Postabortion contraception in Brazil: experience in a reference service during the covid-19 pandemic.

Background: During the covid-19 pandemic, despite sexual and reproductive health (SRH) services being considered essential, in Brazil, only 55% of abortion services remained in operation. This restriction of access could lead to an increase in unplanned pregnancies, unsafe abortion practices, and, consequently, an increase in the maternal mortality rate. In addition to the difficulty of consolidating information for monitoring and evaluating SRH services. In this scenario, postabortion contraception (PAC) during hospital admission is essential, especially with the postabortion use of long-acting reversible methods (LARC), such as intrauterine devices (IUDs), since they are effective, economical, safe and with immediate contraception.

Objective: To evaluate postabortion contraceptive methods, mainly LARC, during hospital admission after spontaneous abortion and legal termination of pregnancy and their associated factors through the abortion surveillance network.

Methods: a cross-sectional study with women of any age admitted for spontaneous abortions or legal interruption procedures at the Women's Hospital at State University of Campinas (UNICAMP), Brazil, between July 2017 and November 2022. The study was approved by the Research Ethics Committee from UNICAMP. The dependent variable was IUD insertion. The independent variables were clinical, sociodemographic characteristics, vulnerable groups and period of hospitalization (pre-pandemic: until 10/03/2020; pandemic: from 11/03/2020). For statistical analysis, Cochran-Armitage trend tests and an adjusted logistic regression model were used, with the significance of the coefficients evaluated by the p-value, obtained through the Wald statistics associated with each parameter, as well as the confidence interval.

Results: 675 women were hospitalized during the period, 547 for spontaneous abortions and 128 for legal termination. Of these, 499 (79%) had at least one vulnerable factor and 45.2% started PAC during hospital stay, as injectables (48.5%), oral contraceptive pills (34.8% ) and IUDs (13.4%). There was a trend towards increased use of IUDs before hospital discharge (p < 0.01), especially in hospitalizations that occurred during the pandemic period, in the most vulnerable groups (p < 0.01) and women with previous abortions (p < 0.05). The factors independently associated with a higher frequency of IUD insertion were presence of 3 or more vulnerability factors (coefficient 4.50; 95% confidence interval [CI] 1.12 to 7.88; p = 0.01); hospitalization during the pandemic period (coefficient 2.56; CI 1.14-3.99; p < 0.01) and the number of abortions (coefficient 0.61; CI 0.09-1.13; p = 0. 02).

Conclusion: Reducing access barriers to highly effective and long-acting contraceptives is an important step towards curbing the rates of unplanned pregnancies. Increasing rates of postabortion IUD use in vulnerable populations and in the context of the pandemic reinforce the importance of the epidemiological surveillance strategy in reducing exposure to preventable risks such as unsafe abortion and managing SRH policy strategies to reduce the maternal mortality rate.