Profession: Specialist in Obstetrics and Gynaecology
Affiliation: San Filippo Neri Hospital, Rome
Mirella Parachini is an Italian citizen born in Brussels (Belgium).
After graduating in Medicine and Surgery from the Rome Catholic University in 1978, she specialised in Obstetrics and Gynaecology in 1983 at the “La Sapienza” University in Rome.
She is presently Medical Director in the Gynaecology and Obstetrics Department at the San Filippo Neri Hospital of Rome.
She worked for 20 years (1980-2000) with AIED (Italian Association for Demographic Education), a private Family Planning Centre which contributed to spreading contraception in Italy during the seventies and setting up termination of pregnancy services (IVG) in several hospitals following the approval of the law on abortion in 1978.
Mirella Parachini is a member of FIAPAC (International Federation of Professional Abortion and Contraception Associates) since the year 2000 , having being the past president and presently the vice-president.
Attitudes of women, media and society towards contraception: Are we making progress?
Mirella Parachini (Italy)
San Filippo Neri Hospital, Via Cola di Rienzo 190, 00192, Rome, Italy
Objective. A review of the main modifications about the attitudes towards contraception of women, media and society in the last years.
Results. The diffusion of modern contraception has certainly contributed to the reduction in the number of unwanted pregnancies in developed countries. These new methods have been adopted by individuals and couples because of the major changes of attitude towards sexuality, the nature of marriage and other forms of union, the place of women in societies and, more specifically, the position of women in the work place. In developing countries surveys find that awareness of contraception is nearly universal among married women and that most people approve of family planning. In most countries the mass media, especially television and radio, are a key source of information about family planning. Despite great progress over the last several decades, more than 120 million women worldwide want to prevent pregnancy, but they and their partners are not using contraception. Millions more are using family planning to avoid pregnancy but fail, for a variety of reasons.
Conclusions. The job of family planning will never be finished.
Examples from Italy
The Italian law no.194 approved in 1978, is often considered one of the most advanced inWestern Europe. An abortion may only be carried out in a public hospital and there are no special abortion clinics inItaly. The conscience clause is partially responsible for many of the difficulties in availability of services. The Article 9 provides for the non-participation of staff of any level who work in hospitals and do not want to participate in abortions for reasons of conscience. The objectors are freed from activity specifically directed to the interruption of pregnancy but not from assistance before or after the abortion. It is the responsibility of the hospital to ensure the procedure is efficient and the Region is responsible for the to the provision of the services. This brings to remarkable differences from one region of the country to another. For example the Region of Emilia Romagna, where social and medical facilities are easily available, offers better services with access to medical abortion. Conscientious objection is a major limiting factor in the implementation of the law. According to the Secretary for Health’s last report, at a national level nearly 71 % of the gynaecologists are conscientious objectors and in some regions this percentage reaches 80-85%. Medical abortion has been approved since 2009, but only within 49 days of amenorrhea, in spite of the European mutual recognition procedure. In all cases, with only two regional exceptions , a compulsory hospitalization is requested. So far the medical procedure is not readily accessible in all localities. Restrictions in access to abortion and lack of having the choice between a medical or a surgical procedure are currently the major problems.
How to overcome the resistance against medical abortion
Mirella Parachini, MD
San Filippo Neri Hospital, Rome, Italy
OBJECTIVE: To understand how it is possible to overcome the resistance against medical
abortion in order to improve the right of women to choose.
RESULTS: Since the introduction of a pharmacological method to induce early abortion
there has been a strong resistance to it, even in those countries where legal abortion is
allowed with surgical techniques. Today the question about the choice of the method
seems to replace the historical debate about the interruption of an unwanted pregnancy
among pro-life groups and conservative politicians. Many claim that the “abortion pill”
makes women less responsible for their behaviour. On the other hand, even among those
not ideologically against abortion, there is a refusal of medical abortion concerning the lack
of health care assumed with a “self abortion”. Moreover in some countries abortion clinics
are refusing to offer it for fear of legal repercussions. Both medical and surgical abortion
are currently safe and effective when performed by trained practitioners according to
tested protocols under adequate conditions. However anti-choice campaigners try to
involve the public opinion and doctors about the risks of the drug, in an attempt to oppose
the access of the drugs in some countries, like in Canada, Australia and Italy. It is
therefore necessary to increase the information, considering that any medical procedures
is submitted to a scientific control, but keeping out of the debate ideological aims to
maintain restrictions on women’s right to choose.
