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Postabortion Initiation of Long-Acting Reversible Contraception by Adolescent and Nulliparous Women in New Zealand
Journal of Adolescent Health 58 (2016) 160e166
www.jahonline.org Original article
Postabortion Initiation of Long-Acting Reversible Contraception by Adolescent and Nulliparous Women in New Zealand Sally B. Rose, Ph.D. *, and Susan M. Garrett, M.P.H. Department of Primary Health Care and General Practice, University of Otago, Wellington, Wellington South, New Zealand
Article history: Received June 10, 2015; Accepted September 26, 2015 Keywords: Adolescents; Induced abortion; Intrauterine devices; Long-acting reversible contraception (LARC); Pregnancy prevention; Subdermal implants; Unintended pregnancy
A B S T R A C T
Purpose: To describe changes in receipt of immediate postabortion long-acting reversible contraception (LARC) by adolescent and nulliparous women in New Zealand. Methods: Nationally collected data on immediate postabortion receipt of an intrauterine method (intrauterine device [IUD]/intrauterine system [IUS]) or contraceptive implant were analyzed to describe proportions and demographic characteristics of women receiving LARC between 2007 and 2013. Changes in uptake over time were presented for adolescent, nulliparous, and parous women. Results: Postabortion LARC uptake increased between 2007 and 2013, rising from 7.9% to 42.7% for adolescents and from 8.8% to 36.9% for nulliparous women. The increase was highest among nulliparous adolescents with a seven-fold increase in LARC uptake between 2007 and 2013. Adolescents had a five-fold increase and nulliparous women (of all ages) a four-fold increase. In 2013, IUD/IUS use was lowest among adolescents (22.4%) and increased with increasing age (43% by ages 40þ years), whereas implant use was highest among adolescents (20.3%) and decreased with increasing age (to 4.6% by age 40þ years). Nulliparous women had the lowest use of both IUD/IUS and implants in 2013, with 24.6% receiving an intrauterine method (compared with 43.2% for para 3þ), and 12.3% an implant (compared with 17.5% for para 3þ). Conclusions: Despite an overall trend toward increased uptake of postabortion LARC by adolescent and nulliparous women, uptake in these groups still lags behind that of parous and older women. Reasons for differential uptake need to be explored and addressed if necessary to ensure all women have equitable access to the most effective methods of contraception. Ó 2016 Society for Adolescent Health and Medicine. All rights reserved.
There has been growing international recognition of the need to promote and encourage use of long-acting reversible contraception, known as “LARC” (including intrauterine methods and subdermal implants), by young and adolescent women, to reduce rates
Conflicts of Interest: The authors report having no conflicts of interest. * Address correspondence to: Sally B. Rose, Ph.D., Department of Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South 6242, New Zealand. E-mail address: [email protected] (S.B. Rose). 1054-139X/Ó 2016 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.09.025
IMPLICATIONS AND CONTRIBUTION
Postabortion initiation of long-acting reversible contraception has increased among young and nulliparous women in New Zealand but remains lower than for older and parous women. Ensuring adolescent and nulliparous women receive upto-date information and access to long-acting reversible contraception has the potential to further reduce abortion and adolescent pregnancy rates in New Zealand.
of unintended pregnancy and its consequences [1e8]. Younger women are at greatest risk for unintended pregnancy but typically favor methods with high failure rates including oral contraceptives (9% failure rate associated with typical use) and condoms (18% failure rate) [9,10]. By contrast, LARC methods not only have very low failure rates (<1%) [10] but lack reliance on user compliance for efficacy and have long duration of action. Importantly, adolescents are willing to use long-acting methods when given appropriate information and access to these methods at no cost [11]. There is good evidence that immediate postpartum or postabortion
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initiation of LARC significantly reduces rates of rapid repeat adolescent pregnancy and abortion within 12e24 months [3,12e16]. Adolescents initiating a LARC method have up to a 35fold reduction in risk of experiencing a rapid repeat pregnancy within 2 years compared with their counterparts opting for a nonLARC method [15]. Historic concerns about links between intrauterine device (IUD) use, pelvic inflammatory disease and infertility have persisted [4,17,18] contributing to lower utilization rates among young and nulliparous women. The evidence is now clear that IUDs can safely be used by adolescents, nulliparous women and those with a history of pelvic inflammatory disease or sexually transmitted infections with no detrimental effects on future fertility [6,7,19]. Although rates of IUD expulsion may be higher among adolescents (14e19 years) than for older women, rates do not differ for nulliparous and parous women. A slightly higher rate of expulsion is expected with immediate postabortion IUD insertion [20]. However, this increased risk is balanced against significantly higher rates of uptake after immediate postabortion versus delayed insertion (because of failure to attend follow-up appointments) [21], and higher rates of method continuation by adolescents using long- versus short-acting methods (oral contraceptives or Depo-Provera) [22,23]. A number of large-scale projects have clearly demonstrated that when barriers such as cost, lack of access, and lack of provider and patient knowledge about LARC are removed, choice of long-acting contraception can be significantly increased with corresponding decreases in birth and abortion rates [11,24e26]. In the US contraceptive CHOICE project, 69% of 14e17 year olds and 61% of 18e20 year olds wanting to avoid pregnancy for at least a year opted for a LARC method when provided standardized counseling about all contraceptive methods (with emphasis on the superior effectiveness of LARC methods) and offered all methods at no cost [26]. The extent to which adolescent and nulliparous women have historically and are currently prescribed LARC methods in New Zealand is not known. The Multiload Cu375 intrauterine device (CuIUD; Swords, Dublin, Ireland) has been fully subsidized and freely available for many years in New Zealand but the Mirena levonorgestrel-releasing intrauterine system (LNG-IUS; Made in Finland for Bayer NZ Limited, Auckland, New Zealand) costs upward of USD220 (NZ $300) so is anecdotally less frequently prescribed. The two rod Jadelle levonorgestrel (LNG; Made in Finland for Bayer NZ Limited, Auckland, New Zealand)-releasing implant was subsidized by the New Zealand government in 2010 so became widely available at no or low cost, having previously been less readily available and at a cost of USD185 (NZ $250). Once subsidized, use of the LNG-implant increased greatly [27], and there is some evidence to suggest this was particularly true of younger age groups [28]. Data from a single public hospital clinic indicated that adolescent postabortion IUD use increased from 8.3% in 2007 to 22.5% in 2012 [28]. We sought to describe changes in the postabortion initiation of long-acting methods in New Zealand for the period 2007e2013 to determine whether uptake by adolescent and nulliparous women reflects international recommendations that LARCs be deemed first line contraceptive choices for these groups. Methods This retrospective analysis of nationally collected data on postabortion LARC use involved data for all abortions carried out
