Rome, 13-14 Oktober 2006: „Freedom and Rights in reproductive Health“
- Christian Fiala, AT
- Mirella Parachini, IT
10:45Schwangerschaftsabbruch in Europa , Aula Magna sala 1+2Vorsitz:
- Elisabeth Aubény, FR
- Kristina Gemzell-Danielsson, SE
Are the laws patient centred?
Christian Fiala, MD, PhD, Gynmed Clinic, Vienna, Austria
For most women the diagnosis of an unwanted pregnancy is unexpected. The women are
therefore unprepared, be it for carrying the pregnancy to term or having an abortion. They
need a great deal of information within a very short space of time. In case they have taken
the decision to terminate the pregnancy, it is crucial for them to get fast access to medical
It is interesting to analyse legal requirements and regulations in European countries, as to
how far they support the women in this crisis situation in finding a solution.
Societies react differently to the needs of the women, although the past was dominated by
a rigid paternalism, coupled with beliefs that pregnant women could not responsibly make
decisions regarding their own pregnancy. Society therefore “had” to intervene in order to
ensure that the “right” decision was taken.
A huge progress has been made over the last decades to overcome this approach and the
legalisation of abortion has been a corner stone. However there are still many remnants of
the old thinking like obligatory waiting (“cool off”) periods of an arbitrary number of days or
an obligatory counselling.
So far there is no evidence that these restrictions are of any benefit. They do, however,
lead to a delay in the provision of the treatment and have negative effects on the physical
and psychological experience of those affected.
Examples and comparions of european coutries are given in the presentation.
From abortion to contraception
Giuseppe Benagiano, Carlo Bastianelli, Manuela Farris
Department of Gynaecologic Sciences, Perinatology and Child care,
University “la Sapienza”, Rome, Italy
Voluntary abortion has been the source of bitter disagreement even among gynaecologists
and the ethical considerations brought forward in favour or against abortion are so
opposing that nothing one can say will ever create unanimity.
In spite of this reality, attempts should be made at establishing a minimum dialogue
because there is a sufficiently large portion of the international community which would
easily agree with the goal to minimize the need to recur to the voluntary termination of a
The best way to start such a dialogue is to explain why restrictive legislation might be good
to appease the conscience of policy makers and a part of the public, but definitely has
never deterred women from terminating a pregnancy when they felt strongly they could not
afford it, nor has it - per se - moved women to prevent unwanted pregnancies.
In addition, per se legalizing abortion does not entail a more widespread utilisation of the
procedure, and may - on the contrary - help decrease its incidence, provided
decriminalisation is linked to a series of other public health measures. The situation is
however very complex and, in Europe alone, there conflicting examples.
Notwithstanding this diversity, in most countries a law that forbids VTP does not cause a
decrease in the number of women who recur to the procedure, while it has two important
negative consequences. The first is an adverse effect on the reproductive health of
women: illegal abortions are often unsafe and the consequences can be an increased rate
of pregnancy-related morbidity higher secondary infertility and mortality among pregnant
women. The second is the very clear tendency that, because VTP is illegal, nothing is
done to actively reduce its incidence, or, rather, to reduce the reasons leading to the need
for terminating a pregnancy. Finally, decriminalisation makes it possible to evaluate the
true dimension of the problem and set in motion a process aimend at reducing it.
There is no question that contraception is the corner-stone of any fight to reduce abortion,
although the relationship between contraception and abortion is fairly complex. Data from
several industrialized countries indicate that where contraception is well established and
utilised by the vast majority of people and it is associated with a proper sex education, the
need to resort to an abortion has substantially decreased.
To successfully move from abortion to contraception, people's attitudes and behaviour
must be changed. This requires massive training and education programmes, as well as
the will of governments to educate potential users and remove medical obstacles to a wide
utilization. In addition, other obstacles, such as cost of contraceptives, should be removed,
especially in countries with no local production, where the need to purchase them with
hard currency makes them simply unaffordable. Education is the key to success because
a lack of knowledge about the real attributes of individual methods both within the
population and the providers, is at the basis of low prevalence. It is also necessary to fight
misconceptions about the safety of modern contraceptives.In this connection, more
research concerning sexual behaviour and knowledge, attitudes and practice of
contraception is needed in order to change the situation. Also, a proper training for
providers and educational programmes for consumers are badly in demand. Finally, the
possibility for potential users to choose among methods is another very important issue:
It must be stressed that ethical considerations influence the choice of strategies aimed at
decreasing the need to terminate a pregnancy. A good example is the possibility to recur
to emergency contraception. For those accepting the definition of pregnancy endorsed by
a WHO Scientific Group in 1992, emergency contraception - acting before nidation - does
not interrupt a pregnancy and therefore is a means to prevent voluntary abortion. The
problem is thae this definition establishes biological criteria, not moral norms.
In conclusion, we hope that the beginning of the third millennium will be remembered as
the time when a major effort will be made to decrease the need for VPT, protect human life
and ensure the continuation of its natural progression. Decreasing the need to terminate a
pregnancy is an achievable goal if we unite our forces rather than loose an opportunity by,
instead, underlining what divides us. We hope that the International community will begin
to work together, using as a common denominator the desire to reduce the need to recur
to voluntary pregnancy termination.
Voices from countries with illegal abortion
Niall Behan, Chief Executive, Irish Family Planning Association, Dublin
Voices from countries where abortion is illegal are changing radically in Europe.
Traditionally those advocating a pro-choice approach to abortion have emphasised the
difficult circumstances in which women with unwanted pregnancies find themselves. It was
rare for women who have had an abortion be an advocate. Even if a woman was an
advocate she would not usually mention that she had had an abortion.
Over recent years pro-choice advocates have been very successful in raising awareness
of the clandestine abortions and the prosecution of doctors and nurses. Pro-choice
advocates have also been very successful in raising awareness of the difficult journeys
women from Ireland and Malta must make to access safe and legal abortion in other
European countries. As a result of this awareness raising opinion polls show there are very
strong pro-choice majorities in Portugal and Ireland.
This success has led to key changes in both pro-choice and anti-choice advocacy
The aggressive fear tactics which anti-choice advocates imported from the US have clearly
failed in Europe. They have slowly abandoned the aggressive picketing of family planning
clinics and the family homes of pro-choice politicians. The intimidation of pro-choice
activists although still happening, has also reduced significantly. And while anti-choice
organisation, still try to link breast cancer/infertility/traffic accidents and abortion, these
tactics have severely dented their credibility.
