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FIAPAC Seminar October 27-28, 2005, Moscow

FIAPAC Seminar October 27-28, 2005, Moscow. Post-abortion contraception: Methods’ choice. Irina Savelieva, M. D., Ph.D., Research Center Ob. & Gyn., Moscow, Russia. Reproductive health intentions in postpartum and abortion clients. BUT:.

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FIAPAC Seminar October 27-28, 2005, Moscow

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  1. FIAPAC SeminarOctober 27-28, 2005, Moscow Post-abortion contraception: Methods’ choice Irina Savelieva, M. D., Ph.D., Research Center Ob. & Gyn., Moscow, Russia

  2. Reproductive health intentions in postpartum and abortion clients BUT: *E.Vikhlyaeva et al., Eur J Contr. And Repr. Health, 2001 **I.Savelieva, APHA, 2002

  3. In 13 months: rate of repeat abortions *E.Vikhlyaeva et al., Eur J Contr. And Repr. Health, 2001 **I.Savelieva, APHA, 2002

  4. Post-abortion contraception: wide range of methods • Low-dose combined oral contraceptives • Combined injectable contraceptives, patch & ring • Progestogen-only contraceptives • Emergence contraceptives pills • Intrauterine devices (Cu-IUD and LNG-IUD) • Barrier methods: condoms (Male latex, male polyurethane, female condoms), spermicide (film, tablets, foam, gel), diaphragm (with spermicide), cervical cap • Fertility awareness-based methods (symptoms-based methods and calendar-based methods) • Surgical sterilization procedure (female and male)

  5. Post-abortion contraception: counseling • Health-care providers and counselors have a responsibility to ensure that contraceptive services are available and offered to women who have abortions (WHO, 1997) • Providing family planning counseling can increase the proportion of women agreeing to use a contraceptive method before leaving the health facility which provided PAC (strong evidence) (Lema and Mpanga, 2000) • The availability of contraceptive commodities may increase the likelihood patients will report that they intend to use a contraceptive and will be discharged with a method (strong evidence)

  6. Post-abortion contraception: counseling • Well-informed women will be more satisfied with their choices and more likely to use contraceptive method regularly and properly • Providing appropriate leaflets improves knowledge of contraception, in relation to oral contraceptive pill use (BMJ, 1998; 316:1948-52) • Linking family planning services with abortion servicesresultsin more effective family planning use and reduction of repeat abortions (SE) (Sentler et al., 2001)

  7. Post-abortion contraception: counseling • She can become pregnant within a few days after the abortion (Cameron IT, Baird DT., 1988) • There are contraceptive methods that can help her prevent a future unwanted pregnancy • How and where various methods are available (either at time of treatment and/or after discharge • Clinic staff can provide referrals if she has other reproductive-health needs

  8. What does “Informed Choice” means? “Informed” means that: • Clients have the clear, accurate, and specific information that they need • Clients understand their own needs “Choice” means that: • Clients have a range of FP methods to choose from • Clients make their own decisions

  9. Post-abortion contraception: Decision making about a method • Each woman needs comprehensive information on her chosen contraceptive method, including: • Effectiveness • Advantages and disadvantages • How to use the method • Which side effects are common and how to manage them • Complications • STD prevention • How to acquire additional supplies of the method • When to return • Medical Eligibility Checklist • Informed consent

  10. Percentage of women experiencing an unintended pregnancy within the first year of use, USA Trussel J. Contraceptive efficacy. In Hatcher RA, Trussel J.,et al., 2004

  11. Conditions that expose a woman to increase risk as a result of unintended pregnancy • Breast cancer • Complicated valvular heart diseases • Diabetes: insulin-dependent; with nephropathy/retinopathy/neuropathy or other vascular diseases; or of >20 years of duration • Endometrial or ovarian cancer • High blood pressure (systolic > 160 mm Hg or diastolic > 100 mm Hg) • STI / HIV / AIDS • Ischemic heart disease • Malignant gestational trophoblastic disease • Malignant liver tumours (hepatoma); Schistomiasis with fibrosis of the liver; Severe (decompensated) cirrhosis • Sickle cell disease • Stroke • Thrombogenic mutations • Tuberculosis WHO, 2004