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in all clinics in New Zealand between 2007 and 2013. Ethical approval was granted by the University of Otago Human Ethics Committee-Health (11 June 2014, ref D14/179). Setting Abortion is provided as a core publically funded health service in New Zealand performed at one of 22 licensed facilities (including one private fee-for-service clinic). Women must be seen by a general practitioner or family planning doctor for confirmation of the pregnancy, diagnostic tests, and referral to an abortion service. Abortion is legal (up to 19 weeks) providing two certifying consultants agree that one of several grounds are metdmost commonly “danger to mental health” [29]. Data collection The registered medical practitioner performing the abortion must complete a two page form detailing the patient’s ethnicity, date of birth, pregnancy history, residency status, grounds for performing the abortion, type of procedure, complications, contraception used at conception, and since 2007 long-acting contraceptive method inserted at the time of the procedure (if any). The completed form is forwarded to the Abortion Supervisory Committee (ASC) which is appointed by Parliament, under the Contraception, Sterilisation, and Abortion Act 1977. The ASC has the responsibility of reviewing the provisions of the abortion law in New Zealand, and the operation and effect of those provisions in practice [29]. Selected data from the form are collated and analyzed for annual reporting purposes by Statistics New Zealand (StatsNZ) on behalf of the ASC. Information on intrauterine methods (IUD/IUS) inserted at the time of an abortion have been collected on the ASC form since 2007, and implant insertions since 2011, but have not previously been published. A customized data extract was requested from StatsNZ for the years 2007e2013. The data extract included collated data on IUD/ IUS (2007e2013) and implant insertions (2011e2013), as well as insertions by age band (<20, 20e24, 25e29, 30e34, 35e39, and 40þ), parity (0, 1, 2, 3þ), previous abortion (0, 1, 2, 3þ), age band by parity and ethnic group. In New Zealand, ethnicity refers to the ethnic group or groups to which an individual feels they belong and is collected via self-report using the standardized New Zealand 2001 census question [30]. Ethnic group was reported using total count, whereby individuals identifying with more than one ethnic group are included in each of those groups [31]. For confidentiality reasons, StatsNZ provided data in partially collated form rather than individual-level data. Analyses Proportions of women receiving LARC methods (total LARC, IUD/IUS, and implants) were calculated together with 95% confidence intervals for the years 2007e2013 to examine change in uptake over time. For the years 2007 and 2013, rates of LARC use were calculated and compared for selected demographic characteristics of recipients (age, ethnicity, parity, previous abortion, and parity by age). To calculate the magnitude of changes in IUD/ IUS and total LARC use over time, the proportion of LARC recipients in 2013 was divided by the proportion of recipients in 2007 for each demographic subgroup. Numbers of abortions provided and receipt of LARC methods by adolescents (ages 19 and younger), nulliparous, and parous women were collated to
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Table 3 compares postabortion LARC uptake in 2007 and 2013 for age and parity combined. This bivariate analysis showed that LARC use was lower overall among nulliparous women irrespective of age. In 2013, intrauterine methods and implants were equally popular among nulliparous women under 20 (20.4% and 19.5%, respectively), whereas intrauterine methods were more popular than implants among parous under 20 year olds (33.6% vs. 24.7%).
describe changes over time from 2007 to 2013. All reported rates of IUD/IUS and implant uptake in this article refer to insertions taking place at the time of an abortion, before discharge from the clinic. Data were not separately available for IUD and IUS insertions. Results Total postabortion LARC use in New Zealand (2007e2013)
Postabortion LARC use by adolescents and nulliparous women (2007e2013)
In total, there were 115,183 abortions performed in New Zealand between 2007 and 2013 and 38,828 LARC placements (33.7%). Table 1 presents selected demographic characteristics of women undergoing abortions in New Zealand between 2007 and 2013, together with numbers, proportions (and 95% confidence interval) of women receiving immediate postabortion IUD/IUS, implants, and total LARC. Overall number of abortions have decreased over time, as have proportions of adolescent and nulliparous women undergoing abortion. Proportions of women receiving LARC methods increased significantly each consecutive year. IUD/IUS uptake increased in all years except 2010e2011 where uptake dropped slightly coinciding with the introduction of government funded contraceptive implants.
Figure 1 depicts the numbers of adolescents undergoing abortion and receiving postabortion LARC each year, with implant and IUD/IUS usage shown as a proportion of the total number of abortions received by this age group. Numbers of abortions clearly declined during the 7-year data collection period, almost halving between 2007 and 2013. Overall, LARC use increased by five times during this period, rising from 7.9% to 42.7%. The proportions of women receiving an IUD declined in 2011 immediately after the availability of governmentsubsidized implants, then increased again in the subsequent years. Postabortion LARC use by nulliparous women (2007e2013)
Demographic characteristics of postabortion LARC recipients in 2007 and 2013
Figure 2 depicts the numbers of nulliparous and parous women (of all ages) undergoing abortions and receiving postabortion LARC each year, with implants and IUD/IUS usage shown as a proportion of the total numbers undergoing abortion. The decline in abortion numbers over time was greater for nulliparous than parous women. Proportions of women receiving LARC increased over time for both parous and nulliparous women but were still lower overall for nulliparous women in 2013 (36.9% vs. 55.5%).
Table 2 presents demographic characteristics of women receiving immediate postabortion LARC in 2007 and 2013 and the magnitude of change in proportions receiving LARC over time. In both periods, differences in LARC uptake were apparent within demographic subgroupsdproportions receiving LARC methods increased with increasing age, parity, and numbers of previous abortion. Between 2007 and 2013, the gap between receipt of a LARC method by parous and nulliparous women lessened. LARC use by parous women was 3.6 times greater than by nulliparous women in 2007 but only 1.5 times greater in 2013. Over time, LARC use increased significantly across all demographic subgroups, but the magnitude of this increase was greatest for adolescents (more than a five-fold increase in overall LARC use) and nulliparous women (four-fold increase). These univariate data showed that implants were most commonly received by adolescents, women with three or more children or past abortions, and those of New Zealand Maori or Pacific ethnicities.
Discussion Receipt of a LARC method for immediate postabortion use has been steadily increasing in New Zealand since recordkeeping began in 2007. The biggest increases observed were among adolescents (with a five-fold increase in LARC use between 2007 and 2013) and nulliparous women (four-fold increase). These results suggest that there has been a favorable shift in prescribing of postabortion LARC methods to young and
Table 1 Characteristics of women undergoing abortion in New Zealand and proportions (n, % 95% CI) receiving immediate postabortion IUD/IUS and implants between 2007 and 2013 Year
2007 2008 2009 2010 2011 2012 2013
Characteristics of women undergoing abortion in New Zealand
Receipt of immediate postabortion LARC
Total
Total LARC
Age under 20 years
Nulliparous
No previous abortion
IUD/IUS
Implant
n
n
%
n
%
n
%
n
%
95% CI
n
%
95% CI
n
%
95% CI
18,382 17,940 17,550 16,630 15,863 14,745 14,073
4,277 4,180 3,952 3,473 2,890 2,540 2,144
23.3 23.3 22.5 20.9 18.2 17.2 15.2
9,197 8,721 8,370 7,785 7,147 6,504 6,159
50.0 48.6 47.7 46.8 45.1 44.1 43.8
11,884 11,312 11,104 10,223 9,821 9,160 8,940
64.7 63.1 63.3 61.5 61.9 62.1 63.5
3,721 4,760 5,374 5,448 6,135 6,729 6,661
20.2 26.5 30.6 32.8 38.7 45.6 47.3
19.7e20.8 25.9e27.2 29.9e31.3 32.0e33.5 37.9e39.4 44.8e46.4 46.5e48.2
3,721 4,760 5,374 5,448 4,632 4,687 4,751
20.2 26.5 30.6 32.8 29.2 31.8 33.8
19.7e20.8 25.9e27.2 29.9e31.3 32.0e33.5 28.5e29.9 31.0e32.5 33.0e34.5
d d d d 1,503 2,042 1,910
d d d d 9.5 13.8 13.6
9.0e9.9 13.3e14.4 13.0e14.1
CI ¼ confidence interval; IUD ¼ intrauterine device; IUS ¼ intrauterine system; LARC ¼ long-acting reversible contraception.
