Women’s experiences: Are they satisfied?
Annie Bachelot (France)
Unit INSERM-INED 822, Hôpital de Bicêtre, 82 rue du Général Leclerc, 94 276 Le Kremlin-Bicêtre Cedex, France
This study aimed to document women’s experience of a home-use medical abortion and to compare it to women‘s experience of a hospital-use of misoprostol administration.
A total of 43 women participated in in-depth interviews, 4-6 weeks following their abortion, after their follow-up visit. For 12 women this abortion was not the first one.
Home-use of misoprostol affords women more privacy, comfort and control of their abortions, allowing someone familiar to provide support. The partners‘ participation seemed very important for women. But the home procedure can also create more anxiety than the hospital procedure, especially concerning the need for hospital admission in case of excessive bleeding, or the success of abortion. Women expressed their need for more explanations from clinicians. The different aspects of private status, “medical ability transfer” and social recognition of such abortions were explored.
Both home and hospital procedures should be available to allow women to make their own choice.
About 15% of pregnancies
terminate spontaneously in the
ﬁrst trimester .The majority of these miscarriages
are unrecognized clinically.. As the levels of
progesterone fall expulsion of the products of
conception occur spontaneously and resumption
of cyclical ovarian activity with 2-3 months.
Modern methods of medical abortion using
mifepristone and a prostaglandin simulate closely
the mechanisms which occur in spontaneous
abortion suggesting that it is likely that the
majority will resolve spontaneously without further
intervention(Baird 2002) . Blockage of the action
of progesterone with mifepristone results in
powerful uterine contractions which together with
an increased sensitivity to prostaglandin leads to
expulsion of the fetus and placenta.(Baird 2002).
Extensive research over the last 30 years has now
identiﬁed a simple regimen (Mifepristone followed
by misoprostol) which is highly effective(on-
going pregnancy<1%), is free from serious
side effects and does not require sophisticated
facilities(WHO2003). Several studies have shown
that abortion can be safely delivered by relatively
unskilled health workers (mid-level providers
MLP) who have been trained to follow an agreed
protocol of treatment(Shannon &Winnikoff 2009
Warriner et al2011). By devolving provision of
abortion to MLP the access to abortion should
be greatly widened. As predicted in the original
report of medical abortion with mifepristone and
gemeprost that “this combination would have
particular application in countries where skilled
medical and surgical experience are in short
supply” (Rodger & Baird 1987 )
Who should control the effectiveness of the procedure? I. BANGOU
(Guadeloupe) maintained that it should be the specialist and the general
practitioner who started the treatment.
How should it be controlled? T. HUSSON (France) indicated that a good way of
ensuring the success of the method is to measure hCG 10 days after
misoprostol. It should be below 75% of the initial value before the abortion. An
ultra-sound at follow-up is also an excellent method.
During the discussion, C. GEMZELL reported that Sweden has excellent results using mifepristone 600 mg + gemeprost 1 mg, administered vaginally. Some
centres perform 70% of their abortions in this way.
Many speakers from the floor suggested that the method should be made
easier, with the misoprostol being taken at home.
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)
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.
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.
Access to medical abortion
Marge Berer, Editor, Reproductive Health Matters and Chair, International Consortium for
Medical Abortion, London, UK
Although more than one method of abortion has been available for many years, in most
countries the provider chooses the method and may be skilled in one method only. This
paper discusses choice and acceptability of medical abortion from the perspective of both
women and abortion providers and argues that choice of method is important for both.
Safety, efficacy, number of visits, how the method works, how long it takes for the abortion
to be complete and cost all affect acceptability. Medical abortion is considered more
natural because it happens in women’s own bodies and can take place at home before
nine weeks of pregnancy; surgical abortion with vacuum aspiration is simple and over
quickly. Unless the costs of both methods are similar, however, women and providers will
tend towards whichever is the cheaper option, limiting choice. Medical abortion is effective
from when a woman misses her period through 24 weeks of pregnancy, and more women
and providers need to be made aware of this. In legally restricted situations, complications
tend to be less serious and easier to treat with early medical abortion than after unsafe
invasive methods. Ideally, both medical and surgical methods should be available, but
each can be provided without the other.
Consequences of the laws for women and political challenges in Europe
Marge Berer (Great Britain)
London, United Kingdom
There will always be some women who seek abortion after 12 weeks of pregnancy and in fewer cases at 20-24 weeks and even later, with the numbers diminishing rapidly at later gestations. Late abortions, the women who have them and the providers who do them are especially stigmatised. The number of providers willing to carry out abortions drops rapidly after 12–16 weeks of pregnancy and even more beyond 20 weeks. Many abortion laws do not permit second trimester abortion at all, except perhaps to save the life of the woman. Those that do distinguish second trimester abortion usually have more restricted grounds and/or bureaucratic approval processes.
Abortion “tourism” is a long-standing reality in Europe. The illegality of abortion after 12 weeks is less of a public health problem because women can travel for abortions, and the problems for women are hidden. In countries where abortion is legally restricted, morbidity and mortality are greater from complications of second trimester abortion than first trimester. The reasons are due not just to pregnancy being more advanced but due to greater risks from self-medication, the conditions in which the abortion is performed, lack of access to training in best practice for providers, less safe methods used and lack of access to timely, skilled follow-up care in case of complications. Moreover, deaths from second trimester abortions may be hidden in mortality statistics.
Women seeking late abortion are often in a precarious position personally (e.g. very young). Fetal indications are mostly not identified until 20–22 weeks. Where abortion for fetal indications is legal, many of the barriers women otherwise face don’t occur. Indeed, abortion may be encouraged. Where it is not legal, women may be forced to continue pregnancies and deliver even though the baby will certainly die soon after birth.