Increasingly anti-choice advocates have moved to what can best be referred to as “a
sweet stuff strategy”. They have tried to adopt human rights language which is focused on
the needs of women. For example, they are likely to say a woman with an unplanned
pregnancy has “ a right to better options than abortion”. They are increasingly drawing
parallels with the rights of ethnic minority groups and the rights of a foetus. They rarely
discuss contraception or religion.
There is an acknowledgement that they have lost ground in the moral or cultural debate
and they now want to focus on abortion as a danger to a womans health.
Bouyed by the increased support for the pro-choice perspectives, but faced with the
refusal of governments to act, pro-choice advocates are increasingly pursuing change
through human rights and legal instruments. We see this most clearly in Tysiac Vs Poland,
D. Vs Ireland and A.B.C. vs Ireland but also in the judicial review that UK Family Planning
Association have pursued in Northern Ireland.
Voices from countries where abortion is illegal are more optimistic than ever. Their voices
speak of the right to privacy, the woman’s right to life, equality and freedom from cruel and
inhumane treatment. In countries where abortion is illegal individual women who have
been denied their human rights are now more willing to pursue their Government through
the courts to vindicate their rights.
Women’s right for induced abortion within the EU
Katarina Lindahl, secretary general RFSU, The Swedish Association for Sexuality
What is neded to make Womens right to safe abortion a real possibility in all Europe!
The presentation will discuss the current situation for women in Europe concerning
access, legislation and security as well as changes that lately have been made.
Political and legal obstacles to safe and legal abortion will be discussed and the
consequences for women when laws are restrictive.
In that part comparison between countries like Sweden and countries with very strict
legislation will briefly be made.
Here a brief mentioning of the arguments in a more global context will be made, e.g. if or
to what extent arguments are imported to Europe from e.g. USA?
I will also discuss abortion as a right and touch on the most important arguments when
abortion is discussed in Europe.
Abortions as a right or as a health issue are two often discussed strategies. What is the
best way to argue in Europe, and where shall the issue be discussed? Is the European
parliament a useful arena?
12:30Neue Entwicklungen bei der Durchführung von Abbrüchen, Aula Magna sala 1+2Vorsitz:
- Jean-Jacques Amy, BE
- Giovanna Scasselatti, IT
Medical abortion general recommendations
Kristina Gemzell, MD, PhD, Professor
Dept. of OB/Gyn, Karolinska University Hospital/Institutet, Stockholm, Sweden
Medical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined
with a prostaglandin has been available in Europe since 1988 for termination of pregnancy
up to 49 days of amenorrhea. In the UK (1991), Sweden (1992) and later on Norway the
method is approved up to 63 days of amenorrhea. Today medical abortion is available in
around 30 countries. Since the introduction of the method research has focused mainly on
the following issues: To find the optimal dose of mifepristone, the optimal type, dose and
route of administration of a prostaglandin analogue, to increase acceptability of the method
and to define the duration of pregnancy for which it can be used.
During this time it has been shown that the dose of mifepristone can be reduced without
affecting its priming effect on the myometrium and cervix. Misoprostol has emerged as the
most optimal prostaglandin analogue with its effect being dependent on the duration of
pregnancy, and on the dose and route of administration. Based on pharmacokinetics and
effect on uterine contractility, it could be hypothesised that a newly developed slow-release
form of misoprostol may offer an alternative to conventional misoprostol. Our studies
further confirm the safety, efficacy and high acceptability of home-use of misoprostol.
Home-use of misoprostol allows women more flexibility, privacy and control in their
With the introduction of mifepristone the non-surgical, non-invasive methods for 2nd
trimester abortion could be dramatically improved and has become the recommended
method in many centres. More recently medical abortion has also become increasingly
used in the interval 9 to 13 weeks.
In conclusion the combined treatment with mifepristone and misoprostol is a highly
effective and safe method to terminate pregnancy provided that the dose and route of
misoprostol is adjusted to the pregnancy length. Detailed counseling, adequate pain
management and information and the possibility of getting advice on the telephone are
likely to increase acceptability.
The impact of misoprostol availability on abortion safety
Aníbal Faúndes1, Leonel Briozzo2, Gonzalo Vidiella2
1Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP),
Campinas, SP, Brazil, 2Department of Obstetrics and Gynecology, School of Medicine. University of the
Republic. Montevideo, Uruguay.
In developing countries with restricted abortion laws, poor women have a very high rate of
unsafe abortions, which are usually induced by the introduction of sharp objects through
the cervix, causing infection and hemorrhage. Consequently, unsafe abortion is a main
cause of maternal deaths, up to being the first cause in Argentina and Uruguay in recent
years. Misoprostol became available in the 1980s. The label explained that it could not be
used during pregnancy, as it could cause abortion. That information was used by
pharmacy’s clerks, to respond to the demand of women requesting a remedy for delayed
menses. In a few years, from the late 1980’s to the early 1990’s, most abortions in Brazil
were induced with misoprostol. The same was observed in other Latin American countries
the following years. Initially women used excessive dosage and some severe
complications and death (rupture uterus) were reported. In a short time, however, women
learnt to use misoprostol more effectively and safely. Coincidentally, physicians throughout
Latin America noticed a reduction in severe post-abortion complications and during the last
decade several studies confirmed the positive impact of the availability of misoprostol on
safety of abortion, by reducing septic complications, but also severe bleeding. Studies
have shown a temporary association between increases in the sales of Misoprostol and
reduction in the complications of unsafe abortion. Other studies have compared
complications of clandestine abortions induced with misoprostol and by other unsafe
means, showing the much greater safety of abortions induced with misoprostol. An
interesting social intervention was evaluated in Uruguay. Physicians from the largest
maternity hospital that attends one quarter of all deliveries in the country were alarmed by
the maternal deaths resulting from unsafe abortion. Based on the risk reduction strategy, a
special outpatient clinic for women who wanted to abort was open. Women are diagnosed,
offered alternatives to abortion and given the available evidences on the risks of different
form abortion induction, including different doses and routes of misoprostol administration.
Virtually all women who persisted in the intention to abort used misoprostol. Since then, no
maternal deaths have been observed compared with an average of 4 deaths a year during
the preceding three years. In addition, the severity of post-abortion complications have
been dramatically reduced, showing the capacity of misoprostol to save life in
environments where abortion legislation is still very restrictive.
