Review question
We compared the initiation rate, effectiveness, and side effects of insertion of a contraceptive implant (implant for birth control) at the same visit as an abortion versus delayed insertion at a follow-up visit.
Background
The contraceptive implant is a highly effective method of birth control that is reversible and provides long duration of pregnancy protection. This method is suitable for almost all women, including women who have a pregnancy ended by removal or expulsion. Because many women do not return for a postabortion follow-up visit and have low rates of contraception uptake, the insertion of a contraceptive implant at the abortion visit is a promising approach that deserves consideration.
Study characteristics
We searched for randomized controlled trials (studies where participants are randomly assigned to one of two or more treatment groups) up to March 2021. We looked at whether insertion of contraceptive implants at the same visit as abortion compared with at the time women returned for a follow-up visit affected the use of this contraceptive method. We included three studies with a total of 1162 women selecting implant contraception following an abortion assigned to immediate insertion at the visit or at a follow-up visit.
Key results
Use of a contraceptive implant may be higher when it is inserted at the same visit as abortion. The evidence suggests that immediate insertion probably improves the initiation of contraceptive implants. However, immediate insertion may slightly increase the utilization rate at six months. There appeared to be little or no difference between groups in overall failure rate of medical abortion and bleeding side effects at one month after abortion. The evidence also indicates that immediate insertion of contraceptive implants probably reduces unintended pregnancy rate within six months after abortion.
Certainty of the evidence
Overall, the certainty of the evidence was moderate to very low. Further good-quality, well-designed randomized controlled trials will provide meaningful results on the rates of unintended pregnancy, and side effects following contraceptive implant placement at the same visit as abortion, compared to insertion within six weeks after.
Provision of progestin-releasing implants concurrently with abortifacient agents likely has little or no negative impact on overall failure rate of medical abortion. Immediate insertion probably improves the initiation rate of contraceptive implant, as well as unintended pregnancy rate within six months after abortion, compared to delayed insertion. There may be no difference between immediate and delayed insertion approaches in bleeding adverse effects at one month after abortion.
Contraceptive implants are one of the most effective contraceptive methods, providing a long duration of pregnancy protection and a high safety profile. Hence this method is suitable for optimizing the interpregnancy interval, especially for women undergoing abortion.
Women who have had abortions are at high risk of rapid repeat pregnancies. Provision of effective contraception at the time of an abortion visit can be a key strategy to increase access and uptake of contraception. A review of the evidence was needed to evaluate progestin-releasing implants for immediate use at the time of abortion, including whether immediate placement impacts the effectiveness of medical abortion, which relies on antiprogestogens.
To compare contraceptive implant initiation rates, contraceptive effectiveness, and adverse outcomes associated with immediate versus delayed insertion of contraceptive implants following abortion.
We searched for all relevant studies regardless of language or publication status up to September 2019, with an update search in March 2021. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Ovid EBM Reviews), MEDLINE ALL (Ovid), Embase.com, CINAHL (EBSCOhost) (Cumulative Index to Nursing and Allied Health Literature), Global Health (Ovid), LILACS (Latin American and Caribbean Health Science Information database), Scopus, ClinicalTrials.gov, and the WHO ICTRP. We examined the reference lists of pertinent articles to identify other studies.
We sought randomized controlled trials (RCTs) comparing immediate versus delayed insertion of contraceptive implant for contraception following abortion.
We followed the standard procedures recommended by Cochrane. To identify potentially relevant studies, two review authors (JS, LS) independently screened the titles, abstracts, and full texts of the search results, assessed trials for risk of bias, and extracted data. We computed the risk ratio (RR) with 95% confidence intervals (CIs) for binary outcomes, and the mean difference (MD) with 95% CIs for continuous variables.
We found three RCTs including a total of 1162 women. Our GRADE assessment of the overall certainty of the evidence ranged from moderate to very low, downgraded for risk of bias, inconsistency, and imprecision.
Utilization rate at six months may be slightly higher for immediate compared with delayed insertion (RR 1.10, 95% CI 1.05 to 1.15; 3 RCTs; 1103 women; I2 = 62%; low certainty evidence). Unintended pregnancy within six months after abortion was probably lower with immediate insertion compared with delayed insertion (RR 0.25, 95% CI 0.08 to 0.77; 3 RCTs; 1029 women; I2 = 0%; moderate certainty evidence). Immediate insertion of contraceptive implants probably improves the initiation rate compared to delayed insertion following medical abortion (RR 1.26 for medical abortion, 95% CI 1.21 to 1.32; 2 RCTs; 1014 women; I2 = 89%; moderate certainty evidence) and may also improve initiation following surgical abortion (RR 2.32 for surgical abortion, 95% CI 1.79 to 3.01; 1 RCT; 148 women; I2 = not applicable; low certainty evidence). We did not pool results for the implant initiation outcome over both abortion types because of very high statistical heterogeneity.
For medical termination of pregnancy, we found there is probably little or no difference between immediate and delayed insertion in overall failure of medical abortion (RR 1.18, 95% CI 0.58 to 2.40; 2 RCTs; 1001 women; I2 = 68%;moderate certainty evidence).
There may be no difference between immediate and delayed insertion on rates of abnormal bleeding at one month after abortion (RR 1.00, 95% CI 0.88 to 1.14; 1 RCT; 462 women; I2 = not applicable; low certainty evidence).