The psycho-social aspect of the second trimester abortion with teenagers
Milica Berisavac, Rajka Argirovic, Radmila Sparic, Nebojsa Markovic, Ivan Pavlovic, Ivana Cmiljic (Serbia)
Institute for Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia
Introduction. There are numerous barriers for establishing communication with and education of teenagers in respect of protection from unwanted pregnancies and sexual behavior. Unwanted pregnancy at this age is often detected in the second trimester, due to sense of fear and embarrassment to confide with the mother, friend, or partner, as well as to the sense of possible condemnation and lack of understanding of the environment. The legal procedure stipulating the abortion in the second trimester is explicit. Both the psychological and physical immaturity, uncompleted education, often unstable and temporary relationship, can cause a significant alteration of teenagers’ mental health. A sexual relationship with drug users additionally complicates the psychological state of the patients.
Method. The retrospective study encompasses all the patients who were hospitalized during the years 2006 and 2007 due to second trimester abortion. We analyzed the age of the patients, the knowledge of methods of protection from unwanted pregnancy, gestational age in which the unwanted pregnancy was diagnosed, the psychological state of the patients and indications for the abortion.
Results. During the study period there were 173 second trimester abortions at the Institute for Gynecology and Obstetrics Clinical Center of Serbia, 18 of which with under-age patients (9.33%). Teenagers did not have any or of little knowledge on contraceptive methods. In the group to the age of sixteen a greater gestational age was diagnosed (18-20 weeks). In the age group from 16 to 18 the gestational age was 16-18 weeks. Three teenagers were mentally retarded, and one pregnancy happened at the institution. Reactio depresiva was indication for abortion in 15 cases. The abortive procedure was performed by application of hypertonic Na Cl, with abortive interval of 20-24 hours.
Discussion. In younger life age, advanced gestations were detected. The fear of condemnation by the family and the environment affected the late reference at younger teenagers. Even with older teenagers, there were no decisions to continue the pregnancy because they did not have the support of the family, partner nor had they the financial means or completed education. The absence of knowledge on protection methods from unwanted pregnancy imposes the necessity of comprehensive education of this population group, and inappropriate relationships in the family deprived of sincerity and understanding, bring the under-aged patient to the medical institution late in the pregnancy.
Psychological aspects of second trimester abortions for medical indications
Chantal Birman (F)
The Midwife’s Role in Helping Parents Through a Termination of Pregnancy
Before dealing with the subject proper, I feel I should describe briefly the situation in France.
Ultrasound was introduced in 1974. Early in the eighties the complete system for prenatal diagnosis was put in place. Over the same period, we learned how to extend the term of pathological pregnancies. Concurrently, progress in the management of prematurity helped these neonates to survive.
Currently, fewer than 20% of terminations are performed under the provisions of the 1975 Act that allows such procedures where the mother’s health is at risk. Some 80% are carried out for foetal indications. Indications for terminations on medical grounds involve 1% of all births. The number of such terminations due to foetal abnormalities went from 1 in 400 births en 1981/83 to 1% in 1989/90. Down’s syndrome represents 50% of all anomalies found and 90% of these pregnancies are terminated. However, 30% of abnormalities escape antepartum detection (references: « Faire vivre et laisser mourir » by Dominique Memmi who recompiled data taken from the degree in social anthropology done by M. Piejus).
The reason I have given these figures is to show that we midwives, whose role is to see mothers through their confinement, are confronted regularly, though not daily, with terminations of pregnancies for medical reasons.
Over one year, these terminations involve few tours of duty and, for me, seldom number more than 5. At the Maternité des Lilas, where I work, two midwives are on duty and I always volunteer unless my colleague has managed the woman before I begin my shift. The terminations are performed in the delivery room, between normal births.
It has been my experience that the vast majority of these procedures are done in the second three months of the pregnancy, rarely in the last three months.
In France, we induce labour by the well-known Mifegine/Misoprostol protocol. Analgesia is induced in two phases:
1° Fentanyl perfusion with the flow rate adjusted to the requirement of the woman;
2° epidural analgesia when required.
It should be noted that conversely to the appeals of their partners and the opinions of the medical team, most women (of course not all of them) are less inclined to ask for immediate pain relief. For some of them, pain is a physical support for their intangible – because incomprehensible –torment caused by the anomaly.
We midwives also are reminded by the painful contractions that this child, just like those of the other women giving birth, has become incarnate within this body and will soon be born dead or alive.
While French legislation allows terminations on medical grounds, it outlaws infanticide. Application varies from one facility to another.
The couple will not get the child of their dreams.
The couple give birth to a dead baby.
But the thing is that this child is abnormal; that is, a monster. Remember that monster derives from the Latin [from Old French monstre, from Latin monstrum (portent), from mon‘re (to warn)] and the term conveys at once the idea of foreboding and demonstrating or showing. Indeed the anomaly is only realised once it is revealed by the scrutiny of the ultrasonographer or the geneticist.
The parents break both their lineages of normal children and register forever the anomaly in both families. Through this deed, for which they are not responsible, they actualise their monstrous parenthood and can bestow affection on the child they have borne.
The voice of the midwife points out that the woman giving birth in the next room to a normal baby cannot be blamed for that normality. The voids between us are made of all these unanswered questions, and the unwinnable revolt against utterly unjust circumstance.
Right then, the parents also want to vanish with their baby; yet they already know full well that the time afterwards is to come, that in it they will be survivors, and that life goes on.
You have to be mad to go through pregnancy terminations however much - or little - involved you may be. For my part, I feel that the most fragile, because at once the most vulnerable, without being able to incorporate his grief is the father. It takes modesty to help him through. Often, I try to come to their aid through their wives, explaining to the women what is about to happen. In fact, the women have an inkling of what is to come; but not the men. Such indirect assistance helps the father realise that there are limits and that the madness in which he is entangled will come to an end.
Strangely, the process of cervical dilation mimics the abnormality. Instead of being steady and predictable, as with the delivery of a normal child, the cervix remains hard, almost entirely effaced, only just patent, with a presentation bulging behind it. Suddenly, and quite unpredictably, the cervix opens and the foetus proceeds into the vagina, or is even expelled.
