeykar, H. (2007). Safety and acceptability with the use of a contraceptive vaginal ring after surgical or medical abortion. Contraception, 75(5), 367-371.
Gaffield, M. E., Kapp, N., & Ravi, A. (2009). Use of combined oral contraceptives post abortion. Contraception, 80(4), 355-362.
Goldberg, A. B., Cardenas, L. H., Hubbard, A. E., & Darney, P. D. (2002). Post-abortion depot medroxyprogesterone acetate continuation rates: A randomized trial of cyclic estradiol. Contraception, 66(4), 215-220.
Hognert, H., Kopp Kallner, H., Cameron, S., Nyreli, C., Jawad, I., Heller, R., … Gemzell-Danielsson, K. (2016). Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion-a randomized controlled equivalence trial. Human Reproduction, 31(11), 2484-2490.
Kilander, H., Alehagen, S., Svedlund, L., Westlund, K., Thor, J., & Brynhildsen, J. (2016). Likelihood of repeat abortion in a Swedish cohort according to the choice of post-abortion contraception: A longitudinal study. Acta Obstetricia et Gynecologica Scandinavica, 95(5), 565-571.
Korjamo, R., Mentula, M., & Heikinheimo, O. (2017). Immediate versus delayed initiation of the levonorgestrel-releasing intrauterine system following medical termination of pregnancy – 1 year continuation rates: A randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 124(13), 1957-1964.
Lahteenmaki, P., & Luukkainen, T. (1978). Return of ovarian function after abortion. Clinical Endocrinology, 8(2), 123-132.
Langston, A.M., Joslin-Rohr, S.L., & Westhoff, C.L. (2014). Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice. Contraception, 89(2), 103-8.
Laursen, L., Stumbras, K., Lewnard, I., & Haider, S. (2017). Contraceptive provision after medication and surgical abortion. Women’s Health Issues, 27(5), 546-550.
Marrs, R. P., Kletzky, O. A., Howard, W. F., & Mishell, D. R. (1979). Disappearance of human chorionic gonadotropin and resumption of ovulation following abortion. American Journal of Obstetrics & Gynecology, 135, 731-736.
Park, J., Robinson, N., Wessels, U., Turner, J., & Geller, S. (2016). Progestin-based contraceptive on the same day as medical abortion. International Journal of Gynaecology & Obstetrics, 133(2), 217-220.
Peipert, J. F., Madden, T., Allsworth, J. E., & Secura, G. M. (2012). Preventing unintended pregnancies by providing no-cost contraception. Obstetrics & Gynecology, 120(6), 1291-1297.
Pohjoranta, E., Mentula, M., Gissler, M., Suhonen, S., & Heikinheimo, O. (2015). 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. Human Reproduction, 30(11), 2539-46.
Raymond, E. G., Weaver, M. A., Louie, K. S., Tan, Y. L., Bousieguez, M., Arangure-Peraza, A. G., … Winikoff, B. (2016a). Effects of depot medroxyprogesterone acetate injection timing on medical abortion efficacy and repeat pregnancy: A randomized controlled trial. Obstetrics & Gynecology, 128(4), 739-745.
Raymond, E. G., Weaver, M. A., Tan, Y. L., Louie, K. S., Bousieguez, M., Lugo-Hernandez, E. M., … Winikoff, B. (2016b). Effect of immediate compared with delayed insertion of etonogestrel implants on medical abortion efficacy and repeat pregnancy: A randomized controlled trial. Obstetrics & Gynecology, 127(2), 306-312.
Roberts, H., Silva, M., & Xu, S. (2010). Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand. Contraception, 82(3), 260-265.
Rocca, C. H., Goodman, S., Grossman, D., Cadwallader, K., Thompson, K. M. J., Talmont, E., . . . Harper, C. C. (2018). Contraception after medication abortion in the United States: Results from a cluster randomized trial. American Journal of Obstetrics & Gynecology, 218(1), 107.e101-107.e108
Rose, S. B., Garrett, S. M., & Stanley, J. (2015). Immediate postabortion initiation of levonorgestrel implants reduces the incidence of births and abortions at 2 years and beyond. Contraception, 92(1), 17-25.
Schmidt-Hansen, M., Hawkins, J.E., Lord, J., Williams, K., Lohr, P.A., Hasler, E., & Cameron, S. (2020). Long-acting reversible contraception immediately after medical abortion: systematic review with meta-analyses. Human Reproduction Update, 26(2), 141-160.
Schreiber, C. A., Sober, S., Ratcliffe, S., & Creinin, M. D. (2011). Ovulation resumption after medical abortion with mifepristone and misoprostol. Contraception, 84(3), 230-233.
Steinauer, J. E., Sokoloff, A., Roberts, E., Drey, E. A., Dehlendorf, C. E., & Prager, S. W. (2014). Immediate versus delayed initiation of the contraceptive patch after abortion: A randomized trial. Contraception, 89(1), 42-7.
Stoddard, A., & Eisenberg, D. L. (2011). Controversies in family planning: Timing of ovulation after abortion and the conundrum of postabortion intrauterine device insertion. Contraception, 84, 119-121.
Tang, O. S., Gao, P. P., Cheng, L., Lee, S. W., & Ho, P. C. (1999). A randomized double-blind placebo-controlled study to assess the effect of oral contraceptive pills on the outcome of medical abortion with mifepristone and misoprostol. Human Reproduction, 14(3), 722-725.
Tang, O. S., Xu, J., Cheng, L., Lee, S. W., & Ho, P. C. (2002). The effect of contraceptive pills on the measured blood loss in medical termination of pregnancy by mifepristone and misoprostol: A randomized placebo controlled trial. Human Reproduction, 17(1), 99-102.
World Health Organization. (2014a). Clinical practice handbook for safe abortion. Geneva: World Health Organization Press.
World Health Organization. (2014b). Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations. Geneva: World Health Organization Press.
World Health Organization. (2015). Medical eligibility criteria for contraceptive use (5th ed.). Geneva: World Health Organization Press.
World Health Organization. (2018). Medical management of abortion. Geneva: World Health Organization Press.
