Systemic hormonal contraception initiation after abortion: A systematic review and meta-analysis

Background: Immediate contraceptive initiation, including start of a method before abortion completion, is a convenient option for women seeking abortion care. Objectives: To evaluate the effect of systemic hormonal contraception initiation on medical abortion effectiveness and the safety of hormonal contraceptive methods following abortion. Data sources: PubMed, Popline, Cochrane Library, and Clinicaltrials.gov. Study eligibility criteria: Studies that assessed medical abortion effectiveness after systemic hormonal contraception initiation and the safety of hormonal contraception initiation after abortion. Participants: Pregnant persons undergoing or who had recently undergone an abortion. Interventions: Initiation of systemic hormonal contraception post abortion or on the day of the first pill of the medical abortion. Study appraisal and synthesis methods: We assessed study quality using the US Preventive Services Task Force evidence grading system. We created narrative summaries and calculated pooled relative risks when appropriate. Results: We identified 16 studies for inclusion, 7 randomized controlled trials, and 9 cohorts. Nine studies assessed medical abortion effectiveness with hormonal contraception initiation and generally found no decreased risk of abortion success or increased risk of additional treatment. One fair-quality study reported a small increase in ongoing pregnancy rate with immediate depot medroxyprogesterone (DMPA) compared with delayed DMPA initiation (3.6% vs 0.9%, risk difference 2.7%, 90% confidence interval 0.4-5.6). We identified no bleeding-related safety concerns following hormonal contraception initiation after medical or surgical abortion. Pooled results were too imprecise to draw firm conclusions. Limitations: Included studies were poor or fair quality and primarily in high-income or upper-middleincome settings. Conclusions: Abortion effectiveness did not differ between immediate vs delayed initiation of most systemic hormonal contraceptive methods after a first trimester medical abortion. However, immediate DMPA initiation did show increased ongoing pregnancy. Bleeding effects with hormonal contraception initiation postabortion appeared minimal. (C) 2021 Published by Elsevier Inc.