Maria Ekstrand

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    Sexual risk taking for self and partner as perceived by young men in Sweden

    Maria Ekstrand, T. Tydén, M. Larsson (Sweden)

    Uppsala University, Uppsala, Sweden

    Purpose. We conducted a qualitative interview study guided by the main concepts of the Health Belief Model (HBM) in order to explore young men’s perceptions of (i) risk for themselves and their partners in connection with unprotected intercourse and (ii) the main barriers to practicing safe sex.

    Methods.In-depth interviews with 22 Swedish males aged 16-20 were analyzed using qualitative content analysis.

    Results.Risks connected to unprotected sex with a new partner (such as sexually transmitted infections and/or unintended pregnancy), were generally perceived as low. The young men calculated risks and considered preventative strategies based on perceived susceptibility, severity and whether or not risks were considered as immediate or distant. For example, HIV/Aids was by most perceived as highly severe, but few worried about personally getting infected. Chlamydia-infection was associated with high susceptibility, but most viewed Chlamydia as an infection which would not do much harm. The young men worried more about the personal consequences regarding sexual risk taking; eventual consequences for a temporary partner were of minor concern. No one wanted to become a teenage father, but most were confident that any resulting pregnancy would not be carried to term; this led to decreased motivation for sharing pregnancy-preventing practices with their partner.

    The main barriers to condom use were interference with spontaneity, pleasure reduction, fear of loosing erection, and embarrassment or distrust. Other obstacles were the girl’s use of hormonal contraception, and difficulties in communicating about safe sex.

    Conclusion.Male disengagement and uneven gender distribution in issues regarding sexual and reproductive health are matters of concern. Helping young men gain confidence in their abilities to share contraceptive responsibility with their partners, and challenging the contemporary picture of western masculinity, may constitute important public health strategies for protecting young people’s sexual and reproductive health.

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    Swedish teenager’s  perception of teenage pregnancies, abortion, sexual behaviour and contraceptive habits

    a focus group study among 17-year-old female high school students


    Maria Ekstrand, RN*, Margareta Larsson, RNM**, Louise von Essen, PhD***,

     Tanja Tydén, PhD****


    ** Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden

    *** Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden

    ****Department of Public Health and Caring Sciences and Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden


    Background: Sweden has the highest abortion numbers among the Nordic countries. Since 1995 the abortion rate among teenagers has increased with nearly 50 %. We therefore undertook a study to gain knowledge about female teenagers´ perception of teenage pregnancies, abortion, sexual behavior and contraceptive habits.


    Methods: Six focus group interviews with 17-year-old girls in Sweden were conducted. The interviews were tape recorded, transcribed and analyzed via manifest content analysis.


    Results: Negative attitudes towards teenage pregnancies and supportive attitudes towards abortion were expressed. Risk taking behavior such as negligence in contraceptive use and intercourse under the influence of alcohol were suggested as main reasons behind the increasing abortion numbers among Swedish teenagers. The contemporary, sexualized media picture was believed to influence adolescents in their sexual behavior. Liberal attitudes towards casual sex were expressed. Girls were perceived as more obliged than boys in taking responsibility for contraceptive compliance and avoidance of pregnancy. The apprehension that hormonal contraceptives cause negative side effects was widely spread and the participants were found to have limited knowledge about e.g. abortion and fetus development. The majority were unsatisfied with the quality of sexual education provided by the schools.


    Conclusion: Possible reasons for increased abortion numbers among teenagers in Sweden could be liberal attitudes towards casual sex in combination with negligence in contraceptive use, increased use of alcohol followed by sexual risk taking, fear of hormonal contraceptives and a deterioration of sexual education in the schools.


    Keywords: Attitudes, teenage pregnancies, abortion, sexual risk taking, contraceptives

Ulla Ellerstorfer

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    Obligatory counselling: Germany's example

    Ulla Ellerstorfer (Germany)


    Today, 2008, far away from the sixties and seventies, sexuality and moralities have changed. With one exception. When a woman and a man are making love, having sex with each other, the possibility to become pregnant has not changed for a woman, who can be fertile for more than thirty years. Getting pregnant is no more unusual than forty years ago. Self-determined sexuality does still include fertility.

    In case of being pregnant unexpectedly, it seems, everything today runs smoothly and easy for her. Rare complications in case of abortion, no more long-lasting diseases and no more deaths. There are cost-free counselling services offered by different service-providers which a woman can choose from. The out-patient medical treatment, mostly in day-clinics, is of good quality and includes different methods of abortion.