Preventing infection in abortion care
Janesh Gupta MD, Professor of Obstetrics and Gynaecology
University of Birmingham, Birmingham Women’s Hospital, England, UK
There is controversy of whether prophylaxis treatment or a “screen and treat” policy should
be adopted for preventing infective complications when women undergo abortion. There is
currently compelling evidence that indicates that a universal policy of prophylaxis
treatment to ALL women undergoing abortion should receive antibiotics. It is also a cost-
effective policy. This is the policy adopted in the UK and the evidence will be presented.
Second trimester abortion: medical or surgical abortion?
Michel Tournaire, M. Bornes, S. Gaudu, F. Lewin
Hopital Saint Vincent de Paul, Paris, France
The methods for second trimester abortion vary according to countries and institutions.
Medical methods using preparation of the cervix and misoprostol are predominant in
Europe. Surgical dilatation and evacuation requires practitioners trained for this technique.
It is used for almost all second trimester abortions in the USA and is available in some
institutions in Australia, England, France and the Netherlands. Complications are more
frequent with medical method : retention of placenta that needs secondary surgical
removal, hemorrhage with transfusions and rupture of the uterus, risk that is increased in
the cases of previous cesarean section. Surgical method can be complicated by
perforation of the uterus and laceration of the cervix. The risk for premature birth in
subsequent pregnancies seems to be low for the two methods. Emotional consequences
have been found identical with both techniques. The choice of the method is not based on
scientific data but on the practitioner’s experience. If the two methods could be available in the same institution, this would allow, well informed women to participate using their choice.
15:30Arbeitskreis Grundlagen des medikamentösen Abbruchs, Aula Magna sala 4Vorsitz:Arbeitskreis Praktische Aspekte des medikamentösen Abbruchs Teil 1, Aula Magna sala 3
- Pierre Moonens, BE
Vorsitz:Arbeitskreis Religion und Schwangerschaftsabbruch, Aula Magna sala 1+2
For the counsellor
Christiane Der Andreassian, Hospital Broussais, Paris, France
To give information takes time.
Counselling doesn’t need necessary to be done by doctors.
Well trained, nurse or midwife who belongs to the team can easily do it.
Make sure that woman‘s decision to abort is firmly settled.
Listen to the woman’s motivation behind her choice of the method.
Ensure a proper understanding of the method.
Make sure that women is psychologically able to take upon herself and to comply with the
schedules of the appointments, in particular coming back for ultra sound and follow up visit
Be able to reach an emergency area, during the following 2 weeks, in case of problems.
Discuss any concerns at the follow up visit.
What the women say
Avantages of medical abortion
- Pill, no surgical intervention
- Its more natural
- No doctors touching my body
- Conscious and self experience
- Choose to come back for the misoprostol at the clinic or to stay home in their
Disadvantages of medical abortion
- Not sure when abortion will take place
- More blood loss
- Anxious about cramps, nausea, or eventually diarrhoea
Receive the patient in her request,
- With respect
- With a positive attitude,
- Listen to her in the glo
bality of her situation.
- And of course, provide her with the advice’s most relevant to her choice.
- Giving her the relevant information fitted to her case,
- Understand that the team is available if she needs help.
- Allow her to take responsibility for her own actions with more autonomy and confidence
all along the procedure.
A patient correctly informed will be more comfortable and will improve the chances of
succes of method.
For the doctor
Sophie Eyraud, MD; Sophie Gaudu, MD, email@example.com
Hôpital Antoine Béclère, Centre de régulation des naissances, Clamart, France
The doctor must make sure it is the best solution and the right time for the patient, not
only from a medical, but also from a psychological point of view.
Therefore we should check :
- The intra-uterine location of the pregnancy
- The length of the pregnancy
- The advisability of the treatment
- The treatment of pain
We also must be able to weigh the advantages and disadvantages in terms of the patient’s
Women tend to see the method as less agresive given the absence of surgical intervention
and the possibility to „do their own abortion“ in a familiar environment.
The fact that it takes place rather early in the pregnancy also makes it safer.
But it requires for the woman undergoing the abortion to be actively involved.
We must explain carefully that, unlike aspiration, the procedure takes place over several
days and is statistically less efficient (the failure rate is approximately 2-3%).
As long as the doctor is assured that the method is medically and psychologically
appropriate, medical abortion makes an excellent option for a well-informed woman.
How to introduce medical abortion in a country, the example of NZ
Margaret Sparrow; MD, New Zealand
In 1999 New Zealand abortion providers considered that New Zealand women should be
offered the choice of medical abortion. As no pharmaceutical firm was interested in
importing mifepristone, five doctors formed a not-for-profit company Istar Ltd. The name is
derived from Ishtar or Istar, an ancient Babylonian goddess of love, fertility and war.
In May 2000 Istar signed an agreement with the French manufacturer, Exelgyn and
applied to Medsafe, Ministry of Health for approval of a new prescription medicine.
On August 30 2001 Mifegyne 200mg was approved by the Minister of Health Hon Annette
King and gazetted for use in New Zealand for abortion only.
To comply with the law all abortions in New Zealand must be “performed” in a licensed
institution. For fear of prosecution most clinics except the one at Wellington Hospital,
chose not to use Mifegyne. Second trimester abortions in hospitals were not affected and
the first medical abortion using Mifegyne was carried out in Wellington Hospital in October
In April 2003 Mr Justice Durie in the High Court Wellington ruled that a woman must take
both sets of pills (Mifegyne, followed 48 hours later by prostaglandin) in a licensed
institution, but she does not need to stay on licensed premises between taking the pills,
nor does she need to stay on licensed premises until the abortion is complete. Clinics are
now able to perform early abortions within these limits.
Our experience demonstrates that with persistence, obstacles can be overcome.
Medical abortion in the private practice, the French compromise
Sophie Eyraud, MD; Sophie Gaudu, MD
Hôpital Antoine Béclère, Centre de régulation des naissances, Clamart, France
In France, women who decide to get an abortion have been able to access the abortion pill
through their regular doctor outside the hospital context since November 2004.
Under the new French legislation, which only covers abortions in the first 49 days of
pregnancy, a contract must be signed between the doctor and a referral hospital which
agrees to address any complications that may arise. In one sense, this method may seem
to involve excessive supervision: first because many visits are required and second
because the drugs must be taken in the presence of the doctor. But allowing physicians to
practice non-surgical abortions considerably increases the number of doctors available for
the procedure. This law renders abortion more accessible to French patients and for that
reason we see it as a major advance for women's right to choose.
