Chapter 3. Recommendations and best practice statements across the continuum of abortion care

Post-abortion contraception: Recommendations 41-47 (3.5.4)

3.5.4 Post-abortion contraception

Following an induced or spontaneous abortion, ovulation can return as early as 8–10 days later and usually within one month, and thus contraception initiation as soon as possible within the first month is important for women who desire to delay or prevent a future pregnancy (153, 154). All contraceptive options may be considered after an abortion. The client’s wishes are paramount; if the individual wishes to start or resume a contraceptive method, then all contraceptive options may be considered at any point in care and some methods can be initiated at the time of the abortion (155). States are required to ensure there is access to a wide range of modern, safe and affordable contraceptive methods (36 [para. 8], 49 [para. 33]). Criteria laid out in the WHO publications Ensuring human rights in the provision of contraceptive information and services and Medical eligibility criteria for contraceptive use should be adhered to (156, 157). In-depth consideration of all methods of post-abortion contraception is outside the scope of this guideline.

This section addresses the timing of contraception and the health workers who can provide certain methods. The role of self-management approaches with post-abortion contraception will be discussed further in section 3.6.3.

CLINICAL SERVICES Recommendation 41: Medical eligibility criteria for post-abortion contraception

The following contraceptive methods may be started immediately (MEC Category 1 – no restrictions) after a surgical or medical abortion (first and second trimester, and also after a septic abortion): combined hormonal contraceptives (CHCs), progesterone-only contraceptives (POCs) and barrier methods (condoms, spermicide, diaphragm, cap – note: The diaphragm and cap are unsuitable until 6 weeks after second-trimester abortion)

Intrauterine devices (IUDs) may be started immediately after a first-trimester surgical or medical abortion (MEC Category 1 – no restrictions) or after second-trimester abortion (MEC Category 2 – the advantages generally outweigh the risks), but should not be started immediately after septic abortion (MEC Category 4 – insertion of an IUD may substantially worsen the condition).

Fertility-awareness-based (FAB) methods: Symptom-based methods should only be started after abortion with “caution” (special counselling may be needed to ensure correct use of the method in this circumstance) and the use of calendar-based methods should be delayed (until the condition is evaluated; alternative temporary methods of contraception should be offered).

Notes:

  • Refer to the box below for an explanation of the MEC categories.
  • CHCs include combined oral contraceptives (COCs), the contraceptive patch (P), the combined vaginal ring (CVR) and combined injectable contraceptives (CICs).
  • POCs include progesterone-only pills (POPs), levonorgestrel (LNG) or etonogestrel (ETG) implants, depot medroxyprogesterone acetate (DMPA) injectables, and norethisterone enanthate (NET-EN) injectables.
  • IUDs include copper-bearing IUDs (Cu-IUD) and levonorgestrel-releasing IUDs (LNG-IUD).
  • Symptoms-based methods include the cervical mucus method (also called the ovulation method) and the TwoDay Method, which are both based on the evaluation of cervical mucus, and the sympto-thermal method, which is a double-check method based on evaluation of cervical mucus to determine the first fertile day and evaluation of cervical mucus and temperature to determine the last fertile day.
  • Calendar-based methods include the Calendar Rhythm Method (avoiding unprotected intercourse from the first to the last estimated fertile days, after recording the length of several menstrual cycles as a basis for calculation) and the Standard Days Method (avoiding unprotected intercourse on cycle days 8–19, for people whose cycles are usually 26–32 days long).

Source: Recommendations brought in from WHO’s Medical eligibility criteria for contraceptive use (2015) (157). The wording has been revised to narrative format from the tables in the source guideline.

Key to MEC categories for contraceptive eligibility

Category 1 – A condition for which there is no restriction for the use of the contraceptive method

Category 2 – A condition where the advantages of using the method generally outweigh the theoretical or proven risks

Category 3 – A condition where the theoretical or proven risks usually outweigh the advantages of using the method

Category 4 – A condition which represents an unacceptable health risk if the contraceptive method is used.

CLINICAL SERVICES Recommendation 42: Timing of contraception and surgical abortion

For individuals undergoing surgical abortion and wishing to use contraception: Recommend the option of initiating the contraception at the time of surgical abortion.

Remark:

  • The quality of evidence based on randomized controlled trials was very low.