    Don’t you agree, there is nothing to complain about in Germany?

Margit Endler

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    Background: Unsafe abortion causes an estimated 43 000 maternal deaths each year. Telemedicine abortion services today abridge the lack of access to safe abortion in many countries. We aimed to evaluate the safety and acceptability of abortion through telemedicine at above nine gestational weeks (gw).
    Methods: A retrospective cohort study comparing self-reported adverse outcomes among women in Poland at ≤ and > 9 gw who requested abortion through the telemedical service Women on Web between June 1st and December 31st 2016, confirmed intake and provided follow-up (n=615).
    Results: Among women ≤ and > 9 gw respectively, 3.3% vs 11.7% went to hospital within 0-1 days of the abortion for complaints related to the procedure (AOR 3.82, 95% CI 1.90-7.69). In a stratified analysis the corresponding rate in the highest gestational age group, 11w0d-14w2d, was 22.5% (AOR 9.20, 95% CI 3.58-23.60). Among women ≤  and > 9 gw respectively, the rate of surgical evacuation post-abortion was 12.5% vs 22.6% (AOR 2.04, 95% CI 1.18-3.32),  the rate of overall medical interventions post-abortion was 18.3% vs 29.0% (AOR 1.84, 95% CI 1.13-3.00), the rate of heavy bleeding was 6.8% vs 10.1% (AOR 1.65, 95% CI 0.90-3.04), the rate of low satisfaction was 2.4% vs 1.6% (AOR 0.69, 95% CI 0.14-3.36), the rate of bleeding more than expected was 45.6% vs 57.8% (AOR 1.26, 95% CI 0.78-2.02), and the rate of pain more than expected was 35.6% vs 38.8% (AOR 1.11, 95% CI 0.71-1.71).
    Interpretation: Medical abortion through telemedicine above nine gw is associated with a higher rate of hospital visits for complaints in the days following the abortion compared to abortion at or below nine gw but not with a higher risk of heavy bleeding. It is associated with an increased risk of post-abortion treatment and intervention but not with a lower rate of satisfaction or met expectations.

Joanna Erdman

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    Working within existing legal frameworks to improve access to abortion

    Joanna Erdman, International Reproductive and Sexual Health Law Programme, Faculty of Law,

    University of Toronto, Canada

    Despite the liberalization of criminal laws, safe abortion services remain inaccessible in many countries. Lack of information is a significant access barrier. Women and health providers do not know what the law allows, deterring women from seeking and providers from delivering services within the health sector. Third-party authorization, dignity-denying in service provision and health system administration all further contribute to unsafe abortion by restricting access to lawful services. This presentation explores recent developments in transnational law on access barriers to safe abortion, focusing attention on the legal reasoning or rationale that proved persuasive in the reform of laws, policies and practices restricting access to safe abortion.

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    This presentation interrogates the idea of ‘need’ in abortion law and explores how we assess claims of necessity under international human rights law. Using examples from the Global Abortion Policies Database, the presentation highlights the arbitrariness, overbreadth and dysfunction that characterize much abortion law worldwide, including many liberal regimes. These laws do not achieve the ends they purport to serve, and often undermine ends of public health, safety, and morality. The presentation focuses on the harms of unnecessary abortion law including: public health impacts of dysfunctional laws, access inequalities of overbroad laws and abuses of arbitrary laws. Particular attention is given to the harms by which abortion law becomes normative or even prescriptive of our lives. How law comes to shape the very ways we understand, experience and practice abortion. For example, how law and its institutional controls were traditionally used to define abortion safety, and the impact today on how we regulate self-managed abortion. We have given law much imaginative power over our field. For too long, we built norms of abortion practice in the image of the law, rather than having law serve aims of health and human rights. Today still, we carry over many falsehoods of abortion law into research, practice and policy, such as when health regulations carry on the gatekeeping and punitive work of criminal law. The presentation thus concludes with the idea of ‘freedom from law,’ an open and imaginative outlook that steers us away from the classic terms, binaries, and frames of abortion law that have patterned our field (e.g. risk and harm, time boundaries, set indications, protections and limits). The presentation extends an invitation to think ourselves away from the routines of abortion law and to ask: What do we need or want from law?

Sophie Eyraud

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    For the doctor
    Sophie Eyraud, MD; Sophie Gaudu, MD,
    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
    perceptions :
    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.