Often, to shield the woman from the sounds of neighbouring births, her transfer to the delivery room is delayed. Hence, so that they will know what to expect, the couple must be informed that the birth may occur in the patient’s room. Quiet, cool-headed efficiency of the team appears to be the prime requirement to ensure the smooth progress, both technical and psychological, of these births.
If necessary, once the foetus is born there is time to take the woman to the delivery room, for the placental birth and a uterine exploration. However, expulsion of the foetus on the stretcher is always upsetting to both parents and care providers.
In conclusion, to help people through a termination of pregnancy is to weave mortality with monstrosity. This takes us to the borderline of humanity. You don’t know whether you come through it a better person or a destroyed one. One thing is sure: afterwards, it’s my skin (organ delineating the inside from the outside) that I determinedly scrub under the shower. I have long kept quiet about this cleansing, that I believed private; but my colleagues also feel this need. Now I know why that ablution belongs in traditional and religious rituals surrounding death.
“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?
Contraception and sexuality: Effects on pleasure, spontaneity, and frequency
Johannes Bitzer (Switzerland)
Introduction. Contraception aims at the separation of sexuality and reproduction. Thus each family consultation deals indirectly with sexuality. In usual practice the consultation is however focused on the technical aspects of contraception assuming that the sexual experience and sexual function of the patients are either their private matter or somehow normally functioning anyway or a minor problem. Statistics showing the high prevalence of sexual dysfunctions in women of the reproductive age group indicate that this assumption is wrong. It seems therefore necessary that the family planning professional takes a more active role in the care for the sexual health of their patients.
Methods. Literature research about the relationship between contraceptive methods and Female Sexual Dysfunction. Regular case discussions and supervision by two trained sexologist in our family planning consultation unit elaborating a basic management program for clients with sexual problems.
Results. Results concerning the prevalence of FSD in women using different contraceptive methods are contradictory and variable due to methodological problems and lack of well designed studies. COCs seem to have a negative impact on desire and pleasure and even on pain in a small group of “vulnerable” women.
To respond to sexual complaints of patients the professional for contraception needs some special knowledge, understanding, communicative skills and technical competences.
The training program will be presented.
Integrating abortion training in sexual and reproductive health care
University Hospital Basel, Basel, Switzerland
Preventing unwanted pregnancies is a main objective of sexual and reproductive health care. This is achieved by women and men-friendly contraceptive services including patient centred counselling, availability of all methods, shared decision making, follow-up care etc. In reality, women are still very often confronted with unwanted pregnancies which they experience as a threat to their global health. These women need a high standard of abortion care including easy and rapid access to abortion services; non discriminative, empathic care; shared decision making about the available methods; safe and professional procedures by well trained professionals; qualified and appropriate follow up including postabortion contraception.
These qualities should be provided by recognised abortion training for health care professionals in the field of sexual and reproductive health
Abortion training: The training has to be based on 3 elements:
- Knowledge about epidemiological data, early and late pregnancy development, endocrine and non endocrine factors involved in pregnancy development, diagnostic procedures to determine the pregnancy week, diagnosis of missed and threatened abortion
- Knowledge about medical and non medical abortion techniques (dosages, timing, procedure) efficacy, risks, side effects, Standard operating procedures
- Knowledge about postabortion contraception
- Case for medical abortion. Exact procedure
- Technique of surgical abortion (simulation) assisting, performing under supervision, performing alone
- IUD and implant insertion
Group discussion about ethical and psychosocial, sociocultural aspects of abortion and critical incident reporting
Prof. Dr. med. Johannes Bitzer, Switzerland
Head of Department of Obstetrics and Gynecology University Hospital Basel
Introduction: Contraceptive compliance describes the application of a contraceptive method in accordance with the prescription and/or the specific behavior given or described by a medical professional. Non compliance is the discrepancy between the „real“ use or behavior and the „ideal or prescribed“ use or behavior.
From the literature and clinical experience it is well known that this discrepancy is high reaching up to 50% of contraceptive users which do not comply. We wanted to explore the reasons for this considerable non compliance.
Methods: Search of the literature to unwanted pregnancy. abortion, discontinuation, reasons for non-compliance, solution strategies
Results: Several studies show a rate of 40-50% of unplanned pregancies; almost half of the unplanned pregnancies are teminated. Discontinuation of contraceptive methods lies around 50% during the first
year of use. The reasons are:
Method related factors: - Side effects
Person related factors: - Cognitive factors (lack of information, irrational beliefs)
Emotional factors: - Ambivalence regarding the wish for a child, sexual or relationship
conflicts, behavioral problems (forgetting etc)
Environmental factors: - Lack of accessability, distress, overload
Four major strategies to improve compliance can be distinguished:
a) Development of long acting methods independent of the user’s behavior
b) Diminution of side effects and improvement of quality of life during use
d) Adding heath or therapeutic benefits to the contraceptive effect of methods
e) Improvement of counselling quality by including motivational interviewing techniques
Conclusion: Non compliance is one of the major challenges in contraceptive care. The reasons are multi-dimensional and include person related, method related and environmental factors. Strategies to improve compliance have therefore to target different levels: Improving tolerability, health benefits and user friendliness of methods on one side and improving quality of counseling by intergrating communication techniques like information giving and motivational interviewing on the other hand.
Going ForwardThe prevalence of contraceptive use and the
abortion rate are very different among countries.
We know that the abortion rate is high in
countries where the prevalence of use a modern
contraceptive method is low. Combined hormonal
contraceptives (COC) are one of the most popular
methods of birth control. This is a reliable form
of contraception, having a theoretical failure
rate of 0.1% and, due to problems related with
compliance an actual failure rate of 2-3%. The
pill use is very different among countries. It will
be important to try to understand why these
differences exist. Despite the safety of current
COCs, fears of adverse metabolic and vascular
effects and possible oncological effects remain.