Source: Part of Recommendation 13 carried forward from WHO (2012) (19). Only the component of the existing recommendation that is relevant to surgical abortion has been retained, with the word “recommend” used to clarify that it is a strong recommendation and revisions made to include all contraceptive methods).

CLINICAL SERVICES Recommendation 43: Timing of contraception and medical abortion

For individuals undergoing medical abortion with the combination mifepristone and misoprostol regimen or with misoprostol alone:

  1. For those who choose to use hormonal contraception (pills, patch, ring, implant or injections): Suggest that they be given the option of starting hormonal contraception immediately after the first pill of the medical abortion regimen.
  2. For those who choose to have an IUD inserted: Suggest IUD placement at the time that success of the abortion procedure is determined.

Remark (for Recommendations 43a and b):

  • This recommendation applies to the combination mifepristone plus misoprostol regimen and the use of misoprostol alone. The letrozole plus misoprostol combination regimen is not mentioned here because the included studies informing these recommendations did not assess this regimen.

Remarks (for Recommendation 43a only):

  • Immediate initiation of intramuscular depot medroxyprogesterone acetate (DMPA) is associated with a slight decrease in the effectiveness of medical abortion regimens (158). However, immediate initiation of DMPA should still be offered as an available contraceptive method after an abortion.
  • Indirect evidence was used as a basis for decision-making on initiation of hormonal contraception as an option for individuals undergoing medical abortion with misoprostol alone.
  • No data were available on the use of combined hormonal contraception (pills or injections) by those undergoing medical abortion.
  • Individuals who choose to initiate the contraceptive ring should be instructed to check for expulsion of the ring in the event of heavy bleeding during the medical abortion process.

Source: Recommendations 4a and 4b carried forward from WHO (2018) (120).

SERVICE DELIVERY Recommendation 44: Insertion and removal of intrauterine devices (IUDs)

Type of health worker Recommendation Rationale
Traditional and complementary medicine professionals Suggest   Condition: In contexts with established health system mechanisms for the participation of these professionals in other tasks related to maternal and reproductive health. Their basic training generally covers the relevant skills needed for this task. This option is probably feasible and may promote continuity of care for women and increase access in regions where these professionals constitute a significant proportion of the health workforce.
Auxiliary nurses Suggest

Condition: In the context of rigorous research.

The recommendation comes originally from the OptimizeMNH guideline (138).
ANMs Nurses

Midwives

Recommend The recommendation comes originally from the OptimizeMNH guideline (138).
Associate/advanced associate clinicians

Generalist medical practitioners

Specialist medical practitioners

Recommend The recommendation comes originally from the OptimizeMNH guideline (138), where this task was considered to be within their typical scope of practice.a
Source: Recommendation carried forward from WHO (2015) (23).

a For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

SERVICE DELIVERY Recommendation 45: Insertion and removal of implants

Type of health worker Recommendation Rationale
Community health workers Suggest

Condition: In the context of rigorous research.

The recommendation comes originally from the OptimizeMNH guideline (138).
Traditional and complementary medicine professionals Suggest

Condition: In contexts with established health system mechanisms for the participation of these professionals in other tasks related to maternal and reproductive health and where training in implant removal is given along with training in insertion.

Although insufficient direct evidence was found for the safety and effectiveness of this option, their basic training covers the relevant skills needed for this task. This option may promote continuity of care for women.
Auxiliary nurses/ANMs Suggest

Condition: In the context of targeted monitoring and evaluation.

The recommendation comes originally from the OptimizeMNH guideline (138).
Nurses

Midwives

Recommend The recommendation comes originally from the OptimizeMNH guideline (138).
Associate/advanced associate clinicians

Generalist medical practitioners

Specialist medical practitioners

Recommend The recommendation comes originally from the OptimizeMNH guideline (138), where this task was considered to be within their typical scope of practice.a
Source: Recommendation carried forward from WHO (2015) (23).

a For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

In a health-care facility or other setting with sterile conditions.

Implementation consideration

The removal of implants can require greater skills than insertion; any health worker trained to independently insert implants should also be well trained on implant removal (23).

