Last reviewed: November 1, 2022
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 person 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.
In practice:
- 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.
- Satisfaction with contraceptive services/uptake amongst medical abortion clients is greater when contraception is initiated at the same time as mifepristone.
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, ovulation typically resumes within three to four weeks; however, people can ovulate in as little as eight days (Boyd & Holmstrom, 1972; Lahteenmaki & Luukkainen, 1978; Schreiber et al., 2010; Stoddard & Eisenberg, 2011). At least 85% of people 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 et al., 1979). Given the rapid return to fertility, all people who wish to begin contraception
the time of their abortion. If the preferred method is not available, referral should be provided and, if desired, an interim method (World Health Organization [WHO], 2014b).
Safety and acceptability of postabortion contraception
For adults, 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 adolescents: Depot medroxyprogesterone acetate (DMPA) injection is classified by WHO as a category two for those under 18 years of age, due to concerns about effects on bone mineral density. Sterilization may be performed on young people, 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 et al., 1994; Cameron et al., 2012; Kilander et al., 2016; Korjamo, Mentula, & Heikinheimo, 2017; Langston, Joslin-Rohr, & Westhoff, 2014; Peipert et al., 2012; Pohjoranta et al., 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 et al., 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 (Kim et al., 2021; WHO, 2015; WHO, 2022). Fertility awareness-based methods may be initiated once a the person 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 (Kim et al., 2021; WHO, 2015; WHO, 2022). IUDs may be inserted and sterilization performed as soon as it is reasonably certain that the person is no longer pregnant (WHO, 2014a; WHO, 2022).
A person’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 (WHO, 2022).
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. A 2022 systematic review, which included these three studies, concluded that provision of progestin-releasing implants, concurrently with abortifacients, has little or no negative impact on medical abortion success, and decreases subsequent unintended pregnancy (Sothornwit et al., 2022).
WHO recommends that generalist and specialist medical practitioners, associate and advance associate clinicians, midwives, and nurses can safely and effectively insert and remove subdermal implants. WHO suggests that in contexts with established health system mechanisms to include traditional and complementary medicine professionals in other tasks related to maternal and reproductive health, and where training in implant removal is given along with training in insertion, these health workers can insert and remove implants. Auxiliary nurses and auxiliary nurse midwives can insert and remove implants in the context of targeted monitoring and evaluation, and community health workers can insert and remove implants in the context of rigorous research. For further information about health worker roles in abortion care, see Appendix C: World Health Organization recommendations for health worker roles in abortion care.
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 et al., 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%); %); a 2021 systematic review suggests that those choosing DMPA initiation on the same day as mifepristone should be informed of the slightly increased risk of ongoing pregnancy (Kim et al., 2021). 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 et al., 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 (Kim et al., 2021). 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 et al., 1999; Tang et al., 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 et al., 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).
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. 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). Two systematic reviews of randomized comparative trials (Cavallaro et al., 2020; Nelson et al., 2022) found that contraceptive counseling and provision at the time of abortion increases contraceptive use, although some individuals may prefer not to discuss contraception in depth at the time of their abortion visit, particularly if they already know what postabortion contraceptive method they want (Cansino et al., 2018). 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 et al., 2017; Benson et al., 2016).
A recent systematic review examining contraceptive preferences included four studies among people seeking abortion services (Dam et al., 2022). Ease of use and effectiveness were important features of preferred contraceptive methods, as were cost, familiarity with the method, presence of hormones, and side effects, among others.
References
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