Misperceptions and concerns about side effects,
especially those affecting menstrual cycle, fertility
and body weight increase, are often reasons for
discontinuation. Making contraception available
is not enough to prevent abortion: women should
be able to choose a contraception method that
suits their personal expectations - only then
will unwanted pregnancies be successfully
avoided and the abortion rate will decrease. For
contraceptive efﬁcacy, a woman’s/couple’s free
and informed choice is required.
Medical termination of pregnancy up to the 10th
week: an experience of two obstetric centres in
Ce´u Almeida, M; Bombas, T; Silva, I; Ribeiro, S;
Monteiro, J; Fernandes, T; Moura, P
Maternidade Bissaya Barreto – CHUC, Portugal
Since 2007, termination of pregnancy (TOP) on request is legal in
Portugal up to the 10th week of gestation and we perform mainly
This study investigated the efﬁcacy and the safety of medical
TOP up to the 10th week of gestation in the two major obstetric
services in central Portugal, over 16 months.
A retrospective study was performed of the clinical outcome of
women requesting a TOP, over the previous 16 months. We
considered three groups regarding gestational age: Group 1:
£49 days; Group 2: 50–62 days; Group 3: ‡63 days and studied
the efﬁcacy and the safety.
We included 1276 women who had had a medical TOP. Group
1: 41.5% (529), Group 2: 41.5% (530) and Group 3: 17% (217).
The mean age was 51 days. The global efﬁcacy was 99%. In three
groups, the efﬁcacy of medical TOP was 99.6%, 99.2% and 96.8%
(P < 0.01) in groups 1, 2 and 3. We performed an aspiration per
failed TOP or incomplete TOP in 1.1%, 3.3% and 6.1%
(P < 0.01) of group 1, 2 and 3, respectively. The global rate of
complications was 5.4%. Group 1: 4.2%; Group 2: 5.4% and
Group 3: 8.3% (p=NS), mainly related with an uncompleted TOP
(4.5%), haemorrhagic complications (0.6%) and infection (0.3%).
Medical TOP is a safe method up to the 10th week of gestation
with a low incidence of complications, most of them (80%) due
to incomplete TOP. In the group with a gestational age of 63 days
or more, the efﬁcacy was lower but similar to the efﬁcacy
speciﬁed on the labelling.
Unintended pregnancy can disrupt treatment and recovery for women of reproductive age with cancer. Although some cancers and treatmentss impair infertility, many women with cancer are physically capable of conceiving. Little is known about contraception counseling and abortion in cancer care. Several studies indicate that cancer surviviors in different countries have more abortions than their siblings. Women are overloaded with information at cancer diagnosis adn fertility isues are freuqently forgotten. In a Swiss study of reproductive-aged women with breast cancer 62 of 100 participants needed contraception counseling at time of cancer diagnosis. 17% of women in an Australian sample never had the question: What should I do about contracpetion ? answered during their cancer care. Also some women believe that they could not get pregnant during and after treatment, despite having no clinical diagnosis of infertility. One study found that women who had contraceptive counseling had alomost even times higher use of effective contraceptive methods. A US study demonstrated a higher use of emergency contraception among female young adult cancer survivors. In conclusion using contraception to time pregnancies for periods of better health, is highly relevant for women with a recent cancer diagnosis. Improving reproductive health care for women with cancer is essential. Collaboration between healthcare providers couselling involved into cancer treatment and family planning doctors/nurses/midwifes needs improvenment.
The time of an abortion is a window of opportunity for contraceptive counselling. Clinical practice shows us that we can and must provide contraceptive counselling at the first abortion appointment and not leave it for follow-up. There were some concerns that during the time of an abortion the women will be too distressed with the information regarding the abortion decision and abortion method and so will not able to consider the information about contraception. The women and the couples must be informed that fertility returns rapidly after first trimester abortion. Well informed women were able and motived to choose and start a contraception method at the time of the abortion. Starting a contraceptive method at the time of the abortion is safe and good practice. For medical abortion, combined hormonal contraception, oral progestogen, injectable and implant could be start or inserted on the day of misoprostol administration. For surgical abortion these methods could be started or inserted on the day of the procedure. For surgical abortion, an intrauterine device could be inserted at the time as the operation.
Immediate insertion of an IUD/IUS is safe, results in higher method uptake compared to interval insertion but the expulsion rate seems to be marginally higher. A randomized trial showed that IUD/IUS insertion as early as one week after medical abortion is safe and results in high method uptake and no difference in expulsion rate compared to the insertion at 3-4 weeks. Providing information, updated practices and access to contraception at the time of the abortion will contribute to an immediate start of a contraceptive method and to a lower risk of repeated abortion.
Consequences of unwanted childbirth: Outcomes for women and unwanted children
Catherine Bonnet (France)
Unwanted childbirth is still a reality in developed countries on 2008. For centuries unwanted childbirths were part of any family life until the end of the XIX century when society began to manage the beginning of the contraception. On the second part of the XX century it was possible to say “a baby if I wish and when I wish”. In spite of legalized abortions, they are still women who discover from the second trimester until the birth pregnancy unplanned, babies unwished.
Clinical consequences of unwanted childbirth. Every birth is a personal history case but it may be interesting to describe several types of cases:
How to reduce the negative outcomes for both children and women?
Nongluk Boonthai, Bureau of Reproductive Health, Department of Health, Ministry of Public Health, Thailand - Co-author: Kamheang Chaturachinda, Women’s Health and Reproductive Rights Foundation
With the largest population of any region of the world, Asia has the largest absolute number of abortion
around 26 million per year Nearly half of the world’s unsafe abortion take place in Asia and almost one third in South Asia alone. Unsafe abortion accounts for 12% of maternal death in Asia worldwide there is a declining trend in abortion between 1995 to 2003. Asia is no exception the rate of abortion declined from 33 to 29/1000 women of reproductive age. At the same time contraceptive use (CPR) in Asia, as estimated by UN, climbed from an estimate of 65.6 percent in 2000 to an estimate of 68.2 in 2010 and a further estimated climb to 70 percent in 2020.This climb in CPR is hand in hand with the reduction in UN estimate of Asia’s total fertility rate( TFR )from 2.6 in 2000 to 2.4 in 2010 and to 2.2 in 2020.