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    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)
    was 98%.
    - 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)

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    The health system modernization law in 2016 allows the practice of instrumental TOP without general anesthesia in primary care centers subject to partnership agreement with a hospital. The aim is to diversify the care offer and facilitate abortion access for women   : proximity, rapidity, and real ability for women to choose the method. The Regional Heath Agency (Ile de France) has commissioned REVHO to assess the feasibility and to assist primary care centers in this practice. We have developed tools and training for medical practitioners and for the staff. Five pilot primary care centers were interested and eligible. Two years have been necessary for implementing the law providing for reimbursement of such practice by French social security (February 2018) and administrative constraints have delayed the beginning of this new practice outside the hospital. Last June, the first three surgical abortions were performed in Aubervilliers with great success and women’s satisfaction. As for any new practice, it will take several years before a generalized implementation with possible extension to other structures and other professionals

Carol Shand

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    The song „The Knitting Needle Bill“
    Carol Shand, MD New Zealand
    Explanatory notes for the song by Dr Carol Shand & Dr Margaret Sparrow
    This song* was written in 1976 at the height of the abortion debate in New Zealand (NZ).
    In the 19th Century, abortion laws in NZ and Australia (based on UK law) were restrictive.
    A test case occurred in June 1938 when Dr Aleck Bourne, London, carried out an abortion
    on a 14 year old girl who had been raped. Mr Justice Macnaghten directed the jury that an
    abortion was not unlawful if carried out on the grounds of preserving the health (as
    opposed to the life) of the woman. In 1967 a more liberal law was passed in the UK but NZ
    and Australian did not follow suit. Most abortions were clandestine acts. NZ women with
    money could travel to the UK or Japan for a legal abortion. Poor women relied on do-it-
    yourself techniques, backstreet abortionists or doctors acting covertly within NZ.
    Each State in Australia has different abortion laws. In 1969 a Melbourne court case
    exposed police corruption and political interference but the result was an acquittal,
    liberalising the law in the State of Victoria. In Sydney in 1971 the jury in another trial
    involving an abortion “clinic” again failed to convict, effectively liberalising the law in the
    State of New South Wales. After this, clinics in these two States operated more openly and
    the trans-Tasman traffic increased greatly. (Auckland to Sydney is 2146 km)
    In May 1974 a private abortion clinic opened in Auckland to test whether NZ would also
    accept a more liberal interpretation of the law. Rich or poor now had access to a safe NZ
    service. The police raided the clinic in September 1974 and one of the operating doctors 

    was brought to trial. Fearing that a NZ jury might not convict (as had happened in
    Melbourne and Sydney) anti-abortionists lobbied for parliamentary change.
    In September 1974 Dr Gerald Wall MP introduced a Bill (The Knitting Needle Bill) to try
    and close down the Auckland clinic, by restricting abortions to hospitals. The Bill was
    passed in May 1975 but never enacted due to an error of drafting. The clinic remained
    open. Another attempt in August 1976 to restrict abortions to hospitals was made by the
    Minister of Health, Air Commodore Gill. Parliament rejected this as they had already
    appointed a Royal Commission in June 1975 to review contraception, sterilisation and
    abortion. The Commission produced a very conservative report in March 1977. This
    resulted in a redrafting of the abortion laws which although still restrictive on paper, in
    practice deliver a reasonable although excessively bureaucratic service. The Prime
    Minister at the time, Rob Muldoon was also anti-abortion.
    The writer of the song, Dr Erich Geiringer (1917-1995), a medical doctor, a refugee from
    Vienna, ran a weekly talkback radio session and this song was one of the satirical songs
    he wrote and sang on Radio Windy. The illustrations depict from Top left: a rampant
    farmer in black wool singlet, and gumboots, smoking heavily. Top centre: Coat of Arms per
    Qantas (Australian airline) with NZ icons of rugby, sheep, beer and knitting needles. Top
    right: Bernadette. The bottom scenes depict various illegal abortion methods: Higginson
    syringe, herbs, potions, hot bath and gin etc. The satire ostensibly mocks the rich young
    miss who hopes to enjoy a days shopping, trip to the opera and visit to the famous Bondi
    beach after her quick Australian abortion and is cross that liberalised legal practice might
    limit her fun. In fact the song was intended to remind the politicians that a repressive law
    would oppress only the poor who would be forced to resort again to dangerous backstreet
    *Tune: Victorian Music Hall song “She was poor but she was honest”
    Chorus: “It’s the same the whole world over, it’s the poor wot gets the blame. It’s the rich wot gets the gravy. Ain’t it all a bleeding