Effectiveness, acceptability and uptake of early versus standard intrauterine contraception following provision of first trimester medical post abortion care in Central Uganda

Abstract

Background: Unintended pregnancies continue to cause a public health threat in low- and middle- income countries (LMIC) due to restrictive abortion laws and the high unmet need for contraception. Over 40% of these unintended pregnancies end up as abortions, with significant subsequent abortion-related complications. Although accessible and highly effective in LMIC to reduce the burden of unintended pregnancies, the uptake of intrauterine devices (IUDs) is less than five percent. Despite fertility return within two-weeks after abortion treatment, there is paucity of information on the ideal timing of IUD insertion after medical management of first trimester abortions. It’s against this background that we set out to explore the following objectives to streamline patient care in central Uganda. Specific Objectives: 1. To explore the healthcare providers' perceptions on post abortion intrauterine contraception after medical management of first trimester incomplete abortion. 2. To determine the level and factors associated with uptake of intrauterine contraception after medical management of first trimester incomplete abortion. 3. To compare the expulsion and continuation rates at six months between early versus standard intrauterine contraception insertions after medical management of first trimester incomplete abortion. 4. To explore the women’s and their partners' perceptions on post abortion intrauterine contraception after medical management of first trimester incomplete abortion. Methods: This project was conducted at five public health facilities in central Uganda between 1st May, 2022 and 31st May, 2023 using explanatory sequential mixed methods. The first sub-study explored healthcare providers’ perceptions on post abortion intrauterine contraception, to understand the barriers and facilitators towards their recommendation of intrauterine contraception. Forty-five in-depth interviews were conducted among healthcare providers of different cadres in central Uganda. The case study design was used to explore the healthcare providers’ perceptions. Themes were identified using the conventional inductive content analysis. xii The second sub-study evaluated the uptake of intrauterine contraception and the predictors of the uptake using a cross-sectional study. Data from 650 participants were collected using interviewer- administered questionnaires. The primary outcome was uptake of post abortion IUDs, defined as the actual insertion of the post abortion IUDs. The third sub-study was a multicenter non-inferiority randomised controlled trial (RCT) among 1,050 women with first trimester incomplete abortions managed by sublingual misoprostol. After choosing either copper or levonorgestrel IUDs, participants were randomly assigned to early or standard insertion arms in a ratio of 1:1, using block size of 4. The primary outcomes were IUD expulsion and continuation rates at six-months. Participants and clinicians were unblinded to treatment allocation. The non-inferiority margin was set at 5% for the upper limit of the two-sided 95% CI for the absolute risk difference, p-value 0.0001. The trial was registered at ClinicalTrials.gov NCT05343546. The fourth sub-study explored the perceptions of the women and their partners on post abortion intrauterine contraception in fifteen in-depth interviews. Using inductive content analysis, themes and subthemes were generated. Results: From the analysis in the qualitative study among healthcare providers, three themes emerged. Theme one covered health system related barriers in regards to IUD provision such as healthcare providers’ and health facility challenges. The second theme focused on the challenges in post abortion contraceptive counselling focusing on IUDs. The third theme covered the motivating factors and participants’ views on how to scale up IUD uptake and provision within post abortion care in Uganda. We found that lack of appropriate healthcare providers’ knowledge and skills on IUD provision, and heavy workload, negatively impacted IUD provision. Inadequate facilities, IUD stock-outs, and minimal community sensitization, limited the utilization of IUDs. The prevalence of post abortion IUD uptake among all women assessed was 370/1911 (19.4%; 95%CI 17.7 to 21.2). The prevalence of IUD acceptors among those who accepted any form of contraceptives was 370/650 (56.9%; 95%CI 53.1 to 60.7). The median age of the participants was 27  IQR (30, 23) years. The post abortion IUD uptake was independently associated with religion- being a Pentecostal (Adjusted PR=2.49, 95%CI= (1.19-5.23), p-value=0.015), monthly earning > one million Ugx (270 USD) (Adjusted PR=1.88, 95%CI= (1.44-2.46), p-value<0.001), and staying <5 kilometres from the health facility (Adjusted PR=1.34, 95%CI= (1.04-1.72), p-value=0.035). Women who were not cohabiting with their partners, were less likely to choose IUDs (Adjusted PR=0.59, 95% CI= (0.44-0.79), p-value<0.001). In the non-inferiority RCT, 528 (50.3%) participants were randomized to early and 522 (49.7%) participants to standard insertion arms. A total of 532 (50.6%) participants chose levonorgestrel IUDs, 488 (46.6%) participants chose copper IUDs, while 30 (2.9%) participants opted against IUDs. In an intention-to-treat analysis, expulsion occurred in 23 (4.4%) of 528 participants in the early insertion arm and in 24 (4.6%) of 522 participants in the standard arm; Adjusted Risk Difference (ARD)(standard-early) was -0.01(95% CI: -0.001 to 0.07, p-value = 0.93). The IUD continuation rates at six-months were 91.1% in the early and 90.2% in the standard insertion arms. ARD (early-standard) was 0.009 (95% CI: -0.11 to 0.12, p-value = 0.88). No serious adverse events occurred in both arms. In the qualitative study among women and their partners, three themes emerged: 1) perceived women’s and their partners’ barriers in accessing post abortion IUDs such as myths and misconceptions on IUDs, spouse refusal, IUD-related side effects. 2) Women’s and their partners’ experiences while using post abortion IUDs such as increased lubrication, freedom from prior contraceptive side effects, assurance of early return to fertility after IUD removal, menstrual irregularities and abdominal pain following IUD insertion. 3) Motivators and recommendations to the uptake of IUDs such as peer influence, client-healthcare provider relationship, spousal approval of IUDs and community sensitization on IUDs using social media platforms. Conclusions: Health system barriers including healthcare providers’ skills and knowledge gaps, supply chain challenges, influence the uptake of post abortion intrauterine contraception. With provision of on-job refresher trainings, mentoring and supervision of healthcare providers, the subsequent uptake of IUDs among post abortion women was nearly 60%. Understanding the socio- cultural context of women and their partners, is pivotal in the uptake of post abortion IUDs. Our findings reveal that early IUD insertion after medical treatment of first trimester incomplete abortions, was non-inferior to standard IUD insertion, with respect to IUD expulsion and continuation rates. To enhance the utilization of early IUD insertion, healthcare providers ought to provide evidence-based counselling to demystify individual and community misconceptions on IUD use. Regardless of their sociodemographic status, women seeking post abortion care should be provided with high-quality integrated services by trained providers, offering a range of contraceptive methods. Such efforts may not only prevent unintended pregnancies but also improve health equity across the country. Study utility: Our study demonstrates that early insertion of post abortion IUDs is non-inferior to the standard insertion after first trimester medical management of incomplete abortions. Women can safely utilize early insertion of IUDs after medical management of their abortions. With return to fertility as early as within two-weeks after treatment of first trimester incomplete abortion, women should be encouraged to utilize early insertion of IUDs, to prevent subsequent unintended pregnancies. Measures should be underway to update policies and pre- and in-service training in post abortion counselling and family planning provision after medical management of first trimester abortions. Efforts to address health system barriers and understand the socio-cultural context of women and their partners, are pivotal in improving the uptake of post abortion IUDs.