Since 1997, 17 countries around the world liberalized their abortion laws, 4 countries in Asia are among them (Bhutan, Nepal, Cambodia, Thailand ). With the population of just over 63 millions, abortion law in Thailand promulgated in 1956 permits abortion if it is done by a physician with the consent of the patient. Grounds for abortion include maternal health as well as pregnancy arising from sexual crimes , pregnan-cy in the young, ages under 15 years old. There is no hard national data on unsafe abortion. It is not officially collected. Moreover, abortion is socially controversial, stigmatized and condemned. Poor women lacked access to the safe service and therefore suffered most from unsafe abortion and its complications including sequelae of secondary infertility.
The number of unsafe abortion is estimated to be somewhere between 300,000-400,000 cases annually, mostly done “underground”, while there are approximately 800,000 births occurring each year. The cost, economically, physically and psychologically to women and to the nation is unacceptable. In spite of legal freedom to safe abortion access to safe abortion is still limited due to negative attitude of the health care provider. Only a hand full of providers in the govern-ment sector and a few private organizations provide out let for safe abortion in large cities, using Vacuum Aspiration. Almost all other Thai providers still use exclusively dilatation and curettage (D&C).
Lack of service providers is another problem. There are only 2,000 OB-GYN. and not all are willing to provide abortion. The myth that abortion is illegal plus negative personal and religious beliefs and their unwillingness to provide the service, resulted in poor access to safe abortion. Abortion seekers went to see quacks instead.
Over the past 50 years many attempts were made to amend the law; all were unsuccessful. The Thai Medical Council and the Royal Thai College of Obstetricians and Gynaecologists (RTCOG) decided to widen the criteria for termination of pregnancy by defining health to include mental aspect. The new regulation was approved in December 2005.
More works still need to be done. The negative attitude of the physicians toward abortion has to be changed. The use of D&C has to be replaced by vacuum aspiration. Therefore, to increase access, trainings on safe abortion using vacuum aspiration are being conducted. The Women’s Health and Reproductive Rights Foundation of Thailand (WHRRF) a non-profit, non-governmental organization. It is established to eliminate unsafe abortion and promoting safe abortion in Thailand through advocacy research, education and training by using the most up to date abortion technology. It has been collaborating with the Department of Health and the RTCOG, have carried out training workshop on prevention of unsafe abortion and use of MVA (Manual Vacuum Aspiration) through our established training centers in the 4 regions of the country. The 3 day- training include conceptual training, socio-economic, legal impacts of unsafe abortion , value clarification manual skill in using MVA on simulated first trimester pregnant uteri model using HAWAIIAN PAPAYA fruit. During the last years we have trained physicians and nurses from provincial and regional hospitals in all regions over Thailand. We have also organized the First International Congress on Women’s Health and Unsafe Abortion in January 2010 (IWAC 2010). There were over 600 attendees from over 62 countries worldwide attended. The second congress is planned for January 2012.
Ivar Brod, Pan Am Pharmaceuticals, Inc., New York, USA
Christian Fiala MD, Gynmed Ambulatorium, Vienna, Austria
Misoprostol has been widely used in Ob/Gyn practice since the early days of its appearance on the market. However, Pfizer, the current manufacturer, so far has rejected continuous requests to add these indications. Moreover, in countries like Estonia and Latvia where registration expired, manufacturer refused to prolong it. We believe that the company’s reasons were financial only, since the price of Misoprostol is more than 10 times lower than the price of other prostaglandins, injectable or jelly, produced by this company. This reason overweighs the fact that other prostaglandins (E2 and F2a analogs) can cause heavy adverse effects, like myocardial infarction and bronchospasm, which is not the case for Misoprostol (E1 analog).
The use of Misoprostol in Ob/Gin in USA is based on FDA’s general recognition that off-label use of approved medicine is acceptable, if it’s based on published scientific evidence. Similar recommendations have been accepted by the European Community Pharmaceutical Directive as well as by British National Formulary. There are no such policies in countries of Eastern Europe - Russia and other post-communist countries. Data that is being analyzed is mainly from Russia, which is typical for all of these countries. Existing legislation there does not provide any positive information about the off-label use of medicine. Moreover, in case of Misoprostol, medical authorities periodically issue directions prohibiting the access to it, due to the lack of indication by the manufacturer. The first of such Directive Letters was issued in April 1999 by Russian Ministry of Health forbidding the use of prostaglandins for off-label indications. The last Directive Letter as of July 2003 forbids directly the Ob/Gyn use of Misoprostol. The breach of these directives can be assumed as a criminal case.
One of the biggest problems for countries like Russia, where 60% of pregnant women prefer abortion and 15% of women in reproductive age are sterile, is to conduct a gentle abortion procedure in order to avoid any harm to female’s reproductive system. Many experts acknowledge that medical termination of pregnancy, using mifepristone followed by Misoprostol, is the most merciful abortion method. Mifegyne (mifepristone), known as the most excellent medicine for medical termination of pregnancy, has been registered in Russia in 1999. Ban of Misoprostol use significantly deprived Russian women the right to choose this method of medical abortion.
There is one more serious aspect resulted from Misoprostol ban in obstetrics in Russia. Help to pregnant women during childbirth is particularly important in this country where more than 10% of deliveries present with high risk of complications for mother and a baby. More than 1/3 of those caused by failure to progress in labor. Russian Ob/Gyn specialists found direct correlation between using Mifegyne and Misoprostol and raising the Bishop range from 0-3 to 4-7. As a result, this method was patented and these indications were formulated in the instruction. Misoprostol ban in obstetrics makes it impossible to use this remarkable mode.
The literature supporting Misoprostol Ob/Gyn use is rather vast – more then 400 publications in leading medical journals. Among them there are publications of experts in Russia, Ukraine, Latvia, Lithuania, and others. Moreover, in Russia in 2004 is published a spacious monograph devoted to Ob/Gyn use of Misoprostol. However, most of all reported brilliant results were based on the use of Misoprostol in research institutions, not in general practice.