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Table 2 Demographic characteristics of women receiving immediate postabortion LARC in New Zealand in 2007 and 2013, and the magnitude of change over time Patient characteristics
2007
2013
Abortions
Total LARC (IUD/IUS)a
Abortions
Total LARC
n
n
%
95% CI
n
n
%
95% CI
n
%
339 1,019 925 714 517 207
7.9 18.7 25.9 28.0 28.5 28.6
7.1e8.8 17.7e19.8 24.5e27.4 26.3e29.8 26.4e30.6 25.3e32.0
2,144 4,386 3,174 2,237 1,451 681
915 2,077 1,566 1,085 694 324
42.7 47.4 49.3 48.5 47.8 47.6
40.6e44.8 45.9e48.8 47.6e51.1 46.4e50.6 45.2e50.4 43.8e51.4
480 1,392 1,159 848 579 293
22.4 31.7 36.5 37.9 39.9 43.0
811 923 1,063 924
8.8 25.8 33.5 38.0
8.2e9.4 24.3e27.2 31.9e35.2 36.0e39.9
6,159 2,875 2,816 2,223
2,272 1,442 1,598 1,349
36.9 50.2 56.7 60.7
35.7e38.1 48.3e52.0 54.9e58.6 58.6e62.7
1,516 1,034 1,240 961
1,935 1,119 455 212
16.3 25.5 30.6 33.5
15.6e17.0 24.3e26.9 28.3e33.1 29.8e37.3
8,940 3,312 1,210 611
3,931 1,713 651 366
44.0 51.7 53.8 59.9
42.9e45.0 50.0e53.4 50.9e56.6 55.9e63.8
1,869 1,125 571 580 35 3,721
17.7 26.1 24.9 19.7 17.2 20.2
17.0e18.5 24.8e27.5 23.2e26.8 18.3e21.2 12.3e23.2 19.7e20.8
8,015 3,459 1,712 2,405 158 14,073
3,710 2,001 934 888 55 6,661
46.3 57.8 54.6 36.9 34.8 47.3
45.2e47.4 56.2e59.5 52.2e56.9 35.0e38.9 27.4e42.8 46.5e48.2
Age-band <20 years 4,277 20e24 years 5,445 25e29 years 3,574 30e34 years 2,547 35e39 years 1,814 40+ years 725 Parity 0 9,197 1 3,582 2 3,170 3+ 2,433 Previous abortion 0 11,884 1 4,380 2 1,485 3+ 633 Ethnic group NZ European 10,546 NZ Maori 4,304 Pacific 2,289 Asian 2,947 MELAA 203 Total 18,382
IUD/IUS
Magnitude of increase in % use
Implant n
%
IUD/IUS
Total LARC
435 685 407 237 115 31
20.3 15.6 12.8 10.6 7.9 4.6
2.84 1.70 1.41 1.35 1.40 1.50
5.41 2.53 1.90 1.73 1.68 1.66
24.6 36.0 44.0 43.2
756 408 358 388
12.3 14.2 12.7 17.5
2.80 1.40 1.31 1.14
4.19 1.95 1.69 1.60
2,760 1,268 466 257
30.9 38.3 38.5 42.1
1,171 445 185 109
13.1 13.4 15.3 17.8
1.90 1.50 1.26 1.26
2.70 2.03 1.76 1.79
2,721 1,281 580 751 48 4,751
33.9 37.0 33.9 31.2 30.4 33.8
989 720 354 137 7 1,910
12.3 20.8 20.7 5.7 4.4 13.6
1.92 1.42 1.36 1.58 1.77 1.67
2.62 2.21 2.19 1.87 2.02 2.34
CI ¼ confidence interval; IUD ¼ intrauterine device; IUS ¼ intrauterine system; LARC ¼ long-acting reversible contraception; MELAA ¼ Middle Eastern, Latin American, and African ethnic group; NZ ¼ New Zealand. a Total LARC use in 2007 includes only intrauterine methods, implants were not widely available.
nulliparous women in New Zealand that aligns with current international recommendations. However, uptake in these groups remains lower than for older and parous women. Higher uptake of intrauterine methods was associated with increasing age and parity in 2007, and this pattern persisted in 2013. The availability of funded (free) implants from late 2010 and high uptake of this method by younger age groups had the effect of increasing overall LARC use in New Zealand, particularly by adolescents, thus minimizing the age-related differences that were apparent in 2007.
Study limitations Strengths of the study include the nation-wide focus and inclusion of complete data (from all abortion care facilities) relating to postabortion LARC insertions in New Zealand over a 7-year period. Limitations of our study include the possibility that LARC use was underestimated because of the format of the data collection form and absence of data on implant use before 2011. The ASC form from which contraceptive data were collected includes a tick box for clinicians to indicate where an IUD or
Table 3 Immediate postabortion LARC uptake in New Zealand in 2007 and 2013 presented by parity and age Patient characteristics
Nulliparous <20 years 20e24 years 25e29 years 30e34 years 35e39 years 40+ years Parous <20 years 20e24 years 25e29 years 30e34 years 35e39 years 40+ years
2007
2013 a
Abortions
Total LARC (IUD/IUS)
Abortions
Total LARC
n
n
%
95% CI
n
n
3,709 3,252 1,361 557 242 76
203 328 157 71 41 11
5.5 10.1 11.5 12.7 16.9 14.5
4.8e6.3 9.1e11.2 9.9e13.4 10.1e15.8 12.4e22.3 7.5e24.4
1,820 2,480 1,133 484 171 71
568 2,193 2,213 1,990 1,572 649
136 691 768 643 476 196
23.9 31.5 34.7 32.3 30.3 30.2
20.5e27.7 29.6e33.5 32.7e36.7 30.3e34.4 28.0e32.6 26.7e33.9
324 1,906 2,041 1,753 1,280 610
IUD/IUS
Magnitude of increase in % use
Implant
%
95% CI
n
%
95% CI
n
%
95% CI
IUD/IUS
Total LARC
726 945 377 149 53 22
39.9 38.1 33.3 30.8 31.0 31.0
37.6e42.2 36.2e40.0 30.5e36.1 26.7e35.1 24.2e38.5 20.5e43.1
371 646 305 130 46 18
20.4 26.0 26.9 26.9 26.9 25.4
18.6e22.3 24.3e27.8 24.4e29.6 23.0e31.0 20.4e34.2 15.8e37.1
355 299 72 19 7 4
19.5 12.1 6.4 3.9 4.1 5.6
17.7e21.4 10.8e13.4 5.0e7.9 2.4e6.1 1.7e8.3 1.6e13.8
3.7 2.6 2.3 2.1 1.6 1.8
7.3 3.8 2.9 2.4 1.8 2.1
189 1,132 1,189 936 641 302
58.3 59.4 58.3 53.4 50.1 49.5
52.8e63.8 57.1e61.6 56.1e60.4 51.0e55.8 47.3e52.9 45.5e53.6
109 746 854 718 533 275
33.6 39.1 41.8 41.0 41.6 45.1
28.5e39.1 36.9e41.4 39.7e44.0 38.6e43.3 38.9e44.4 41.1e49.1
80 386 335 218 108 27
24.7 20.3 16.4 12.4 8.4 4.4
20.1e29.8 18.5e22.1 14.8e18.1 10.9e14.1 7.0e10.1 2.9e6.4
1.4 1.2 1.2 1.3 1.4 1.5
2.4 1.9 1.7 1.7 1.7 1.6
CI ¼ confidence interval; IUD ¼ intrauterine device; IUS ¼ intrauterine system; LARC ¼ long-acting reversible contraception. a Total LARC use in 2007 includes only intrauterine methods, implants were not widely available.