  12. Post- abortion contraception: when method should be started? Most methods can be used without risk after a safe abortion Surgical abortion Medical abortion Just after abortion After confirmation of POC expulsion

  13. Medical Eligibility Criteria for Contraceptive Use Medical Eligibility Criteria for contraceptive use, 2004

  14. Post-abortion contraception: surgical sterilization • Sterilization can safely be performed at the time of induced abortion (Cheng MC, Cheong SC, Chew SC., 1979) • However combined procedures are associated with higher rates of failure and of regret on the part of the woman (Penny GC, et al, 1997) • Sterilization procedure has some medical restrictions in case of complications after abortion (postabortion sepsis or fever, severe haemorrhage, severe trauma to the genital tract, uterine perforation, acute haematometra)

  15. Post-abortion contraception: COC • Use of oral contraceptives in the immediate post abortion period is safe (strong evidence) (Niswonger et al., 1968) • Benefits of COC • Very effective when used correctly • Can be used as long as a woman wants to prevent pregnancy. No rest period needed. • Can be used from adolescence to menopause • Monthly periods are more regular; lighter monthly bleeding and fewer days of bleeding • Help prevent: ectopic pregnancy, endometrial cancer, ovarian cancer, ovarian cysts, pelvic inflammatory disease, benign breast disease • Can prevent or decrease iron deficiency anemia • Fertility returns soon after stopping see O. Serova

  16. Post-abortion contraception: Intrauterine devices • It is safe and effective to insert an IUD for contraceptive use immediately after first-trimester, spontaneous or induced abortion (Aral K, et al., 1993; Bitsch M, et al., 1990; WHO, 1983) • There was no differences in risk of complications for immediate versus delayed insertion of an IUD after abortion (WHO, 2004) • Expulsion was greater when an IUD was inserted following a second-trimester abortion versus following a first-trimester abortion (Stanwood et al., 2001) • There were no differences in safety or expulsions for post-abortion insertion of an LNG-IUD compared with Cu-IUD see M - L Brival, S. Rogovskaya

  17. Post-abortion contraception: emergency contraception • Greater awareness and use of EC can reduce rates of unintended pregnancy and abortion • Use of EC may have prevented more than 50 000 US abortions in 2000(Johnes et al., 2002) • If EC methods would be more available it would allowed to prevent 1,7 millions unwanted pregnancies and abortions would be decreased by twice (Boonstra, 2002) • ECPs containing LNG the most commonly used and most convenient form of EC 1,5 mgLNG see Emergency contraception session

  18. Post-abortion contraception: Barrier methods • Women with conditions which make pregnancy an unacceptable risk should be advised that BM for pregnancy prevention may not be appropriate for those who cannot use them consistently and correctly because of their relatively-higher typical-use failure rates • Male latex condoms are proven to protect against STI/HIV • Repeated and high-dose use of the spermicide nonoxynol-9 was associated with increased risk of genital lesions, which may increase the risk of acquiring HIV infection Wilkinson D et al. Cochrane Database of Systematic Reviews, 2002, 4:CD003936

  19. Partner’ «participating» in the abortion’ procedure, % (WIN project, Perm 1999-2002) • Have discussed pregnancy prevention with husband/ partner • Wish partner to participate in counseling • Partner come with woman • Partner participated in the talk about how to prevent pregnancy • Partner have been invited to follow-up visit

  20. Who do and who should makes the decision about contraception • Only 10% of all providers and 18% of providers who do CC have ever discussed FP with client’s partner • More than 90% thought that provision of RHS to men would improve women’s health

  21. Improvement women’s health Implementingof Family planning counseling in all levels of health care services  Access of using modern methods of contraception  Reducing of abortion rate, including repeat abortion and abortion after delivery

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