We have to stress, that the situation with Misoprostol is special because it is officially recommended to be used in Ob/Gyn by World Health Organization issuing in May 2003 the guidance “Safe Abortion: Technical and Policy Guidance for Health Systems”. We believe that these recommendations allow us to call upon medical authorities in countries of Eastern Europe to acknowledge that Misoprostol was proven to be a prominent drug in Ob/Gyn and to define the way of its appropriate use. Women should not be held hostage by the economic considerations of a private pharmaceutical company in the United States.
Implementing first-trimester public-sector legal abortion services in Mexico’s Federal District
Christopher Bross, Raffaela Schiavon, Rubén Ramirez, Patricio Sanhueza (IPAS, Mexico)
Christopher Bross, Ipas, 300 Market Street, Suite 200, Chapel Hill, NC 27516, USA
The passage of the law legalizing first trimester abortion in Mexico’s Federal District marked an important milestone in the campaign to reduce unsafe abortion, both in Mexico and within the Latin America region. Within three days of passage of the law, women began receiving legal abortion services in designated hospitals of the Federal District’s Ministry of Health (MOH). Ipas has been providing training and technical assistance to the MOH in support of its efforts to provide high-quality abortion services. This presentation will look at the experience in launching and sustaining public sector services during the first year, training and equipping needs identified and implemented by the MOH, technical assistance provided by Ipas and selected partners, and observable trends from the official data. In particular, the presentation will provide a brief context about the law, key aspects of the official guidelines that were emitted by the MOH within 2 weeks following the law’s passage, the evolution of service provision within the health system, trends in abortion technologies utilized in public services and number and characteristics of women receiving legal abortion services in the public sector. By the end of first year, more than 8,000 women had received a legal abortion in public hospitals. The mean age of women was 25 years and 55% of abortion clients were single. Seventy-nine percent resided in Mexico City, 85% identified themselves as Catholics, 84% received their first abortion, and 57% were experiencing their first pregnancy. The mean gestational age at request was 8 weeks and in 95% of the cases, the women requested the abortion for personal reasons. Only 5% reported they were seeking an abortion because of rape, risk to health or congenital malformations. Overall, 34% of procedures were performed using sharp curettage, 29% with MVA and 37% with misoprostol alone. However, the trends in type of procedure indicate a dramatic shift away from previously common practice of sharp curettage towards misoprostol alone or misoprostol in combination with MVA.
Continuation rate of contraceptive implant ﬁtted
on the day of a termination of pregnancy
Brown, A; Nixon, H
NHS Greater Glasgow and Clyde, UK
Sandyford is an integrated sexual health service with over 100 000
visits annually. Our termination of pregnancy (TOP) service sees
over 1500 women annually. Around 30% of TOPs are in women
who have previously had at least one TOP. As a strategy to reduce
repeat TOP, we encourage uptake of long-acting reversible
contraception on the day of a TOP. Anecdotally, clinic staff were
reporting that many women having a contraceptive implant on
the day of abortion were returning in a short time to have it
Aim: To assess: uptake of contraceptive implant on the day of the
TOP; and continuation rate at one year after the TOP.
Methods: Records of women attending from May to October
2010 were accessed to record: method of contraception provided
on day of the TOP; rate of removal at one year after the TOP;
and reason for removal.
Results: During the 6 month period, 707 women had a TOP.
One hundred and ﬁfty-two women (21%) had a contraceptive
implant ﬁtted on the day of the TOP.
During the ﬁrst year, 27 women had the implant removed for
reasons including bleeding (20), mood problems (2), weight gain
(2), planned pregnancy (2) and not sexually active (1).
One hundred and twenty-ﬁve women (82%) continued with
the implant for at least 1 year after insertion.
Discussion: Published series demonstrate implant continuation
rates of around 75% at 1 year. Implants are cost-effective at one
year of use. In our audit, women having an implant ﬁtted on the
day of the TOP do not have a higher removal rate than standard
Helen Nixon and Audrey Brown, NHS Greater Glasgow and Clyde, UK
Annually over 13000 women undergo therapeutic abortion in Scotland. Over 25% of these abortions are carried out in women who have previously undergone abortion. One strategy to reduce the number of abortions is to ensure the provision of reliable contraception on the day of abortion.
To describe national campaigns to increase uptake of long-acting reversible contraception, and to improve contraceptive provision at the time of medical abortion,
to describe a local training programme to achieve the national standards
to compare the provision of reliable contraception at the time of medical abortion before and after the introduction of the above
Methods: Case notes of women requesting medical abortion and accessing our abortion assessment clinic were reviewed for a 3 month period in 2007 (n=180) and 2010 (n= 157). Method of contraception chosen at the time of abortion assessment was recorded, as was method of contraception provided on the day of abortion.
% requesting method in 2007
% supplied with method in 2007
% requesting method in 2010
% supplied with method in 2010
Discussion: Women who choose the oral or injectable contraception are usually provided with the method on the day of medical abortion in both 2007 and 2010. Although 19% of women chose a contraceptive implant in 2007, only 1% of women were fitted with an implant on the day of medical abortion. Several national campaigns, and local projects to enable medical abortion unit staff to fit contraceptive implants, took place during 2008 and 2009. Between 2007 and 2010, there was an increase in number of women choosing a contraceptive implant, from 19% to 32%. In addition, a contraceptive implant was fitted on the day of medical abortion in 26% of women, compared to 1% three years previously. Intra-uterine contraceptive methods are not fitted on the day of medical abortion in our unit. Despite around 1 in 10 women choosing this method, they cannot be provided with their chosen method at the time of abortion. Most women fail to return for interval IUD/IUS insertion, potentially leaving them at risk of further pregnancy. Consideration should now be given to improving timely provision of intra-uterine methods.