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Figure 1. Receipt of postabortion IUD/IUS and implants by under 20 year olds in New Zealand between 2007 and 2013 (LARC use is shown as a percentage for each year).
implant was fitted. A blank tick box would either indicate that no method was inserted or might in a small number of instances represent an omission in completing the form. Data collection did not include postabortion implant insertions until 2011 (the year following subsidization of this method). Therefore, total LARC use would have been underestimated for the year 2010 and possibly for the years prior as a small number of women may have received implants before 2010 (anecdotally this was uncommon). Data for IUD/IUS were combined so relative proportions of women choosing CuIUD and LNG-IUS could not be determined. Past research suggests that postabortion use of LNGIUS is low in New Zealand (around 6% at one large public hospital clinic) [32] due to the high device cost [33]. Individual-level data were not available for analysis, instead precollated data were provided on each of the variables described (with the exception of age and parity which was provided as a combined variable). The nature of the data prohibited multivariate analysis to assess the relative contribution of covariates (e.g., age, ethnicity, and pregnancy history) on LARC use.
Implications Reasons for the relatively lower rates of LARC uptake among young and nulliparous women in this study are not clear but likely reflect a combination of patient and provider-related factors. It could be argued that young and nulliparous women have different intentions toward future pregnancy (desiring children within the next few years) and are, therefore, reluctant to start a method prescribed for a 5-year period. Contrary to this, around two thirds of adolescents in the CHOICE study wanting to avoid pregnancy for at least a year chose a LARC method when given appropriate information and access to these methods at no cost [26]. There are no local data to draw on regarding provider attitudes or practices relating to LARC provision in New Zealand. Studies conducted elsewhere have identified barriers to LARC provision such as outdated knowledge about medical eligibility criteria for LARC and a reluctance to prescribe LARC methods to young and nulliparous women [18,34,35]. A US survey of 1,150 obstetricianegynecologists found that fewer than half (45%)
Figure 2. Receipt of postabortion IUD/IUS and implants by nulliparous and parous women (of all ages) in New Zealand between 2007 and 2013 (LARC use is shown as a percentage for each year).
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considered adolescents appropriate candidates for an IUD and nearly a quarter (22%) did not consider nulliparous women suitable candidates [35]. A New Zealand study showed that 11% of women had a second abortion within 2 years of their first and 20% within 4 years. Those aged 16e19 years had a significantly higher risk of return [36]. The trend toward increased use of LARC by younger women attending for abortion in the present study is therefore encouraging. With the exception of the widely publicized subsidization of LNG-implants in 2010, this trend appears to have occurred in the absence of regional or nation-wide strategies to promote LARC uptake that have been successfully implemented elsewhere [24e26]. The popularity of the no-cost LNG-implant may have contributed to a greater overall awareness of long-acting methods in New Zealand. Increased access to LARC methods has been cited as a contributing factor to the declining abortion rate in New Zealand [37,38]. This decline has been greatest among women aged 19 years and younger [29] and is mirrored by a decreasing adolescent pregnancy rate [39]. This study provides new information about the incidence of immediate postabortion LARC initiation in New Zealand but does not allow us to estimate the extent to which long-acting methods are routinely discussed and prescribed to young and nulliparous women in general health care settings. There are no data on general population LARC use in New Zealand. The New Zealand Family Planning Association reported that the proportion of women choosing LARC more than doubled between 2009 and 2014, with 12.3% of women who were receiving contraception opting for a LARC method in 2014 (4.8% implant, 4.5% CuIUD, and 3% LNG-IUS) [40]. Family Planning specializes in contraceptive provision, so this figure is likely to be higher than LARC prescribing in other primary health care settings in New Zealand. Overall LARC uptake by adolescents in New Zealand has improved significantly with the availability of free (funded) LNGimplants but remains lower than for older women. Further research is needed to determine whether lower uptake by young and nulliparous women reflects patient preferences or barriers to access. Ensuring there is equitable access to the most effective forms of contraception for all reproductive aged women could assist in further reducing abortion and adolescent pregnancy rates. Acknowledgments The authors thank Anne Howard, Statistics New Zealand Tatauranga Aotearoa for the extraction of customized data pertaining to postabortion contraceptive use. Funding Sources This research was funded by grants from the University of Otago and ISTAR Limited (a charitable organization involved in the supply of the medication Mifepristone to Licensed institutions in New Zealand and Australia). References [1] Russo JA, Creinin MD. Update: Contraception. OBG Management 2010;22: 16e23. [2] Teal SB, Romer SE. Awareness of long-acting reversible contraception among teens and young adults. J Adolesc Health 2013;52:S35e9. [3] Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120: 1291e7.
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[4] Russo JA, Miller E, Gold MA. Myths and misconceptions about long-acting reversible contraception (LARC). J Adolesc Health 2013;52:S14e21. [5] Hillard PJA. What is LARC? and Why does it matter for adolescents and young adults? J Adolesc Health 2013;52:S1e5. [6] American College of Obstetricians and Gynecologists. ACOG committee opinion No. 450. Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009;114: 1434e8. [7] American Academy of Pediatrics Committee on Adolescence. Contraception for adolescents. Pediatrics 2014;134:e1244e56. [8] National Institute for Health and Clinical Excellence (NICE). Long-acting reversible contraception (update). Nice Clinical Guideline 30. 2014. Available at: http:// www.nice.org.uk/guidance/cg30/evidence/full-guideline-194840605. Accessed June 9, 2015. [9] Finer LB, Zolna MR. Unintended pregnancy in the United States: Incidence and disparities, 2006. Contraception 2011;84:478e85. [10] Hatcher R, Trussell J, Nelson A, et al. Contraceptive Technology. 20th edition. Atlanta, USA: Ardent Media; 2011. [11] Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, longacting contraception and teenage pregnancy. N Engl J Med 2014;371: 1316e23. [12] Stevens-Simon C, Kelly L, Kulick R. A village would be nice but .: It takes a long-acting contraceptive to prevent repeat adolescent pregnancies. Am J Prev Med 2001;21:60e5. [13] Rose S, Lawton B. Impact of long-acting reversible contraception on return for repeat abortion. Am J Obstet Gynecol 2012;206:37.e1e6. [14] Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: Do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012;206:481.e1e7. [15] Baldwin MK, Edelman AB. The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: A review. J Adolesc Health 2013;52:S47e53. [16] Langston AM, Joslin-Roher SL, Westhoff CL. Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice. Contraception 2014;89:103e8. [17] Carr S, Espey E. Intrauterine devices and pelvic inflammatory disease among adolescents. J Adolesc Health 2013;52:S22e8. [18] Black KI, Lotke P, Lira J, et al. Global survey of healthcare practitioners’ beliefs and practices around intrauterine contraceptive method use in nulliparous women. Contraception 2013;88:650e6. [19] Sufrin C, Averbach S. Testing for sexually transmitted infections at intrauterine device Insertion: An evidence-based approach. Clin Obstet Gynecol 2014;57:682e93. [20] Madden T, McNicholas C, Zhao Q, et al. Association of age and parity with intrauterine device expulsion. Obstet Gynecol 2014;124:718e26. [21] Okusanya BO, Oduwole O, Effa EE. Immediate postabortal insertion of intrauterine devices. Cochrane Database Syst Rev 2014;7:Cd001777. [22] Rosenstock JR, Peipert JF, Madden T, et al. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol 2012;120: 1298e305. [23] Deans EI, Grimes DA. Intrauterine devices for adolescents: A systematic review. Contraception 2009;79:418e23. [24] Arrowsmith ME, Majeed A, Lee JT, et al. Impact of pay for performance on prescribing of long-acting reversible contraception in primary care: An interrupted time series study. PLoS One 2014;9:e92205. [25] Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspect Sex Reprod Health 2014;46:125e32. [26] Mestad R, Secura G, Allsworth JE, et al. Acceptance of long-acting reversible contraceptive methods by adolescent participants in the contraceptive CHOICE Project. Contraception 2011;84:493e8. [27] Medsafe (New Zealand Medicines and Medical Devices Safety Authority). Removal difficulties with Jadelle and Implanon. Prescriber Update 2013; 34:27e8. [28] Rose SB, Garrett SM. Post-abortion initiation of long-acting reversible contraception in New Zealand. J Fam Plann Reprod Health Care 2015;41: 197e204. [29] Abortion Supervisory Committee. Report of the Abortion Supervisory Committee 2014. New Zealand; Available at: http://www.justice.govt.nz/tribunals/abortionsupervisory-committee/annual-reports/asc-annual-report-2014. Accessed June 9, 2015. [30] Statistics New Zealand. Ethnicity definition. Wellington, New Zealand. 2006, Available at: http://www.stats.govt.nz/surveys_and_methods/methods/ classifications-and-standards/classification-related-stats-standards/ethnicity/ definition.aspx. Accessed June 9, 2015. [31] Didham R, Callister P. The effect of ethnic prioritisation on ethnic health analysis: A research note. N Z Med J 2012;125:58e66. [32] Rose SB, Garrett S, Stanley J. Immediate postabortion initiation of levonorgestrel implants reduces the incidence of births and abortions at 2 years and beyond. Contraception 2015;92:17e25.