Immediately following the passing of these new measures, we organized a network
between hospitals and doctors working outside of hospitals in order to foster the practice
of non-surgical abortion. The network REVHO* was funded by the Ile de France region’s
public health care system and its activities included training doctors and evaluating the
quality of the care and the satisfaction of patients and health care professionals.
We report the first year's results here:
- In 2005 the network included 59 physicians (primary care and gynecologists) and 7
- 2503 women interrupted a pregnancy with the help of a doctor belonging to the network.
- No serious complication arose.
- The average duration of pregnancy was 6 weeks.
- The average age of the patients was 29 years.
- The success of the method (defined as the absence of a need for surgical intervention)
- Mild complications included:
- progressive pregnancy (0.7%)
- full retention of the egg (1.2%)
- significant hemorrhages (0.7%)
- partial retention of the ovular products (2.5%),
The experience of the REVHO network successfully created close linkage between
doctors working in the city and the hospital, thus encouraging the development of the
procedure with the full support of professionals and great satisfaction of the patients .
According to this initial evaluation, the introduction of non surgical abortion outside the
hospital appears to be both safe and efficient.
* REVHO : Réseau Entre la Ville et l’Hôpital pour l’Orthogénie (network between the city
and the hospital for family planning)
- Elisabeth Aubény, FR
Vorsitz:Freie Vorträge, Tarragona room
How to verify success hCG or ultrasound
Christian Fiala, MD, PhD, Gynmed Clinic, Vienna, Austria
Objectives: Medical abortion with Mifepristone and Misoprostol is effective in 95-98.6% of
cases. We compared ultrasound examination and HCG testing to determine the
effectiveness of the treatment.
Study Methods: 217 women with an unwanted pregnancy up to 49 days of amenorrhea
were treated between 26 April and 10 November 1999. They received 600mg Mifepristone
and 400µg Misoprostol 48 hours later. Expulsion was not verified routinely. An ultrasound
examination and HCG test was performed on day one and between days 6-18.
Results: The treatment was successful in 98.6 % of cases. A total of three curettages had
to be performed; one for continued pregnancy, missed abortion and haemorrhage
respectively. One patient had a missed abortion but expelled after hormone withdrawal.
Expulsion of the sac was verified in six patients. HCG levels at the control visit dropped to
3 % in average (SD 3) ranging from 1-17 % in all cases of successful abortion, with three
exeptions of 27%, 32% and 44%. The two missed abortions and the persistent pregnancy
led to an HCG rate of 91%, 159 % and 7900% respectively.
Endometrium measured 10 mm on average (SD 4) at the control visit in the cases of
successful abortion, ranging from 1-24 mm. Diagnosis of successful treatment could be
based on ultrasound examination in only 66% of cases, owing to the early stage of the
pregnancy in the remaining cases.
Conclusion: Measuring HCG level before and after treatment gave a reliable result in
98.5% of successful abortions, compared to 66% with ultrasound examination.
Is ultrasound necessary
Danielle Hassoun, MD, Paris, France
The question remains whether Ultrasound (US) is a mandatory requirement for performing
medical abortion. In fact, it is very useful in diagnosing early pregnancy, in allowing early
diagnosis of ectopic pregnancy and finally in confirming success or failure of the method.
However, not having access to US technology should not be considered as a barrier to
introducing medical abortion.
To diagnose very early pregnancy requires very good equipment and highly trained
providers. Without a vaginal probe, the diagnosis of a pregnancy less than 6 weeks
remains nearly impossible.
At the follow up visit, the use of US can confirm the success or failure of the method and
especially the reassurance there is no on going pregnancy but it can also be responsible
for unnecessary interventions because of faulty interpretations of the images.
In high resource settings, where the equipment is readily available and the providers are
highly trained, the possible risk is that US may be used as a replacement for clinical exam,
resulting in a potential loss of clinical skills.
In low resource settings, where the equipment is possibly inadequate and providers not
sufficiently trained to use it, relying on their very good clinical skill
can make them good medical abortion providers.
Lessons learned after almost 20 years of experience in this field show that US is not a
requirement when clinical exam and BHCG (when accessible) are concordant with the
condition that the providers maintain a good level of clinical skill.
Meta analysis of 200mg vs 600mg
Clinical Pharmacology Unit of Lyon, Faculté de Médecine Laënnec, Lyon, France
Although mifepristone has been approved in Europe, USA and Israel for termination of
pregnancy (TOP) at a dose of 600 mg in combination with prostaglandins, 200 mg is a
widely used dose, and has even been recommended by the WHO. We have therefore
assessed the evidence in favor of using 200 mg instead of 600 mg mifepristone for TOP.
Two main end points have been considered jointly: success (complete expulsion of the
conceptus) and ongoing pregnancy, the worst modality of failure. Because it is impossible
to prove the identity of two treatments, choosing between 200 mg and 600 mg
mifepristone has been dealt with as a non-inferiority issue. Non-inferiority limits have been
set from the pivotal studies used to grant the marketing authorization in France, resulting
in absolute values of -4% for success and 0.5% for ongoing pregnancy, corresponding to a
consented loss in success of 4% and a consented increase in ongoing pregnancies of
67%. The results of the 4 randomized trials comparing 200 mg with 600 mg mifepristone
(in combination with either oral misoprostol or intravaginal gemeprost) have been
summarized by a meta-analysis (rate difference method). These studies involved 1739
women allocated to 200 mg and 1743 to 600 mg mifepristone at up to 63 days
amenorrhea. Success ranged between 89.3% and 93.6% in the 200 mg and between
88.1% and 94.3% in the 600 mg group. Ongoing pregnancy ranged between 0.55% and
2.78% in the 200 mg and between 0% and 1.89% in the 600 mg group. The meta-analysis
showed a 0.4% [-1.4%, 2.3%] absolute difference in rate of success, allowing to conclude
to the non-inferiority of 200 mg compared with 600 mg mifepristone. For ongoing
pregnancy, the difference was 0.4% [-0.3%, 1.0%], which did not allow to consider 200 mg
non-inferior to 600 mg mifepristone. Two sensitivity analyses gave similar results.
