Immediate IUD insertion after second trimester abortion: implications for service delivery

O Somefun,M Endler,D Constant

doi:10.1186/s12913-021-07306-2

O Somefun, M Endler + Show 1 more

Open Access

https://doi.org/10.1186/s12913-021-07306-2

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Abstract

BackgroundThe availability of modern contraception including long-acting reversible contraceptives (LARC), is a fundamental component of postabortion care. Findings from a recent randomized controlled trial (RCT) in South Africa comparing immediate to delayed insertion of the copper intrauterine device (IUD) after medical abortion (MA) at 17-20 gestational weeks showed that immediate insertion resulted in higher IUD use at 6 weeks postabortion, but that expulsion rates were significantly higher than for delayed insertion. This study aims to explore barriers, facilitators, and context-specific factors relevant to the implementation of immediate IUD provision after second trimester medical abortion.MethodsWe performed a qualitative study alongside the RCT in which we conducted in-depth interviews with 14 staff providing healthcare to study participants and 24 study participants. Research questions explored barriers and facilitators to implementation of immediate IUD insertion, contraceptive decision-making, and the impact of context and supplementary trial activities on service provision. Interviews were recorded and transcribed, with translation into English if needed. We performed a triangulated thematic analysis at the level of the transcribed interview text.ResultsContraceptive counselling at the abortion facility by a study nurse improved knowledge, corrected misconceptions, and increased demand for the IUD postabortion. Women expressed a clear preference for immediate insertion. Convenience, protection from pregnancy and privacy issues were paramount and women expressed preference for engagement with staff who knew their abortion history, and with whom they had an established connection. Doctors and nurses were generally in favour of immediate insertion and said it could be incorporated into standard care if women wanted this. This contrasted with the need for interventions by the research team to reinforce adherence by staff to provide contraception as allocated during the trial.ConclusionsWomen and staff favour immediate IUD insertion after second trimester medical abortion, but service delivery may require structures that ensure timely insertion postabortion, continuity of care, communication that mitigates loss to follow-up and training of staff to ensure competence.

Highlights

The availability of modern contraception including long-acting reversible contraceptives (LARC), is a fundamental component of postabortion care
We developed semi-structured interview guides that were adapted to the role of clinical staff in study procedures, the study arm to which women belonged, and the decisions they made regarding the intrauterine device (IUD)
We offered participation to all resident doctors and nurses at the hospital providing the second trimester medical abortion care, as well as all primary healthcare nurses who had provided the IUD to 2 or more participants in the delayed arm of the randomized controlled trial (RCT) (n = 14)

Summary

Introduction

The availability of modern contraception including long-acting reversible contraceptives (LARC), is a fundamental component of postabortion care. Comprehensive abortion care, including postabortion contraception, reduces recurring unintended pregnancies, increases birth spacing and improves maternal health [1]. While long-acting reversible contraception methods (LARC) such as the IUD are most effective for planning and spacing pregnancies [3], use of the IUD in South Africa is low, at 2-3% [2], despite free provision in the public sector. Barriers to effective contraceptive uptake and use persist in South Africa and include poor provider attitudes, lack of training in LARC insertion, long waiting hours, little or no contraceptive counselling, and high rates of discontinuation due to both personal and structural factors [4]. Recent training programs to improve access to the IUD postpartum have shown promise in Southern Africa [6, 7], generally, uptake remains low [2]

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