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[33] Rose SB, Cooper AJ, Baker NK, et al. Attitudes towards long-acting reversible contraception among young women presenting for abortion. J Women’s Health 2011;20:1729e35. [34] Harper C, Thompson K, Waxman NJ, et al. Provision of long-acting reversible contraception at US abortion facilities and barriers to immediate postabortion insertion. Contraception 2009;80:197e8. [35] Luchowski AT, Anderson BL, Power ML, et al. Obstetrician-gynecologists and contraception: Practice and opinions about the use of IUDs in nulliparous women, adolescents and other patient populations. Contraception 2014;89:572e7. [36] Rose SB, Stanley J, Lawton BA. Time to second abortion or continued pregnancy following a first abortion: A retrospective cohort study. Hum Reprod 2014;30:214e21.
[37] Family Planning New Zealand. Pregnancy and abortion rates drop - disparity still a concern. Forum 2014; Available at: http://issuu.com/familyplanningnewzealand/ docs/forum_march_2014_issuu. Accessed June 9, 2015. [38] Abortion Supervisory Committee. Report of the abortion supervisory committee 2013. New Zealand. Available at: http://www.parliament.nz/ resource/en-nz/50DBHOH_PAP25739_1/224b90a3ac6fd5dde32f5e144a0 d0730bf4f1321. Accessed June 9, 2015. [39] Statistics New Zealand. 2013 census New Zealand births Tables. 2013. Available at: http://www.stats.govt.nz/browse_for_stats/population/births/ births-tables.aspx. Accessed June 9, 2015. [40] Family Planning New Zealand. Contraceptive statistics e Our local data. Family Planning E-News Update, March 2015.
www.jahonline.org Original article
Postabortion Initiation of Long-Acting Reversible Contraception by Adolescent and Nulliparous Women in New Zealand Sally B. Rose, Ph.D. *, and Susan M. Garrett, M.P.H. Department of Primary Health Care and General Practice, University of Otago, Wellington, Wellington South, New Zealand
Article history: Received June 10, 2015; Accepted September 26, 2015 Keywords: Adolescents; Induced abortion; Intrauterine devices; Long-acting reversible contraception (LARC); Pregnancy prevention; Subdermal implants; Unintended pregnancy
A B S T R A C T
Purpose: To describe changes in receipt of immediate postabortion long-acting reversible contraception (LARC) by adolescent and nulliparous women in New Zealand. Methods: Nationally collected data on immediate postabortion receipt of an intrauterine method (intrauterine device [IUD]/intrauterine system [IUS]) or contraceptive implant were analyzed to describe proportions and demographic characteristics of women receiving LARC between 2007 and 2013. Changes in uptake over time were presented for adolescent, nulliparous, and parous women. Results: Postabortion LARC uptake increased between 2007 and 2013, rising from 7.9% to 42.7% for adolescents and from 8.8% to 36.9% for nulliparous women. The increase was highest among nulliparous adolescents with a seven-fold increase in LARC uptake between 2007 and 2013. Adolescents had a five-fold increase and nulliparous women (of all ages) a four-fold increase. In 2013, IUD/IUS use was lowest among adolescents (22.4%) and increased with increasing age (43% by ages 40þ years), whereas implant use was highest among adolescents (20.3%) and decreased with increasing age (to 4.6% by age 40þ years). Nulliparous women had the lowest use of both IUD/IUS and implants in 2013, with 24.6% receiving an intrauterine method (compared with 43.2% for para 3þ), and 12.3% an implant (compared with 17.5% for para 3þ). Conclusions: Despite an overall trend toward increased uptake of postabortion LARC by adolescent and nulliparous women, uptake in these groups still lags behind that of parous and older women. Reasons for differential uptake need to be explored and addressed if necessary to ensure all women have equitable access to the most effective methods of contraception. Ó 2016 Society for Adolescent Health and Medicine. All rights reserved.
There has been growing international recognition of the need to promote and encourage use of long-acting reversible contraception, known as “LARC” (including intrauterine methods and subdermal implants), by young and adolescent women, to reduce rates
Conflicts of Interest: The authors report having no conflicts of interest. * Address correspondence to: Sally B. Rose, Ph.D., Department of Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South 6242, New Zealand. E-mail address: [email protected] (S.B. Rose). 1054-139X/Ó 2016 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.09.025
IMPLICATIONS AND CONTRIBUTION
Postabortion initiation of long-acting reversible contraception has increased among young and nulliparous women in New Zealand but remains lower than for older and parous women. Ensuring adolescent and nulliparous women receive upto-date information and access to long-acting reversible contraception has the potential to further reduce abortion and adolescent pregnancy rates in New Zealand.