Conclusion. Although similar rates of success can be expected from 200 and 600 mg
mifepristone combined with either misoprostol or gemeprost, it cannot be excluded that the
use of 200 mg may lead to a clinically significant increase in the number of ongoing
Very early medical abortion
Peter Safar MD Head of Department*,**, Christian Fiala MD, PhD**
Humanis Klinikum Korneuburg*, Gynmed Clinic Vienna, Austria**
Positive heart rate,fetal viability or at least the presence of the cul de sac in ultrasonografic
scanning are at the moment still the basic conditions for most of the abortion service
providers to start with the medical induced abortion.
But the wish of many women, after a clear decision making is different:
they want to start the procedure as soon as possible!
Presenting case reports we describe our standarts, procedures and follow up programmes
for patients which allowes us to start medical abortion with Mifepristone and Misoprostol
right after the early detection (postive HCG test) of an unwanted pregnancy..
Following our guidelines we are able to minimize the risks and the complications of
undetected ectopic and molar pregnancies.
- Mirella Parachini, IT
The Impact of Religion of Abortion Utilization
Stanley K. Henshaw, The Guttmacher Institute, New York, USA,
Three aspects of religion potentially influence abortion practice: religious structures and
authorities, the effect of religious dogma on individual behavior, and religiosity (the
intensity of religious belief).
Religious structures and authorities often influence abortion laws and policies; examples
are the Catholic Church in Latin America and Islamic authorities in Indonesia.
Religious dogma can affect abortion utilization by reducing sexual activity outside of
marriage, influencing the use of contraception, and causing women to continue unwanted
pregnancies. In practice, however, religious affiliation appears to have little effect even
when the religions differ in their positions on abortion. In the United States, Catholic
teenagers are no less likely to be sexually active than are Protestant teenagers, and
though Catholic women are slightly more likely than other women to use withdrawal or
rhythm, their contraceptive use is similar in other respects. Similarly, a survey of abortion
patients found that Catholics were about as likely as other women to have used a
contraceptive method when they became pregnant, though they were more likely to have
used withdrawal or periodic abstinence. The abortion rate among Catholic women is at
least as high as that of Protestant women. Studies in Nigeria and India have found little
relation between religious affiliation and abortion rates.
Religiosity, on the other hand, is associated with negative attitudes toward abortion, almost
without regard to the particular religion. In the United States, religiosity (being a “born-
again” Christian or attending church frequently) is associated with lower rates of sexual
activity among teenagers and lower abortion rates, though not with any particular pattern
of contraceptive use. However, the personality characteristics that influence this religious
behavior may also reduce the need and inclination to choose abortion.
Policy of the US
Vicky Sapporta, MD, President of NAF (National Abortion Federation),
The Religious Right has grown as a political force in the United States. With widespread
access to the White House, members of Congress and state legislators, they have been
trying to restrict women’s access to abortion care by introducing legislation that would ban
abortion, require parental involvement for minors, reduce public funding, require biased
informed consent and waiting periods, and force clinics to comply with other politically
Abortion providers can play a key role in countering the Religious Right by providing the
medical, scientific and provider perspectives in public policy debates about abortion. NAF,
as the professional association of abortion providers in the United States and Canada, has
successfully brought forward providers and patients to highlight the real-life consequences
of restrictive legislation and regulations. As a result, we have been able to expose and
defeat initiatives supported by the Religious Right to further restrict women’s access to
- Lucie Van Crombrugge, BE
30 years legal abortion in Ascoli Piceno, Italy
Tiziana Antonucci, social worker, Daniela De Anglis, Sociologist, Adriana Bisonni,
Consultant, Massimo Cutulli, Gynaecologist, Ennio Painvain Gynaecologist, Maurizio
AIED was founded on 10th October 1953, and the diffusion of the concept and custom of
liberal and responsible sexual relationships has represented from, the very beginning, one
of its principle objectives. The Ascoli Piceno section was created in 1974 and since then its
practise has assisted approximately 20,000 women, and in particular around 11,000
requests from patients and certification for IVG, a few hundred of these received before
the introduction of law 194, in collaboration with CISA. As a consequence of constant
moral objections on the part of every member of staff in the city hospital, the AIED section
of Ascoli Piceno, from 1978 to date, thanks to an agreement with the health authority,
guarantees its patients a path to IVG, in the practise, and during the hospital stay, the
operation and discharge, an experience which is probably unique in Italy.
The method the practise uses is principally characterised by the speed in which the patient
is seen: in almost all cases a woman can be given an internal examination and an ultra
sound scan to determine date, within a week of the request.
Extremely close attention is paid to counselling which is entrusted to the same health
worker who will be working alongside the doctor in the hospital: as well as providing the
patient with the fullest possible information on the practical aspects of the IVG we also give
the woman ample time to make an informed decision about the termination of her
unwanted pregnancy and help her to make a choice of effective contraception.
The operation is carried out using the KARMAN method, and from 1980 to date, without
general anaesthetic, except in extremely rare cases, and is carried out with a strict limit of
three people in theatre: the AIED staff, and the patient.
We find the following very interesting: the percentage of patients who return to the practise
after the operation was maintained at about 30% up to the 70?s, around 40-50% during
the 80’s and 90’s and about 50% rising to a high of 60% from 2000.
Conclusions: - The woman’s satisfaction with the entire IVG process is the element which
we feel guarantees an increased percentage of returns for check - ups and the possible
preventions of recurrence.
In the hospitals where these operations are not carried out, as per law, there is the
possibility of provision for an alternative service, with a possible forward role for lay
consultants, for the quality of care of the IVG service and the prevention of unwanted
pregnancies, in consultation with the health authority.
The IVG process also needs projects that provide for the intervention of local institutes to
promote the use of intrauterine contraception and offer free services for the immigrant
population and those on low incomes.
The clinical evidence will be described and considerations made on the IVG phenomenon,
the application of the law, the freedom of choice of surgical method and doctor.