Uptake of independent counselling in addition to
termination of pregnancy consultation
Nixon, H; Brown, A
Sandyford, NHS Greater Glasgow and Clyde, UK
Sandyford is an integrated sexual health service with over 100 000
visits annually. Our termination of pregnancy and referral
(TOPAR) service sees over 1500 women annually and offers
information, assessment and admission for medical and surgical
termination of pregnancy (TOP). There is access to a trained
counsellor if wished.
Recently in the UK, there have been demands to make
additional counselling or a ‘cooling off’ period compulsory.
Aim: To assess: uptake of counselling in addition to the TOPAR
consultation; and relationship between time to TOP and eventual
Methods: Records of women attending from September to
November 2011 were accessed to record:
(i) certainty of decision at ﬁrst visit.
(ii) uptake of additional counselling.
(iii) waiting time to TOP date and ﬁnal outcome to proceed to
TOP or continue the pregnancy.
Results: Of 384 women with conﬁrmed pregnancies at
(i) Twenty-six decided to continue the pregnancy.
(ii) Three hundred and forty-one wanted a TOP and this was
(iii) Twenty-eight subsequently did not attend for a TOP and
continued the pregnancy.
(iv) Seventeen women wished more time to consider their
decision and were offered an appointment with a trained
counsellor – two women accepted.
(v) Sixof the undecided women continued thepregnancy,
including the two women who attended for counselling and 11 had
(vi) Neither time to the TOP or gestation inﬂuenced the
decision to abort or continue the pregnancy.
Our results suggest that the vast majority of women do not
wish or need additional counselling and that introducing a
‘cooling off’ period or delay would not alter the decision.
Post Abortion Family Planning (PAFP) is a key part of any
comprehensive TOP service as this is a vital opportunity in which
to provide family planning, to avoid future unwanted pregnancies.
In order to understand the factors that may impact on the
uptake of PAFP, MSI undertook a baseline survey of all clients
accessing services in four of the MSI country programmes. The
data was collected for 1 month, September 2011.
In total 4081 clients availed themselves of TOP services across
MSI centres in Ethiopia (1974), Nepal (1160), Vietnam (888), and
The average age of clients was 27–29 years. Ethiopia was the
only programme with a lower than average age of 22 years.
Eighty-three percent of TOP were performed at under 9 weeks
of gestation. Medical TOP was chosen by an average of 61% of
women: Zambia (90%), Vietnam (76%), Ethiopia (62%), Nepal
Sixty-eight percent of women had not been using any
contraception when they became pregnant. Thirteen percent were
using male condom, 9% the oral contraceptive pill, 4% injection,
1% emergency contraception, and 1% traditional methods. No
one had been using implants, IUDs, male or female sterilisation as
a method of contraception when they became pregnant.
This review reﬂects the baseline factors of MSI clients,
including the low use of contraception in women seeking TOP,
and highlights variables to consider when providing PAFP and
informing the ongoing MSI PAFP project that focuses on
increasing levels of PAFP uptake.
Jan Brynhildsen, Faculty of Health Sciences, Linköping University, Sweden
The prevalence of obesity is still increasing. The most rapid increase during the last years has been in female adolescents. Obesity is associated with many health risks including cardiovascular disease, hypertension, the metabolic syndrome, malignancies and venous thromboembolism. Because hormonal contraception might interfere with these risks, both in negative and positive ways, it is important to address and discuss this issue.
The COC-associated risk of thromboembolism seems to be higher in obese than in normal weight women. The interpretations of these data vary and consequently also recommendations vary between different authorities. The situation might be confusing. The obese woman runs a higher risk of endometrial cancer and COC offers protection. COC offers protection against ovarian and endometrial malignancies etc.
During years it has been discussed whether obese women run a higher risk of contraceptive failure. Recent studies indicate that COCs seems to be as effective in obese as in normal weight women.
The management of contraceptive counselling and prescription to the obese woman will be discussed in relation to the options available in the specific situation. Even though fertility might be decreased in obese women there is a strong need for effective and safe contraception
Monitoring the reproductive health
Marcela Bulcu (Italy)
Azienda Ospedaliera S.Camillo, Rome, Italy
In the last forty years, Italy has known signficant demographical changes. Italy’s rate birth is the lowest in Europe and indeed the lowest in the worls today. The fertility rate began to decrease dramatically from the end of the 1960s. The natality rates declined steadily until it reached a value of about 1.2 children per woman during the most recent years. Morover, the infant mortality has been reduced thanks to the success of the reproductive health system.
A positive sign of the demographic developpement is a continuing and satble decline in nembers of legal abortions. A reduction attributed to the correct use of contraceptive methods and the institution of family planning centers in the 1970s.
However, the abortion rate increased among the migrant population, passing from 10,1% in 1996 to 29,6% in 2005 and 31% in 2006. For this reason, a lot of programs and compaigns has been created to promote the reproductive health among the migrants, taking in consideration their life conditions.
Breast objection increased, in some country redoubles respecting anterior years.
Termination is allowed up to 14 weeks of amenorrhoea, on demand by the
A waiting period of 7 days for reconsideration is required between the first
counselling and the abortion procedure.
Counselling is offered but not obligatory.
Minors need the consent of their parents. If that is not possible, they can
choose a responsible adult, who will accompany them.
Who should perform medical abortion
Richard Burzelman, Richard Burzelman is an Assistant Director for Reproductive Health with the Provincial Government Western Cape Province in South Africa since 2002. His responsibilities include development of policies, guidelines and protocols for the reproductive health services in the Province. He has been involved with reproductive health since 1997 when he started managing an abortion service at a district health facility in Cape Town. This service became the referring facility for the Metropole Region giving access to all clients up to 20 gestational weeks. At the time access was limited as the “Choice on Termination of Pregnancy”, Act 92 of 1997 was just introduced and very controversial.
The Reproductive Health Sub-Directorate collaborates with the World Population Foundation (WPF) in the Netherlands, the Johns Hopkins University Centre for Communication Programs, and the Reproductive Health Research Unit in Johannesburg and the Women’s Health Research Unit at the University of Cape Town undertaking reproductive health research.