of unintended pregnancy and its consequences [1e8]. Younger women are at greatest risk for unintended pregnancy but typically favor methods with high failure rates including oral contraceptives (9% failure rate associated with typical use) and condoms (18% failure rate) [9,10]. By contrast, LARC methods not only have very low failure rates (<1%) [10] but lack reliance on user compliance for efficacy and have long duration of action. Importantly, adolescents are willing to use long-acting methods when given appropriate information and access to these methods at no cost [11]. There is good evidence that immediate postpartum or postabortion
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initiation of LARC significantly reduces rates of rapid repeat adolescent pregnancy and abortion within 12e24 months [3,12e16]. Adolescents initiating a LARC method have up to a 35fold reduction in risk of experiencing a rapid repeat pregnancy within 2 years compared with their counterparts opting for a nonLARC method [15]. Historic concerns about links between intrauterine device (IUD) use, pelvic inflammatory disease and infertility have persisted [4,17,18] contributing to lower utilization rates among young and nulliparous women. The evidence is now clear that IUDs can safely be used by adolescents, nulliparous women and those with a history of pelvic inflammatory disease or sexually transmitted infections with no detrimental effects on future fertility [6,7,19]. Although rates of IUD expulsion may be higher among adolescents (14e19 years) than for older women, rates do not differ for nulliparous and parous women. A slightly higher rate of expulsion is expected with immediate postabortion IUD insertion [20]. However, this increased risk is balanced against significantly higher rates of uptake after immediate postabortion versus delayed insertion (because of failure to attend follow-up appointments) [21], and higher rates of method continuation by adolescents using long- versus short-acting methods (oral contraceptives or Depo-Provera) [22,23]. A number of large-scale projects have clearly demonstrated that when barriers such as cost, lack of access, and lack of provider and patient knowledge about LARC are removed, choice of long-acting contraception can be significantly increased with corresponding decreases in birth and abortion rates [11,24e26]. In the US contraceptive CHOICE project, 69% of 14e17 year olds and 61% of 18e20 year olds wanting to avoid pregnancy for at least a year opted for a LARC method when provided standardized counseling about all contraceptive methods (with emphasis on the superior effectiveness of LARC methods) and offered all methods at no cost [26]. The extent to which adolescent and nulliparous women have historically and are currently prescribed LARC methods in New Zealand is not known. The Multiload Cu375 intrauterine device (CuIUD; Swords, Dublin, Ireland) has been fully subsidized and freely available for many years in New Zealand but the Mirena levonorgestrel-releasing intrauterine system (LNG-IUS; Made in Finland for Bayer NZ Limited, Auckland, New Zealand) costs upward of USD220 (NZ $300) so is anecdotally less frequently prescribed. The two rod Jadelle levonorgestrel (LNG; Made in Finland for Bayer NZ Limited, Auckland, New Zealand)-releasing implant was subsidized by the New Zealand government in 2010 so became widely available at no or low cost, having previously been less readily available and at a cost of USD185 (NZ $250). Once subsidized, use of the LNG-implant increased greatly [27], and there is some evidence to suggest this was particularly true of younger age groups [28]. Data from a single public hospital clinic indicated that adolescent postabortion IUD use increased from 8.3% in 2007 to 22.5% in 2012 [28]. We sought to describe changes in the postabortion initiation of long-acting methods in New Zealand for the period 2007e2013 to determine whether uptake by adolescent and nulliparous women reflects international recommendations that LARCs be deemed first line contraceptive choices for these groups. Methods This retrospective analysis of nationally collected data on postabortion LARC use involved data for all abortions carried out
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in all clinics in New Zealand between 2007 and 2013. Ethical approval was granted by the University of Otago Human Ethics Committee-Health (11 June 2014, ref D14/179). Setting Abortion is provided as a core publically funded health service in New Zealand performed at one of 22 licensed facilities (including one private fee-for-service clinic). Women must be seen by a general practitioner or family planning doctor for confirmation of the pregnancy, diagnostic tests, and referral to an abortion service. Abortion is legal (up to 19 weeks) providing two certifying consultants agree that one of several grounds are metdmost commonly “danger to mental health” [29]. Data collection The registered medical practitioner performing the abortion must complete a two page form detailing the patient’s ethnicity, date of birth, pregnancy history, residency status, grounds for performing the abortion, type of procedure, complications, contraception used at conception, and since 2007 long-acting contraceptive method inserted at the time of the procedure (if any). The completed form is forwarded to the Abortion Supervisory Committee (ASC) which is appointed by Parliament, under the Contraception, Sterilisation, and Abortion Act 1977. The ASC has the responsibility of reviewing the provisions of the abortion law in New Zealand, and the operation and effect of those provisions in practice [29]. Selected data from the form are collated and analyzed for annual reporting purposes by Statistics New Zealand (StatsNZ) on behalf of the ASC. Information on intrauterine methods (IUD/IUS) inserted at the time of an abortion have been collected on the ASC form since 2007, and implant insertions since 2011, but have not previously been published. A customized data extract was requested from StatsNZ for the years 2007e2013. The data extract included collated data on IUD/ IUS (2007e2013) and implant insertions (2011e2013), as well as insertions by age band (<20, 20e24, 25e29, 30e34, 35e39, and 40þ), parity (0, 1, 2, 3þ), previous abortion (0, 1, 2, 3þ), age band by parity and ethnic group. In New Zealand, ethnicity refers to the ethnic group or groups to which an individual feels they belong and is collected via self-report using the standardized New Zealand 2001 census question [30]. Ethnic group was reported using total count, whereby individuals identifying with more than one ethnic group are included in each of those groups [31]. For confidentiality reasons, StatsNZ provided data in partially collated form rather than individual-level data. Analyses Proportions of women receiving LARC methods (total LARC, IUD/IUS, and implants) were calculated together with 95% confidence intervals for the years 2007e2013 to examine change in uptake over time. For the years 2007 and 2013, rates of LARC use were calculated and compared for selected demographic characteristics of recipients (age, ethnicity, parity, previous abortion, and parity by age). To calculate the magnitude of changes in IUD/ IUS and total LARC use over time, the proportion of LARC recipients in 2013 was divided by the proportion of recipients in 2007 for each demographic subgroup. Numbers of abortions provided and receipt of LARC methods by adolescents (ages 19 and younger), nulliparous, and parous women were collated to
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Table 3 compares postabortion LARC uptake in 2007 and 2013 for age and parity combined. This bivariate analysis showed that LARC use was lower overall among nulliparous women irrespective of age. In 2013, intrauterine methods and implants were equally popular among nulliparous women under 20 (20.4% and 19.5%, respectively), whereas intrauterine methods were more popular than implants among parous under 20 year olds (33.6% vs. 24.7%).
describe changes over time from 2007 to 2013. All reported rates of IUD/IUS and implant uptake in this article refer to insertions taking place at the time of an abortion, before discharge from the clinic. Data were not separately available for IUD and IUS insertions. Results Total postabortion LARC use in New Zealand (2007e2013)
Postabortion LARC use by adolescents and nulliparous women (2007e2013)
In total, there were 115,183 abortions performed in New Zealand between 2007 and 2013 and 38,828 LARC placements (33.7%). Table 1 presents selected demographic characteristics of women undergoing abortions in New Zealand between 2007 and 2013, together with numbers, proportions (and 95% confidence interval) of women receiving immediate postabortion IUD/IUS, implants, and total LARC. Overall number of abortions have decreased over time, as have proportions of adolescent and nulliparous women undergoing abortion. Proportions of women receiving LARC methods increased significantly each consecutive year. IUD/IUS uptake increased in all years except 2010e2011 where uptake dropped slightly coinciding with the introduction of government funded contraceptive implants.
Figure 1 depicts the numbers of adolescents undergoing abortion and receiving postabortion LARC each year, with implant and IUD/IUS usage shown as a proportion of the total number of abortions received by this age group. Numbers of abortions clearly declined during the 7-year data collection period, almost halving between 2007 and 2013. Overall, LARC use increased by five times during this period, rising from 7.9% to 42.7%. The proportions of women receiving an IUD declined in 2011 immediately after the availability of governmentsubsidized implants, then increased again in the subsequent years. Postabortion LARC use by nulliparous women (2007e2013)
Demographic characteristics of postabortion LARC recipients in 2007 and 2013
Figure 2 depicts the numbers of nulliparous and parous women (of all ages) undergoing abortions and receiving postabortion LARC each year, with implants and IUD/IUS usage shown as a proportion of the total numbers undergoing abortion. The decline in abortion numbers over time was greater for nulliparous than parous women. Proportions of women receiving LARC increased over time for both parous and nulliparous women but were still lower overall for nulliparous women in 2013 (36.9% vs. 55.5%).
