Methods of contraception to be used after abortion are described

2. Abortions account for approximately 8% of maternal
mortality in India.
Majority of these women do not want to become pregnant again in
the in near future.
The unmet need for family planning in the post abortion
period is very high
which if bridged,
can save many mothers from
morbidity and mortality related to abortions
and ease off burden from the health system

3. WHO also recommends spacing of at least 6
months after abortion.
When a woman presents for an abortion
as a result of an unintended pregnancy,
much of the counselling involves the abortion procedure itself.
However, in order to help women avoid future unintended pregnancies,
options for post abortion contraception needs to be
addressed.

4. Return to Fertility after Abortion
First-trimester abortion
After vacuum aspiration
Woman may ovulate within 10 days of an abortion
and can become pregnant
After medical abortion with mifepristone and misoprostol
On an average, a woman will ovulate within 20days , but can
ovulate as early as in 8 days
Second trimester abortion
Within 4 weeks after a second-trimester abortion or miscarriage

5. Post Abortion Family Planning Counseling Messages
 To avoid infection
She should not have intercourse until bleeding stops. If
being treated for infection or vaginal/ cervical injury; she should
wait until she is fully healed.
 She should wait at least 6 months before trying to conceive again
as it reduces the chances of low birth weight, premature birth and
maternal anemia.
 Fertility returns quickly -within 10 days after first trimester
abortion and within 4 weeks after a second trimester abortion.
Roughly 75% women ovulate and 6% conceive within two to six
weeks after abortion,if they are not using contraception

6. Post Abortion Family Planning Counseling
 She can choose from available family
planning methods that
can be started at once.
 If a woman decides not to use contraceptives
at this time, providers can offer information
on all available methods and from where to
obtain them.
 Providers can offer condoms, oral
contraceptives or emergency contraceptive
pills for women to take home and use later.
 Method specific counseling should follow if
she chooses any family planning method

7. MTP should not be denied irrespective of the woman’s
decision to refuse concurrent contraception.
MOHFW Guidelines 2016
 If the woman is not willing to accept a contraceptive
method:
 Do not refuse MTP, as she is likely to go
elsewhere, probably to an illegal abortion
provider, and suffer complications
 Assure the woman that she will not be refused MTP

8. Wait for an opportunity
 to counsel her after the
procedure.
 call her for follow-up
in a week’s time and
counsel her again.
 Record the assessment
findings, procedure,
contraception or refusal
to accept contraception
and advice given
(including referral)
Followup
Card

9. POST ABORTAL CONTRACEPTIVE METHOD
Should be
 Safe
 Highly effective
 Long duration
 Convenient
 Cost effective
 Return of fertility
 Available
 acceptable

11.  All modern contraceptive methods can be safely provided
immediately after the first trimester abortions (caution
to be taken for second trimester abortions).
 Long Acting Reversible Contraception (LARC) methods
like IUCD, Injectible methods and subdermal implants
should be preferred as these are not user dependent and
highly effective too.
 The continuation rate for post-abortion insertion of
IUCD is good.

12. Post-Abortion IUCD
After Surgical Abortion
Can be inserted immediately
when infection and injury to the genital tract
are ruled out or resolved
After Medical Abortion
Can be inserted once the abortion is
complete(around Day 15th)
and the presence of infection is ruled out.

13. Post-Abortion IUCD
Ensure that the woman has received counseling and made an
informed choice.
Cu IUCD 380 A /Cu IUCD 375, providing contraception for
10 years/5 years respectively,
can be inserted as per the preference of the client.
Eligibility Criteria Condition
Immediately following first trimester abortion (Provided there is
no evidence or potential for infection)
MEC Category -1
Immediately following second trimester abortion(Provided there
is no evidence or potential for infection,bleeding and other
contraindications)
MEC Category 2

14. Technique of insertion immediately after abortion
Interval IUCD insertion technique (no touch and withdrawal technique)
with little adaptation
 Use of uterine sound for measuring the height of uterus for fundal placement
is not recommended, as it may cause perforation.
 Right after the confirmation of the completion of evacuation in vacuum
aspiration and before withdrawing the cannula, check the depth of uterus
using the last cannula before completely withdrawing the cannula.
 Then, load the IUCD inside the sterile package and fix the blue gauge at the
length measured by the cannula
 Rest of the steps are same as in interval IUCD insertion technique
After second trimester abortion the technique of
insertion is same as that of interval IUCD
insertion
Be very careful while introducing uterine sound to
measure the length of uterus.

15. Post-Abortion IUCD
1. A back- up method is not needed
If the IUCD is inserted within 12 days after first or second
trimester spontaneous or induced abortions, when there is no
infection.
If it is more than 12 days and the IUCD has been inserted after it is
reasonably ascertained that the woman was not pregnant.
2. If insertion is delayed, a backup method is needed.
3. If infection is present, treat or refer and help the woman
choose another method.
If she still wants an IUCD, it can be inserted after the infection
has completely resolved.
4. Expulsion rate of Post abortal IUCD insertion is nearly same as
that of interval insertion.