Qualifications:Registered Professional Nurse/Midwife (Accoucheur) with Diplomas in Psychiatric Nursing, Operating Room Nursing, Nursing Administration, a Certificate in Termination of Pregnancy and a post-graduate BA Nursing Degree.
Making safe, legal abortion services available to all women is likely to require that all levels of professional health care service providers i.e. the traditional gynecologist, trained physician, and mid-level health professionals participate in the services.
Medical doctors trained in abortion services are not available in many parts of the developing world. This necessitates training of mid-level providers who are not physicians to deliver quality abortion care.
These mid-level providers refers to a range of non-physician clinicians – midwifes, nurse practitioners, clinical officers, physician assistants, and others who are trained to provide basic, clinical procedures related to reproductive health, including bimanual pelvic examination to determine pregnancy and positioning of the uterus, uterine sounding, transcervical procedures, and who could be trained to provide early abortion services.
A previous study in the USA seemed to indicate that complication rates between physicians and other mid-level health care professionals show no difference in first trimester abortion procedures. A study in SA and Vietnam looking at whether there are any differences in medical outcomes between physicians and mid- level providers providing first trimester abortions is currently being completed.
Operations research being undertaken in SA to determine the acceptability and feasibility of medical abortion findings will be presented to policy makers later in the year.
In South Africa, the provision of first trimester surgical terminations have been delivered by registered midwifes since the implementation of the “Choice on Termination of Pregnancy Act” no 92 of 1996. An amendment to the Act later this year will include medical abortions as an added choice for women in the first trimester of pregnancy. In this talk, emphasis will be placed on the South African situation, as an example for other developing countries where there is a shortage of abortion care providers.
Historical background of abortion with an emphasis on medical abortion
Marc Bygdeman, Department of Obstetrics and Gynecology, Karolinska Hospital,
Marc Bygdeman is since 1978 professor of Obstetrics and Gynecology at the Karolinska hospital in Stockholm, Sweden. M. Bygdeman has previously been Head of the department, Medical Director of the hospital as well as President of the Swedish Association of Obstetrics and Gynecology. M. Bygdeman is honorary member of the Royal College of Obstetrics and Gynecology and the American College of Obstetricians and Gynecologists and has been awarded the King of Sweden gold medal for outstanding achievements in education and research. M. Bygdeman has published more than 400 scientific articles mainly concerning infertility, contraception and abortion.
The methods used at present for termination of early pregnancy is vacuum aspiration and the antiprogestin, Mifepristone, in combination with an suitable analogue, either misoprostol or gemeprost. Vacuum aspiration was first described in China in 1958 and started to be introduced in Europe shortly thereafter. It replaced the surgical procedure dilatation ond curettage (D&C). The development of a medical method started when prostaglandin analogues became available. In late 1970 and early 1980 it could be demonstrated that repeated administration of e.g. gemeprost by the vaginal route was highly effective resulting in a frequency of complete abortion of 95% or higher. However, effective dose schedules were associated with a high incidence of side effects such as vomiting and diarrhoea. Even home treatment was shown to be a possibility
In 1982 Herrman and co-workers (Herrman et al. Comptes Rendus 1882; 294;933-940) demonstrated that treatment with mifepristone could terminate early pregnancy. Although mifepristone induced a bleeding in almost all early pregnant patients the frequency of complete abortion, 60 to 85% depending on duration of pregnancy at treatment, was not sufficient for clinical use. Treatment with mifepristone converts the quite early pregnant uterus into an organ of spontaneous activity, ripens the cervix and very importantly increases the sensitivity of the myometrium to prostaglandin by around 5 times. The increased sensitivity and contractility of the uterus can be demonstrated after 24 hours and is fully developed 36 to 48 hours after the administration of mifepristone. We could also demonstrate that the treatment with mifepristone followed 36 to 48 hours later by a prostaglandin analogue was a very effective method to terminate early pregnancy (Bygdeman and Swahn, Contraception 1985; 32:45-51). The high sensitivity of the uterus allowed a low dose of prostaglandin to be used and the prostaglandin related side effects to be significantly reduced. After extensive clinical trials, mifepristone in combination with a prostaglandin analogue, initially sulprostone or gemeprost later mainly misoprostol, was licensed 1988 in France and China for induction of abortion up to 7 weeks, followed in the United Kingdom in 1991 and in Sweden in 1992 up to 9 weeks. Today the procedure is licensed in around 30 countries in different parts of the world including a number of countries in Europe and in the United States. In most of these countries the upper limit for the procedure is 7 weeks.
Mifepristone alone is also used to soften the cervix prior to vacuum aspiration and to induce labour in case of intrauterine foetal death and in combination with a prostaglandin analogue for termination of second trimester pregnancy.
Should gynaecologists be obliged to perform abortions?
Marc Bygdeman (Sweden)
Department of Woman and Child Health, Division for Obstetrics and Gynecology, Karolinska Hospital, S171 76, Stockholm, Sweden
In 1999 the U.N. General Assembly agreed that “where abortion is not against the law, health systems should ensure that such abortion is safe and accessible”. The woman has the right to be treated with respect, empathy and understanding of there difficult situation. However, some health care providers may find that providing care would present for them a personal moral problem – a problem of conscience. Respect for conscience is important but the effect when exercised by physicians and/or other health care personal is to fustrate or negate patients’ legal right of access to abortion. To force gynecologists to perform abortion may therefore not be in the best interest of the woman. It should, however, be stated that conscientious refusal is only valid for performing the abortion. All health care providers, independent of their attitude to abortion, must provide the woman with accurate and unbiased information about their legal rights, the procedure and have the duty to refer the woman in a timely manner to other providers willing to perform abortion. Conscientious refusal to perform abortion is a personal matter and should not be applied to health-care institutions. As in some European countries medical care should be organized so that a woman can obtain an abortion at anytime and to ensure the availability of an adequate number of providers so that women are able to exercise their right to abortion.