Table 2 presents demographic characteristics of women receiving immediate postabortion LARC in 2007 and 2013 and the magnitude of change in proportions receiving LARC over time. In both periods, differences in LARC uptake were apparent within demographic subgroupsdproportions receiving LARC methods increased with increasing age, parity, and numbers of previous abortion. Between 2007 and 2013, the gap between receipt of a LARC method by parous and nulliparous women lessened. LARC use by parous women was 3.6 times greater than by nulliparous women in 2007 but only 1.5 times greater in 2013. Over time, LARC use increased significantly across all demographic subgroups, but the magnitude of this increase was greatest for adolescents (more than a five-fold increase in overall LARC use) and nulliparous women (four-fold increase). These univariate data showed that implants were most commonly received by adolescents, women with three or more children or past abortions, and those of New Zealand Maori or Pacific ethnicities.
Discussion Receipt of a LARC method for immediate postabortion use has been steadily increasing in New Zealand since recordkeeping began in 2007. The biggest increases observed were among adolescents (with a five-fold increase in LARC use between 2007 and 2013) and nulliparous women (four-fold increase). These results suggest that there has been a favorable shift in prescribing of postabortion LARC methods to young and
Table 1 Characteristics of women undergoing abortion in New Zealand and proportions (n, % 95% CI) receiving immediate postabortion IUD/IUS and implants between 2007 and 2013 Year
2007 2008 2009 2010 2011 2012 2013
Characteristics of women undergoing abortion in New Zealand
Receipt of immediate postabortion LARC
Total
Total LARC
Age under 20 years
Nulliparous
No previous abortion
IUD/IUS
Implant
n
n
%
n
%
n
%
n
%
95% CI
n
%
95% CI
n
%
95% CI
18,382 17,940 17,550 16,630 15,863 14,745 14,073
4,277 4,180 3,952 3,473 2,890 2,540 2,144
23.3 23.3 22.5 20.9 18.2 17.2 15.2
9,197 8,721 8,370 7,785 7,147 6,504 6,159
50.0 48.6 47.7 46.8 45.1 44.1 43.8
11,884 11,312 11,104 10,223 9,821 9,160 8,940
64.7 63.1 63.3 61.5 61.9 62.1 63.5
3,721 4,760 5,374 5,448 6,135 6,729 6,661
20.2 26.5 30.6 32.8 38.7 45.6 47.3
19.7e20.8 25.9e27.2 29.9e31.3 32.0e33.5 37.9e39.4 44.8e46.4 46.5e48.2
3,721 4,760 5,374 5,448 4,632 4,687 4,751
20.2 26.5 30.6 32.8 29.2 31.8 33.8
19.7e20.8 25.9e27.2 29.9e31.3 32.0e33.5 28.5e29.9 31.0e32.5 33.0e34.5
d d d d 1,503 2,042 1,910
d d d d 9.5 13.8 13.6
9.0e9.9 13.3e14.4 13.0e14.1
CI ¼ confidence interval; IUD ¼ intrauterine device; IUS ¼ intrauterine system; LARC ¼ long-acting reversible contraception.
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Table 2 Demographic characteristics of women receiving immediate postabortion LARC in New Zealand in 2007 and 2013, and the magnitude of change over time Patient characteristics
2007
2013
Abortions
Total LARC (IUD/IUS)a
Abortions
Total LARC
n
n
%
95% CI
n
n
%
95% CI
n
%
339 1,019 925 714 517 207
7.9 18.7 25.9 28.0 28.5 28.6
7.1e8.8 17.7e19.8 24.5e27.4 26.3e29.8 26.4e30.6 25.3e32.0
2,144 4,386 3,174 2,237 1,451 681
915 2,077 1,566 1,085 694 324
42.7 47.4 49.3 48.5 47.8 47.6
40.6e44.8 45.9e48.8 47.6e51.1 46.4e50.6 45.2e50.4 43.8e51.4
480 1,392 1,159 848 579 293
22.4 31.7 36.5 37.9 39.9 43.0
811 923 1,063 924
8.8 25.8 33.5 38.0
8.2e9.4 24.3e27.2 31.9e35.2 36.0e39.9
6,159 2,875 2,816 2,223
2,272 1,442 1,598 1,349
36.9 50.2 56.7 60.7
35.7e38.1 48.3e52.0 54.9e58.6 58.6e62.7
1,516 1,034 1,240 961
1,935 1,119 455 212
16.3 25.5 30.6 33.5
15.6e17.0 24.3e26.9 28.3e33.1 29.8e37.3
8,940 3,312 1,210 611
3,931 1,713 651 366
44.0 51.7 53.8 59.9
42.9e45.0 50.0e53.4 50.9e56.6 55.9e63.8
1,869 1,125 571 580 35 3,721
17.7 26.1 24.9 19.7 17.2 20.2
17.0e18.5 24.8e27.5 23.2e26.8 18.3e21.2 12.3e23.2 19.7e20.8
8,015 3,459 1,712 2,405 158 14,073
3,710 2,001 934 888 55 6,661
46.3 57.8 54.6 36.9 34.8 47.3
45.2e47.4 56.2e59.5 52.2e56.9 35.0e38.9 27.4e42.8 46.5e48.2
Age-band <20 years 4,277 20e24 years 5,445 25e29 years 3,574 30e34 years 2,547 35e39 years 1,814 40+ years 725 Parity 0 9,197 1 3,582 2 3,170 3+ 2,433 Previous abortion 0 11,884 1 4,380 2 1,485 3+ 633 Ethnic group NZ European 10,546 NZ Maori 4,304 Pacific 2,289 Asian 2,947 MELAA 203 Total 18,382
IUD/IUS
Magnitude of increase in % use
Implant n
%
IUD/IUS
Total LARC
435 685 407 237 115 31
20.3 15.6 12.8 10.6 7.9 4.6
2.84 1.70 1.41 1.35 1.40 1.50
5.41 2.53 1.90 1.73 1.68 1.66
24.6 36.0 44.0 43.2
756 408 358 388
12.3 14.2 12.7 17.5
2.80 1.40 1.31 1.14
4.19 1.95 1.69 1.60
2,760 1,268 466 257
30.9 38.3 38.5 42.1
1,171 445 185 109
13.1 13.4 15.3 17.8
1.90 1.50 1.26 1.26
2.70 2.03 1.76 1.79
2,721 1,281 580 751 48 4,751
33.9 37.0 33.9 31.2 30.4 33.8
989 720 354 137 7 1,910
12.3 20.8 20.7 5.7 4.4 13.6
1.92 1.42 1.36 1.58 1.77 1.67
2.62 2.21 2.19 1.87 2.02 2.34
CI ¼ confidence interval; IUD ¼ intrauterine device; IUS ¼ intrauterine system; LARC ¼ long-acting reversible contraception; MELAA ¼ Middle Eastern, Latin American, and African ethnic group; NZ ¼ New Zealand. a Total LARC use in 2007 includes only intrauterine methods, implants were not widely available.
nulliparous women in New Zealand that aligns with current international recommendations. However, uptake in these groups remains lower than for older and parous women. Higher uptake of intrauterine methods was associated with increasing age and parity in 2007, and this pattern persisted in 2013. The availability of funded (free) implants from late 2010 and high uptake of this method by younger age groups had the effect of increasing overall LARC use in New Zealand, particularly by adolescents, thus minimizing the age-related differences that were apparent in 2007.