Abortion as a human right: recent international human rights body decisions
Christina Zampas, Legal Adviser for Europe
Center for Reproductive Rights, USA
Recent court decisions related to abortion both at the national and international levels
have been supportive of women's right to access safe and legal abortion. This
presentation will focus on the recent decision of the UN Human Rights Committee in the
groundbreaking case of K.L. v. Peru which found in favor of the Center's client. The
Decision establishes that denying access to legal abortion in certain circumstances
violates women's most basic human rights. The presentation will also discuss the
implications of this case worldwide. Finally, the presentation will note some recent and
forthcoming decisions from the European Court of Human Rights on abortion-related
First trimester surgical abortion under local anaesthesia
Raymonde MOULLIER, Vice-President of ANCIC www.ancic.asso.fr; Martine Hatchuel,
Sylvie Osterreicher, Nathalie Trignol
CIVG S. Veil, CHU de Nantes and CIVG C. Vautier, clinique J. Verne, Nantes, France
In France, abortion was legalized in 1975, and suction vacuum aspiration under local
anesthesia (LA) became prevalent especially in non-hospital autonomous clinics. As the
government decided to integrate abortion units within hospitals, surgical abortion under
local anesthesia decreased while the use of general anesthesia increased particularly for
the 12 to 14 weeks of amenorrhea. This trend seems to be occurring throughout Europe.
However, aspiration under LA remains a reliable technique for well trained personnel,
and ideal for the woman who chose LA when it is combined with psychological guidance
and an empathetic staff. This support is of prime importance in patience comfort and
Moreover, since 1975, improvements have been made in the procedure:
cervical priming with misoprostol 400µg 2 or 3 hours before suction or even better with 200
mg of mifepriston 36 or 48 hours before suction, or with association of mifepriston and
misoprostol, especially for the 12 to 14 weeks of amenorrhea.
local anesthesia with lignocaïne 1% or lignocaïne + adrenalin by local infiltration of the
cervix or paracervical block or both is used routinely.
Treatment with ibuprofen (400 mg) 2 hours before suction helps prevent the pain during
the uterin contraction at the end of the procedure. Consequently, pain is either not
perceived or is tolerable for most women.
As adjunct analgesia, some providers are now using auto – inhalation of nitrous oxide and
some practice acupuncture.
All these improvements coupled with attention and empathy from the staff should give LA
a primary place in abortion practice. LA should be routinely proposed to women, and
medical teams trained in the technique.
Intraveneus sedation by non-anaesthetists: Implementation of Dutch guidelines
Willem Beekhuizen, MD, CASA clinics The Netherlands
In this communication the implementation of the Dutch guidelines for deep intravenous
sedation in four abortionclinics is reported. Our experiences may be helpful to other
professionals who are considering to offer intravenous sedation to women who prefer to
have a painless procedure.
Safe and effective intravenous sedation requires strict adherence to guidelines when
administered by physicians who are not anesthesiologists. For that reason national
guidelines were developed in several countries, including The Netherlands, with
cooperation of the Dutch association of anesthetists.
The recommendations in the published guidelines should be used for the formulation of
local protocols in hospitals and clinics and adjusted to the specified speciality and
procedure. However, several years after publication of the guidelines, a number of
countries report a serious lack of implementation of existing guidelines. At present (2006)
the 1998 Dutch guidelines are evaluated and it seems that Dutch abortion doctors are one
of the few subspeciality organizations that formulated interdisciplinairy sedation protocols
appropriate to clinical practice in abortion clinics.
In July 2001 the management of the Dutch CASA-clinics contracted an advisory
anaesthetist and nominated a abortion doctor and a dedicated professional for quality
development to collaborate in the local implementation of guidelines, starting in a single
clinic. Protocols for formal multidisciplinary team training in sedation and resuscitation and
for the availability of appropriate equipment and drugs were formulated. The clarification of
the different responabilties of the teammembers in the process required special attention.
We will present examples of Procedure descriptions and Work Instructions in the Free
Communication. The anaesthetist advised to change to a single drug system: only propofol
iv is administered as a sedative drug. Possible adverse consequences of intravenous
sedation were identified and protocols formulated how to deal with these.
Requirements for both theoretical and practical training were formalised. For each
candidate a personal plan for training was drawn up, depending on his previous
experience. Trainingplans include:
Clinical lessons by the anaesthetist, a pharmacologist and an abortiondoctor
Guideline-texts, Documents of the existing quality system such as Process Descriptions
and Working Instructions for both doctors and nursing staff
Legal and formal aspects of anaesthesia and sedation, responsabilities
Training in skills such as life support, defibrillation and treatment of advesre incidents such
as anaphylactic reactions
A final practical and theoretical exam by the anesthetist completes the training, and a
certificate is granted.
On-going audit of complications was organised within the existing clinical quality
framework of blamefree reporting of accidents or near accidents.
In 2003-2005 this program for safe sedation practice was extended to three more CASA-
Plans for the near future include:
An audit in all clinics to check compliance with protocols.
Construction of a skillslab (inspired by the well known ATLS-training)
Construction of a module in the CASA-EPR for specific recording of sedation related
Incorporation of safe sedation practice into training and revalidation programmes of the
national NGvA (Dutch association of abortion doctors)
Legal but Limited: Abortion Access and Abortion Tourism in Canada
Christabelle Sethna, Professor, University of Ottawa
Marion Doull, Doctoral Candidate, University of Ottawa
In 1969, the Canadian government liberalized the conditions under which a legal
therapeutic abortion could be performed. These conditions proved, however, to be so
restrictive that many women were forced to turn to "abortion tourism," or travel to other
provinces, cities and countries to access an abortion. In 1988, the Supreme Court of
Canada struck down the abortion law as unconstitutional. Yet despite the fact that
abortion now is completely legal in Canada, regional disparities have seriously limited
many Canadian women's access to pregnancy termination.
These disparities have again forced many women to travel far from home to access
abortion services. This paper will provide a history of abortion legislation, abortion services
and abortion tourism in Canada from the 1960s onward.
Misoprostol for cervical priming: Vaginal vs sublingual
Carbonell J. LL.,* Llorente M,* Barambio S.,† Sánchez E.,* Varela L.,* González G.,*
*Clínica Mediterrania Médica, Valencia, España
† Clínica Tutor Médica, Barcelona, España
Objectives: to assess the effectiveness and safety of mifepristone 200 mg 48 hours before
administering misoprostol 600 µg, vaginal versus sublingual route, prior to D&E in 12-to-
Design: Controlled randomized clinical trial. Setting: Clínica Mediterrania Médica,
Subjects: Women with 12-to-20-week pregnancies wanting a voluntary abortion under the
requirements of serious danger for the mother’s mental health and/or fetal malformations,
between 9 July 2004 and 9 February 2006.
Methods: 900 women were randomized to be included in one of the following 4 groups: I)
sublingual mifepristone 200 mg plus misoprostol 600 µg before D&E, II) vaginal
mifepristone 200 mg plus misoprostol 600 µg before D&E, III) sublingual 600 µg
misoprostol before D&E, and IV4) vaginal misoprostol 600 µg before D&E.