16. Female Sterlization
Surgical Abortion
Can be performed
concurrently or within 7 days
post abortion provided woman is
eligible for the minilap /laparoscopic
methods.
Medical Abortion can be performed
after first menstural cycle

17. Post-Abortion Female Sterilization
Eligibility Criteria
 Post‐abortion female sterilization should be performed after confirming
that the woman has received counseling and made an informed choice.
 The procedure should be performed only by providers who have been
trained to perform the procedure.
 Post abortion female sterilization can be performed through
minilap tubectomy after first as well as second trimester abortions.
 Laparoscopic tubal occlusion is not recommended following second
trimester abortions as there are chances of injury to the fallopian tubes/
uterus.
Post-abortion condition
 Uncomplicated A
 Post-abortal sepsis or fever D
 Severe post-abortal hemorrhage D
 Severe trauma to genital tract, cervical or vaginal tears D
 Uterine perforation S
 Acute heamatometra D
MEC Categories for Female
sterilization
A = (accept): there is no reason to deny sterilization .
C = (caution): the procedure is normally conducted
in a routine setting, but with extra precautions.
D = (delay): the procedure is delayed until the
condition is evaluated and/or corrected
S = (special): the procedure should be undertaken in
a setting with an experienced surgeon and staff

18. Approach to incision for Minilap and
Laparoscopic sterilization
depends on the timing and type of abortion:
Minilap Tubectomy:
Supra pubic: in case of an uncomplicated
first-trimester abortion or with MTP
Sub umbilical: in case of immediate
uncomplicated second trimester abortion,
depending on the size of uterus
Laparoscopic Tubal occlusion:
Inferior Umbilical: in case of first trimester
abortion

19. Other Methods of Contraception
Combined Oral Contraceptive pills (COCs)
Progestin-only-pills (POPs)
Centchroman
Injection DMPA,
Condoms and Male Sterilization
can be given immediately ,
after appropriate method specific counseling.
 If starting within 7 days no need for a backup method.
 If it is more than 7 days, she can start any time if it is reasonably
certain she is not pregnant.
She will need a backup method for the first 7 days for COCs,
Injection DMPA or Centchroman and
for the first 2 days in case of POPs.

20. Immediate start of hormonal contraception following
medical or surgical first trimester abortion
 Does not affect the efficacy of the abortion process or
post abortion bleeding.
 However ,effectively prevent ovulation in the next cycle and
reduces the risk of another unintended pregnancy.
 Not associated with increased irregular vaginal bleeding or
clinically significant changes in coagulation parameters when
compared with women using non hormonal or
no contraceptive method following an abortion

21. Combined Oral Contraceptives
(COCs)
OTHER BENEFITS
 Regulate menstrual cycles
 Can be provided by all health workers after first screening
by trained provider
 No interference with sex
 Offer protection against ectopic pregnancy, endometrial
and ovarian carcinoma and benign breast diseases .
 Not suitable for women who are breast-feeding babies less
than six months old

22. INJECTIBLE PROGESTRONE
(Depot Medroxy Progertrone Acetate )
1ST TRIMESTER ABORTION
 Immediately or up to seven days after abortion, using
surgical method
 With MMA, it can be started on day 3 with the dose
of misoprostol
2ND TRIMESTER ABORTION
 Immediately or up to seven days after abortion

23. Injectible Progestrone
 Highly effective
 Confidentiality and privacy maintained
 Can be provided by MBBS doctors and AYUSH/ANMs/Nurses
after screening by the doctors for the first injection
 No interference with sex
 No effect on the quality and quantity of breast milk
 Progesterone only ,No oestrogenic side effects
 Offers protection against ectopic pregnancy, ovarian cancer,
iron deficiency anaemia and uterine fibroids
 Return of fertility takes 7-10 months from date of last injection

24. Progesterone Only Pills (POPs),Lactation Pills
 No estrogenic side effects.
 Can be used safely by
breastfeeding women during
first six months after delivery
 Immediate return to fertility
 Does not interfere with
sexual activity
 Can be provided by doctors
(MBBS and above,
AYUSH)/ANMs/Nurses

25. Centchroman
 Safe for use by breastfeeding women
 To be taken twice wkly for 12wks
then once a wk.
 No steroidal side effects
 Immediate return to fertility
 Should not be given in women with
 polycystic ovarian disease,
 cervical hyperplasia,
 tuberculosis,
 renal disease,
 jaundice/liver disease and severe allergic state

26. Male Sterilization(Vasectomy)
 Permanent method
 No interference with sex
 Enables man to take responsibility for preventing
pregnancy
 Not immediately effective.
 Couple must use another FP method for at least the first
3months. Semen analysis should be done after
3 months to confirm absence of sperms
 Highly effective.
Failure rate:<1 pregnancy/100 women(0.5/100)

27. Conclusions
 Women are highly motivated for contraception when
seeking abortion services.
 Hence,counselling and providing effective
method of contraception is necessary to prevent
future unintended pregnancy.
 Majority of modern contraceptives can be advised
immediately or after a little delay.
 LARC methods are especially suited for
younger women coming for abortion and should
be routinely offered and promoted for post
abortion contraception.
 Post Abortal Contraception will definetly help
in reduction of maternal mortality and
morbidity of our country.