Study limitations Strengths of the study include the nation-wide focus and inclusion of complete data (from all abortion care facilities) relating to postabortion LARC insertions in New Zealand over a 7-year period. Limitations of our study include the possibility that LARC use was underestimated because of the format of the data collection form and absence of data on implant use before 2011. The ASC form from which contraceptive data were collected includes a tick box for clinicians to indicate where an IUD or
Table 3 Immediate postabortion LARC uptake in New Zealand in 2007 and 2013 presented by parity and age Patient characteristics
Nulliparous <20 years 20e24 years 25e29 years 30e34 years 35e39 years 40+ years Parous <20 years 20e24 years 25e29 years 30e34 years 35e39 years 40+ years
2007
2013 a
Abortions
Total LARC (IUD/IUS)
Abortions
Total LARC
n
n
%
95% CI
n
n
3,709 3,252 1,361 557 242 76
203 328 157 71 41 11
5.5 10.1 11.5 12.7 16.9 14.5
4.8e6.3 9.1e11.2 9.9e13.4 10.1e15.8 12.4e22.3 7.5e24.4
1,820 2,480 1,133 484 171 71
568 2,193 2,213 1,990 1,572 649
136 691 768 643 476 196
23.9 31.5 34.7 32.3 30.3 30.2
20.5e27.7 29.6e33.5 32.7e36.7 30.3e34.4 28.0e32.6 26.7e33.9
324 1,906 2,041 1,753 1,280 610
IUD/IUS
Magnitude of increase in % use
Implant
%
95% CI
n
%
95% CI
n
%
95% CI
IUD/IUS
Total LARC
726 945 377 149 53 22
39.9 38.1 33.3 30.8 31.0 31.0
37.6e42.2 36.2e40.0 30.5e36.1 26.7e35.1 24.2e38.5 20.5e43.1
371 646 305 130 46 18
20.4 26.0 26.9 26.9 26.9 25.4
18.6e22.3 24.3e27.8 24.4e29.6 23.0e31.0 20.4e34.2 15.8e37.1
355 299 72 19 7 4
19.5 12.1 6.4 3.9 4.1 5.6
17.7e21.4 10.8e13.4 5.0e7.9 2.4e6.1 1.7e8.3 1.6e13.8
3.7 2.6 2.3 2.1 1.6 1.8
7.3 3.8 2.9 2.4 1.8 2.1
189 1,132 1,189 936 641 302
58.3 59.4 58.3 53.4 50.1 49.5
52.8e63.8 57.1e61.6 56.1e60.4 51.0e55.8 47.3e52.9 45.5e53.6
109 746 854 718 533 275
33.6 39.1 41.8 41.0 41.6 45.1
28.5e39.1 36.9e41.4 39.7e44.0 38.6e43.3 38.9e44.4 41.1e49.1
80 386 335 218 108 27
24.7 20.3 16.4 12.4 8.4 4.4
20.1e29.8 18.5e22.1 14.8e18.1 10.9e14.1 7.0e10.1 2.9e6.4
1.4 1.2 1.2 1.3 1.4 1.5
2.4 1.9 1.7 1.7 1.7 1.6
CI ¼ confidence interval; IUD ¼ intrauterine device; IUS ¼ intrauterine system; LARC ¼ long-acting reversible contraception. a Total LARC use in 2007 includes only intrauterine methods, implants were not widely available.
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Figure 1. Receipt of postabortion IUD/IUS and implants by under 20 year olds in New Zealand between 2007 and 2013 (LARC use is shown as a percentage for each year).
implant was fitted. A blank tick box would either indicate that no method was inserted or might in a small number of instances represent an omission in completing the form. Data collection did not include postabortion implant insertions until 2011 (the year following subsidization of this method). Therefore, total LARC use would have been underestimated for the year 2010 and possibly for the years prior as a small number of women may have received implants before 2010 (anecdotally this was uncommon). Data for IUD/IUS were combined so relative proportions of women choosing CuIUD and LNG-IUS could not be determined. Past research suggests that postabortion use of LNGIUS is low in New Zealand (around 6% at one large public hospital clinic) [32] due to the high device cost [33]. Individual-level data were not available for analysis, instead precollated data were provided on each of the variables described (with the exception of age and parity which was provided as a combined variable). The nature of the data prohibited multivariate analysis to assess the relative contribution of covariates (e.g., age, ethnicity, and pregnancy history) on LARC use.
Implications Reasons for the relatively lower rates of LARC uptake among young and nulliparous women in this study are not clear but likely reflect a combination of patient and provider-related factors. It could be argued that young and nulliparous women have different intentions toward future pregnancy (desiring children within the next few years) and are, therefore, reluctant to start a method prescribed for a 5-year period. Contrary to this, around two thirds of adolescents in the CHOICE study wanting to avoid pregnancy for at least a year chose a LARC method when given appropriate information and access to these methods at no cost [26]. There are no local data to draw on regarding provider attitudes or practices relating to LARC provision in New Zealand. Studies conducted elsewhere have identified barriers to LARC provision such as outdated knowledge about medical eligibility criteria for LARC and a reluctance to prescribe LARC methods to young and nulliparous women [18,34,35]. A US survey of 1,150 obstetricianegynecologists found that fewer than half (45%)
Figure 2. Receipt of postabortion IUD/IUS and implants by nulliparous and parous women (of all ages) in New Zealand between 2007 and 2013 (LARC use is shown as a percentage for each year).
S.B. Rose and S.M. Garrett / Journal of Adolescent Health 58 (2016) 160e166
considered adolescents appropriate candidates for an IUD and nearly a quarter (22%) did not consider nulliparous women suitable candidates [35]. A New Zealand study showed that 11% of women had a second abortion within 2 years of their first and 20% within 4 years. Those aged 16e19 years had a significantly higher risk of return [36]. The trend toward increased use of LARC by younger women attending for abortion in the present study is therefore encouraging. With the exception of the widely publicized subsidization of LNG-implants in 2010, this trend appears to have occurred in the absence of regional or nation-wide strategies to promote LARC uptake that have been successfully implemented elsewhere [24e26]. The popularity of the no-cost LNG-implant may have contributed to a greater overall awareness of long-acting methods in New Zealand. Increased access to LARC methods has been cited as a contributing factor to the declining abortion rate in New Zealand [37,38]. This decline has been greatest among women aged 19 years and younger [29] and is mirrored by a decreasing adolescent pregnancy rate [39]. This study provides new information about the incidence of immediate postabortion LARC initiation in New Zealand but does not allow us to estimate the extent to which long-acting methods are routinely discussed and prescribed to young and nulliparous women in general health care settings. There are no data on general population LARC use in New Zealand. The New Zealand Family Planning Association reported that the proportion of women choosing LARC more than doubled between 2009 and 2014, with 12.3% of women who were receiving contraception opting for a LARC method in 2014 (4.8% implant, 4.5% CuIUD, and 3% LNG-IUS) [40]. Family Planning specializes in contraceptive provision, so this figure is likely to be higher than LARC prescribing in other primary health care settings in New Zealand. Overall LARC uptake by adolescents in New Zealand has improved significantly with the availability of free (funded) LNGimplants but remains lower than for older women. Further research is needed to determine whether lower uptake by young and nulliparous women reflects patient preferences or barriers to access. Ensuring there is equitable access to the most effective forms of contraception for all reproductive aged women could assist in further reducing abortion and adolescent pregnancy rates. Acknowledgments The authors thank Anne Howard, Statistics New Zealand Tatauranga Aotearoa for the extraction of customized data pertaining to postabortion contraceptive use. Funding Sources This research was funded by grants from the University of Otago and ISTAR Limited (a charitable organization involved in the supply of the medication Mifepristone to Licensed institutions in New Zealand and Australia). References [1] Russo JA, Creinin MD. Update: Contraception. OBG Management 2010;22: 16e23. [2] Teal SB, Romer SE. Awareness of long-acting reversible contraception among teens and young adults. J Adolesc Health 2013;52:S35e9. [3] Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120: 1291e7.
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