Main outcomes measured: The degree of cervical dilation achieved before D&E, surgical
time necessary to terminate the pregnancy and side effects of misoprostol.
Results: The average cervical dilation in the mifepristone groups was 12.5 ± 2.8 mm (IC
95% 12.3 – 12.8), versus 8.5 ± 3.2 mm (IC 95% 8.2 – 8.8) in those receiving only
misoprostol. Surgical time in the mifepristone sublingual misoprostol group was 11.9 ± 4.3
minutes versus 13.0 ± 5.3 in the sublingual misoprostol group without mifepristone,
(p=0.007); in the mifepristone vaginal misoprostol group the average surgical time was
12.3 ± 5.0 minutes, versus 13.0 ± 6.2 in the vaginal misoprostol group without
Conclusions: administering mifepristone before D&E with misoprostol in second-trimester
abortions makes surgery easy and, to a certain extent, lessens the risk of cervical injuries,
especially in D&E in advanced gestational periods.
17:15"Du wirst mit Schmerzen abtreiben", Aula Magna sala 1+2Vorsitz:
- Philippe Lefèbvre, FR
- Alberto Stolzenburg, ES
Cervical priming – the evidence
Helena von Hertzen, MD, WHO, Geneva,
Cervical priming before surgical abortion is especially beneficial for women with cervical
anomalies, for young women and for those with advanced pregnancy, as they have a
higher risk of cervical injury or uterine perforation. When the use of laminaria was the main
method to prepare the cervix, WHO Scientific Group recommended routine priming for
durations of pregnancy over 9 completed weeks for nulliparous women, for women
younger than 18 years old and for all women with durations of pregnancy over 12
This recommendation may need to be reviewed as recent research suggests that all
women may benefit from routine priming of cervix with misoprostol: a WHO study including
4791 women demonstrated that routine priming of cervix with two misoprostol tablets of
0.2 mg administered vaginally 3 hours prior to vacuum aspiration in pregnancies of up to
12 weeks decreased the need for further dilatation of the cervix, shortened the time to
complete the procedure and significantly decreased the rate of incomplete evacuation. The
use of laminaria now seems to be outdated, as comparative studies report more
complications after laminaria than after prostaglandins.
The optimal dose of misoprostol is 0.4 mg: lower doses are less effective and higher doses
only cause more side effects. The appropriate interval between misoprostol administration
and vacuum aspiration is 3 hours, because shorter intervals are not sufficient for full
priming effect, even if the dose is increased. Oral, sublingual and vaginal routes of
administration of misoprostol have been used. Only the use of mifepristone can compete
with misoprostol in efficacy and low rate of side effects, but its high price and the long
interval required between the treatment and procedure make it less attractive.
Comprehensive pain treatment in abortion care
Inga-May Andersson, Midwife Msc
Karolinska University Hospital, Stockholm
Background: Pain during abortion is a complex condition with many aspects to pay
attention to in the nursing care of women undergoing abortion. Management of pain during
abortion has been given insufficient attention.
Materials and Methods: Review of the current literature.
Results: The abortion methods have been given a lot of attention in different research
projects. Several studies focus on the regimen of medical abortion. The methods for
surgical abortion are also well evaluated.
Studies show that women’s experience of pain varies with gestational age, maternal age
and parity. Visceral pain, as abortion pain belongs to, is deep and poorly localised often
with high intensity score. Systematically given opioids are not optimal treatment in pain
from urogenithal region; regional blockades are more effective. Early treatment of pain
reduces the pain intensity.
Anxiety is related to pain in a number of procedures and situations. Anxiety combined with
physical (nociceptive) pain makes the total experience of pain more intensive. To reduce
stress related to the physical and emotional aspects of the abortion information is helpful.
It is important for the women to have accurate information before the procedure and high
quality care throughout. The information and care should be as effective as possible in
meeting the needs for the individual woman.
Other non-medical pain management strategies should also be given the necessary
attention. The woman should be offered a choice of abortion methods because women
report less pain if the choice of early abortion has been their own decision. The importance
of positive staff attitudes and a non-judgemental atmosphere in the quality of care is
Conclusions: Pain treatment in abortion care is a complex challenge. Correct information,
positive attitudes together witn non-judgemental atmosphere are important parts to reduce
stress for the women. Medical pain management during abortion should be mixed with
drugs acting both central- and periphere. Paracetamol, kodein and NSAID is
recommended. Local anaesthetic by paracervical blockade is an effective method if
needed. Prophylactic pain treatment should be considered.
Pain management in abortion
Ellen Wiebe MD,
University of British Columbia, Vancouver BC, Canada
Adequate pain control during abortion remains an important challenge in abortion practice.
Pain control methods include general anesthesia, conscious sedation using a narcotic
(usually fentanyl) and sedative (usually midazolam), local anesthesia, oral analgesics,
misoprostol and „verbal anesthesia“. A survey of 640 women from a random sampling of
National Abortion Federation clinics found that the average pain score on an 11-point
scale was 4.65 for abortions performed using conscious sedation and 5.2 for abortions
performed under local anesthesia.
There is evidence that a number of specific techniques and drugs reduce the pain of an
abortion procedure including: buffering the pH of the local anesthetic, using a deep
injection technique, injecting slowly, pre-operative ibuprofen and cervical preparation with
misoprostol. Different surgeons have different pain scores using the same medications
and basic techniques indicating that actual surgical technique also affects the pain scores.
Anxiety and depression scores are highly corelated with pain scores and various methods
of reducing anxiety such as music, low lights, distraction, relaxation techniques etc can be
One of the greatest challenges facing a medical director of an abortion clinic is changing
the behaviour of the doctors working within that clinic to improve patient care and
specifically to reduce the pain experienced during the abortion procedure.
“Should the women feel pain?”
Chantal Birman, Midwife, Maternité des Lilas, Paris, France
These thoughts arose from a comment made by a social worker remarking the high
number of repeat abortions among women who had been victims of incest during their
childhood. Undoubtedly, these women are hoping to heal their trauma by taking a
pregnancy to term. However, such hopes are dashed and subsequent pregnancies follow
on quickly, all ending in a termination. Colleagues working in maternity shelters noticed in
these cases that
(a) talk about contraceptives was totally ineffective, and
(b) the relationship between the life experience of these women, with all the perversions it
may entail, and the gynaecological and obstetric events they have passed through was, in
their eyes, obvious!