SERVICE DELIVERY Recommendation 46: Administration of injectable contraceptives (initiation and continuation)

Community health workers (CHWs) Recommend Limited evidence was found for the safety, effectiveness and feasibility of this option. The skills and knowledge for this task (according to the competency framework) align with the competencies for CHWs.a This option is feasible and acceptable given that CHWs provide other components of abortion care. In addition, this option has the potential to increase women’s choices and reduce inequities in contraceptive access.
Pharmacy workers Recommend Although no evidence was found for the safety, effectiveness, acceptability or feasibility of this option, administering injections is within their typical scope of practice b and the additional training needs for this task would be minimal. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a This option has the potential to increase women’s choices and reduce inequities in contraceptive access.
Pharmacists Recommend Although the available evidence for the safety and effectiveness of this option is of very low certainty, administering injections is within their typical scope of practice b and the additional training needs for this task would be minimal. This option has the potential to increase women’s choices and reduce inequities in contraceptive access.
Traditional and complementary medicine professionals Recommend Their basic training covers the relevant skills needed for this task, hence additional training needs would be minimal. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a This option is feasible and acceptable given that these professionals provide similar services in the existing health system, and thus it may promote continuity of care for women.
Auxiliary nurses/ANMs Recommend The recommendation comes originally from the OptimizeMNH guideline(138).
Nurses

Midwives

Associate/advanced associate clinicians

Generalist medical practitioners

Specialist medical practitioners

Recommend The recommendation comes originally from the OptimizeMNH guideline (138), where this task was considered to be within their typical scope of practice.b
Individual/self
Pregnant woman, girl or other pregnant person Recommend Refer to Recommendation 51 in section 3.6.2 for the rationale, remark, implementation considerations and further information about self-management approaches.
Source: Recommendation updated from WHO (2015) (23).

Note on updating of the recommendation: This was an existing recommendation for which evidence relating to traditional and complementary medicine professionals, pharmacy workers, community health workers and individuals/self (self-administration) was reviewed using GRADE methodology. After review, recommendations for all three of those health worker categories were upgraded from “suggest” to “recommend”. The recommendations for the other health worker categories were not reviewed and remain unchanged, such that all health worker categories and the individual/self now have a strong recommendation for this task. A summary of the evidence is presented in Supplementary material 3, EtD framework on Delivery of injectable contraceptives.

a For this and all health worker recommendations, given the limited evidence for many of the health worker–task combinations, the discussions of the expert panel focused on the competency framework in WHO’s 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women’s values and preferences.

b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

No requirement for location (on-site vs off-site).

Implementation considerations
  • The administration of an injectable contraceptive involves using a syringe and may be intramuscular or subcutaneous.
  • It is important to have adequate mechanisms for the disposal of used sharps, syringes and needles.
  • It is important to ensure a consistent supply of the injectables, especially at the point of sale for women to obtain and use on their own.

The investment in initial training is a consideration where the health worker is not already certified to provide injections. It is important to have mechanisms to link the health worker to the health system and ensure a referral pathway.

SERVICE DELIVERY Recommendation 47: Tubal ligation

Type of health worker Recommendation Rationale
Nurses Suggest   Condition: In the context of rigorous research. The recommendation comes originally from the OptimizeMNH guideline (138).
Midwives Suggest

Condition: In the context of rigorous research.

The recommendation comes originally from the OptimizeMNH guideline (138).
Associate/advanced associate clinicians

Generalist medical practitioners

Specialist medical practitioners

Recommend The recommendation comes originally from the OptimizeMNH guideline (138), where this task was considered to be within their typical scope of practice.a
Source: Recommendation carried forward from WHO (2015) (23). The recommendations will be reviewed for the next update of the WHO guidance on optimizing health worker roles (138).

a For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO POST-ABORTION CONTRACEPTION

  • Contraception should be provided only where the person has given free and informed consent to receive it.
  • States must ensure availability of the full range of contraceptive options, including a wide range of modern, safe and affordable methods.
  • States must ensure adequate access to essential medicines, including contraceptives, in an affordable and non-discriminatory manner.
  • Everyone has a right to evidence-based information on all aspects of SRH, including contraceptives.
  • Contraceptive information and services must be provided without discrimination, coercion or violence.
  • Everyone has a right to privacy and confidentiality in the receipt of contraceptive information and services.
  • Post-abortion contraceptive information and services should be available and accessible to adolescents without requiring parental or guardian authorization.
  • States must guarantee that practices of conscientious refusal/objection do not infringe on the right to contraceptive information and services.

For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.