This is what I want to summarize in my title: what is the value of a woman’s blood? What
does she pay for with her blood?
20:00Update in Contraception, Aula Magna sala 1+2Vorsitz:
- Eva Rodriguez, ES
- Michel Tournaire, FR
- Viveca Odlind, SE (Alle Vorträge)
Viveca Odlind MD, Department of Woman and Child Health, Uppsala University, Uppsala,
and Medical Products Agency, Uppsala, Sweden,
Reduction of unintended pregnancy and the subsequent need for induced abortion is a
great challenge to everyone working with contraceptive method development or family
planning services. Today, a number of effective and safe contraceptive methods are
available, but consistent and correct use remains a problem and discontinuation rates are
often high, particularly with barriers and oral pills. Intrauterine devices (IUD) are among
methods that can provide a high degree of compliance and continuation.
Modern copper IUDs are highly effective, safe, long–acting, easy to insert, reversible, do
not interfere with sexual life and are inexpensive and could therefore be expected to be
highly acceptable to many women. However, use of the IUD varies considerably between
countries. Whereas IUDs are used by 30-40% of fertile women in China, in the USA, only
1–2% of women use an IUD. In the Nordic countries it has been estimated that around
20% of fertile women use IUDs.
Important issues surrounding IUD use include the risk of PID. Safety concerns and
litigations regarding the Dalkon Shield IUD and PID, originating in the 1970s, continue to
taint the reputation of all IUDs, even now, 30 years later. Recent reviews of studies on the
risk of PID have provided reassuring data about the safety of IUDs in women at low risk for
STI, suggesting that development of PID is most strongly related to the insertion process
and to the background risk of STI but not to continued IUD use. According to WHO
medical eligibility criteria for contraceptive use, IUDs could generally be used also by
nulliparous women in monogamous relationships.
The mechanism of action of copper IUDs has been extensively studied and most evidence
suggests that the main contraceptive effect is exerted through prevention of fertilisation.
IUD use should, therefore, not be a concern to those who would object to a method which
only prevented implantation of a fertilized ovum.
The levonorgestrel-releasing IUD (LNG-IUD), through its efficacy and non-contraceptive
benefits on menstrual blood loss, is particularly suitable to women in their later
reproductive years. The low dose of levonorgestrel results in little interference with the
ovarian cycle and few systemic effects. Studies of users of the LNG-IUD have not
suggested an increased risk of breast cancer.
Whilst intrauterine contraception is one of the most important long–term family planning
methods, there are common perceptions which can limit method acceptability. Therefore, it
is important that careful counselling, medical follow–up and removal facilities always
accompany promotion and use of intrauterine contraceptive methods.
Mechanism of action of Emergency contraception
Kristina Gemzell MD, PhD, Professor, Kristina.firstname.lastname@example.org
Dept. of OB/Gyn, Karolinska University Hospital/Institutet, Stockholm, Sweden
Recently post-coital treatment with levonorgestrel (LNG) and the antiprogestin
mifepristone has emerged as the most effective hormonal methods available for
Emergency contraception and LNG in a single dose of 1.5mg has become the
recommended emergency contraceptive pill. However the mechanism(s) of action of these
methods when used for emergency contraception in humans remains largely unknown.
We therefore evaluated the effect of LNG in doses effective for emergency contraception,
on ovulation as well as tubal and endometrial development. Treatment with 1.5 mg LNG in
the late follicular phase inhibited the LH surge in all subjects. No effect on endometrial
development could be found either following preovulatory or postovulatory LNG treatment.
LNG was shown to have no effect on the tubal steroid receptor levels. Furthermore LNG
had no effect on endometrial progesterone receptor concentration and other suggested
markers of endometrial receptivity remained essentially unchanged. Taken together
available data suggest that emergency contraception with a single dose of 1.5 mg of LNG
inhibit or delay ovulation but does not prevent fertilization or implantation.
Increased knowledge on mechanism of action could hopefully increase the acceptability
and thus availability of these methods, to offer women a chance to prevent an unwanted
pregnancy and thus reduce the numbers of induced abortions.
New developments in contraception
Regine Sitruk-Ware, MD
Adjunct Professor Rockefeller University and Population Council, New York, USA
By 2015, the population growth rate will decline but the total world population will reach the
6 billion mark, a 25% increase above today population. Although a steady increase in
contraceptive use has been observed both in developed and less-developed countries, the
contraceptive needs of a significant percent of couples have not yet been met, with an
increase in unplanned pregnancies. Several new products have reached the market during
the last 2 years. Among these are new implants, medicated intrauterine systems,
contraceptive vaginal rings, transdermal patches with longer duration of action, and
several new combined oral contraceptives. In addition new options such as transdermal
sprays and gels, progesterone receptor modulators for a bleed-free, estrogen-free
contraception are under evaluation. These new methods have been developed to meet the
objectives of expanding contraceptive choices for both women and men and, of answering
an unmet need for contraceptives with long-term action that meet the expectations of
consumers. Women give preference to methods that do not interfere with sexual
intercourse and that result in regular withdrawal bleeding or, at least, no unpredictable
bleeding. Men now tend to accept the concept of taking responsibility for the control of the
couple’s fertility, leading to a growth in requests for male contraceptives, an emerging area
of research. Simplicity, reversibility, and effectiveness are the desired features of a male
contraceptive. Implants, gels and combinations of orals and injections are under clinical
development for male contraception.
New areas of basic research include the genomic and proteomic as well as studies of
enzymes involved in the reproductive system. Identifying specific genes and the proteins
induced by these genes and finding molecules that specifically antagonize gene action will
open new avenues for the development of contraceptives that do not modify the hormonal
profile of the individual. The new methods will be targeted to specific interactions within
the reproductive system at the level of the ovary and testis, as well as between
spermatozoa and the ovum. These new approaches also require the engineering of
original drug-delivery methods that reach the target very specifically but do not interact
with other tissues in the body.
In the future, contraceptives may be combined with other medicinal agents to provide dual
protection against both pregnancy and another preventable condition, such as sexually
transmitted infections. Vaginal gels are under development to meet this goal. Some
existing methods prevent other disorders, such as menorrhagia and the anemia it causes.
When a contraceptive method provides dual benefits, women or men may have a greater
motivation to use a contraceptive method, thus reducing contraceptive failures and