CONCLUSIONS. There is a strong resistance at various levels against medical abortion
and a continuous scientific debate is requested from the abortion providers, beyond
Instability of misoprostol tablets stored outside the blister: a potential serious concern for clinical outcome in medical abortion
Veronique Berard1, Christian Fiala2 ,6, Sharon Cameron3, Teresa Bombas4, Mirella Parachini5, Kristina Gemzell-Danielsson6 1ICB - CNRS, Division MaNaPI, Département Nanosciences, Université de Bourgogne, Dijon, France, 2Gynmed Clinic, Vienna, Austria, 3Chalmers Centre, NHS Lothian, Edinburgh, Scotland, UK, 4Obstetric Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 5San Filippo Neri Hospital, Rome, Italy, 6Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden - email@example.com
Objectives: Misoprostol (Cytotec®), is recognised to be effective for many gynaecological indications including termination of pregnancy, management of miscarriage and postpartum haemorrhage. Although not licensed for such indications, it has been used for these purposes by millions of women throughout the world. Cytotec® tablets are packaged as multiple tablets within an aluminium strip, each within an individual alveolus. When an alveolus is opened, tablets will be exposed to atmospheric conditions. The effect of prolonged exposure upon bioactivity of misoprostol and resultant clinical efficacy is unknown. Therefore, this study was undertaken to assess possible changes in tablets exposed to usual European temperature and humidity conditions. Design and Methods: To compare the pharmaco-technical characteristics (weight, friability), water content, misoprostol content and decomposition product content (type A misoprostol, type B misoprostol and 8-epi misoprostol) of misoprostol tablets Cytotec® (Pfizer) exposed to air for periods of 1 to 720 hours (30 days), to those of identical non-exposed tablets. Four hundred and twenty tablets of Cytotec® (Pfizer) were removed from their alveoli blister and stored at 25°C/60% relative humidity. Water content, and misoprostol degradation products were assayed in tablets exposed from 1 to 720 hours (30 days). Comparison was made with control tablets (N=60) from the same batch stored in non-damaged blisters. Results: By 48 hours, exposed tablets demonstrated increased weight, friability, and water content (+78.8%) compared to controls. Exposed tablets also exhibited a decrease in Cytotec® active ingredient (misoprostol) dosage (-5.1% after 48 hours) and an increase in the inactive degradation products (+ 25% for type B, +50% for type A and +60% for 8-epi misoprostol after 48 hours) compared to controls. Conclusion: Exposure of Cytotec® tablets to ‘typical' European levels of air and humidity results in significant time-dependent changes in physical and biological composition that could impact adversely upon clinical efficacy. Health professionals should be made aware of the importance of appropriate storage and handling of Cytotec® tablets.
Psychological assessment in Italian and immigrant women requesting TOP in two central Italian hospitals
Marina Marceca1, Pietro Are2, Mirella Parachini3, Giovanna Scassellati Sforzolini4, Patrizia Facco5, Daniela Valeriani4, Gelsomina Orlando6, Cristina Francesca Damiani6, Paola Lo Pizzo6, Anna Pompili7 1San Giovanni Evangelista Hospital, Tivoli (Rome), Italy, 2ASL Latina, Latina, Italy, 3San Filippo Hospital, Rome, Italy, 4San Camillo Hospital, Rome, Italy, 5Sandro Pertini Hospital, Rome, Italy, 6San Giovanni Hospital, Rome, Italy, 7ASL RM E, Rome, Italy - firstname.lastname@example.org
During the last two decades the number of foreign citizens resident in Italy has been progressively increasing: in 1991 they were 625,000 (361,000 females), incresing to 4,570,317 in 2011 (7.5% of the Italian resident population). Females are 51% of them, about 4.5% of total resident female population. In Italy the induced abortion rate is lower than in other countries, but there are great differences between Italian and immigrant women resident in Italy: in 2009 the induced abortion rate among Italian women was 6.6/1000, compared with 24.1/1000 among foreign women. This study is part of a multicentre one, in press, performed in Italy between women requesting induced termination of pregnancy, in order to evaluate if there are differences in experiences of physical or psychological violence among Italian and immigrant women. Our data concern women who required TOP in Tivoli and Palestrina hospitals, two cities in central Italy, with high foreign populations. A group of 142 women (88 of which were Italians and 54 foreigners) received an anonymous questionnaire during the first visit before abortion. Comparing the results obtained we did not find significant differences between Italian and immigrant women regarding history of intimate violence, but the two groups showed different variables like education, number of children and moreover between repeated abortions.
Indications for mid-trimester abortion throughout Europe
San Filippo Neri Hospital, Roma, Italy
Laws regulating mid-trimester abortions in Europe are more restrictive than first trimester in most countries. European countries can be classified into various categories indicating the circumstances under which a woman can legally obtain mid-trimester abortion. The indications range from countries that prohibit abortion altogether or permit it only to save the life of a woman to countries with additional grounds such as: to preserve the physical and mental health of the woman; in case of pregnancy resulting from rape or incest; in case of risk of foetal impairment. These differences lead to the persistence of the so-called abortion tourism but it has also to be considered that there are legal differences in the access to abortion services for foreign women in various European countries. It is very important for the abortion providers working in countries with restricted access to mid-trimester abortion to be updated about these different legal frameworks. Nowadays, women have access to the internet, giving them authoritative and reliable information. This presentation will provide an overview of the indications for mid-trimester abortion throughout Europe.
Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a checklist in Rajasthan, India: study protocol and intervention adaptation of a randomized controlled trial
Mandira Paul2, Kirti Iyengar1 ,4, Sharad Iyengar4, Kristina Gemzell-Danielsson1, Birgitta Essén2, Marie Klingberg-Allvin3 ,1 1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden, 4Action Research, Training for Health (ARTH) Society, Udaipur, India - email@example.com
Background: The WHO suggests that simplification of the medical abortion regimen will contribute to an increased acceptability among women and providers. It is expected that home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic. This study protocol describes an RCT that aims to evaluate the efficacy of home-based self-assessment after a medical abortion and the acceptability and feasibility of the intervention in a low-resource setting. Method/Design: The study is a randomised, controlled, non-superiority trial that will evaluate the effectiveness and acceptability of self-assessment using a low-sensitivity pregnancy test and a checklist two weeks after medical abortion. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. Eligible women randomised to the self-assessment group will use the low-sensitivity pregnancy test and the checklist at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. To ensure feasibility of the self-assessment intervention an adaptation phase took place at the selected study sites before study initiation. This was to optimize and tailor-make the intervention and the study procedures and resulted in the development of a pictorial instruction sheet on how to use the low-sensitivity pregnancy test and the checklist of danger signs after a medical abortion. Discussion: In this paper, we will describe the study protocol for a randomized controlled trial investigating the efficacy of simplified follow-up in terms of home-based self-assessment, two weeks after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor.
Task sharing in post-termination of pregnancy care
at district level in Uganda; healthcare providers’
perception on safe TOP, post-TOP care and
contraceptive counselling – an exploratory study
Allvin, MK1; Paul, M1; Gemzell-Danielsson, K1;
1 Department of Obstetrics and Gyanecology Karolinska Institutet,
Stockholm, Sweden; 2 Mulago University Hospital, Kampala, Uganda
Background: Termination of pregnancy (TOP) is restricted in
Uganda and poor access to family planning results in unwanted
pregnancies forcing women to have unsafe TOPs and thus posing
a great burden on the Ugandan health system. Post-TOP care is
implemented and unofﬁcial task shifting is taking place as a
pragmatic response to the workload.
Objective: To explore the healthcare providers’ perception on
post-TOP care, with regard to professional competences, medical
and surgical methods, contraceptive counselling and task shifting/
sharing in post-TOP care.
Methods: In-depth interviews (n = 27) with healthcare providers
participating in post-TOP care were conducted in seven health
facilities in the Central region of Uganda. Data was organised
using thematic analysis with an inductive approach.
Results: Post-TOP care was perceived necessary, however
controversial, and together with poor conditions it provoked
frustration, mainly among the midwives. Task sharing was
generally implemented and midwives were identiﬁed as the main
providers. Different uterine evacuation skills were recognised and
midwives would sometimes perform interventions not approved
by hospital guidelines, due to absence of doctors. Misoprostol was
rarely used or accessible at district level, however those with
experience perceived it efﬁcient and safe. An overall demand and
need for further training was identiﬁed.
Conclusions: Developing policies and service guidelines in order
to implement evidence based use of misoprostol in post-TOP care
as well as provision of in-service training is recommended.
Implementation of ofﬁcial task shifting in post-TOP care would
further be a systematic approach to improve quality of care and
accessibility of services in order to reduce TOP-related mortality
Anneli Pehrsson and Pia Karlsson, Licensed Midwives; Karolinska University Hospital, Sweden
Background: According to rules issued by Sweden’s National Board of Health and Welfare, Advice on Abortions 2004: Section 4; Chapter 2, when a woman has made the decision to have an abortion it should be carried out at the earliest possible time.
Our previous routines could not adequately address the waiting times for the required ultrasound examination by physicians. Not every woman who had contacted the clinic <9 weeks gestation could be offered medical abortion. Hence, a project was initiated to train two midwives in transvaginal ultrasonography.
In 2007, the National Board of Health and Welfare decided to make the regulatory changes necessary to broaden the authority of midwives in this context.
Aims: - To train and certify midwives to independently manage medical abortions, perform dating scans by transvaginal ultrasonography, and prescribe mifepristone and misoprostol.
- To provide women with rapid and effective care.
- To be able to offer a medical abortion to any healthy woman <9 weeks gestation.
- To ensure continuity, i.e. the woman meets one and the same person during the entire abortion process.
Methods: - Auscultation/training in transvaginal ultrasonography, at IVF clinic.
- Individual training and supervision in ultrasonography, Center for Fetal Medicine.
- Individual training and supervision in transvaginal ultrasonography, by Prof. Seth Granberg.
- Transvaginal ultrasonography with the department’s gynecologists. Images were reviewed, commented on, and approved by Prof. Seth Granberg. Accompanied by theoretical studies.
- Ten cases of abortion counseling with ultrasound examinations, supervised by C. Rasmussen (Section Chief at the time).
Results: - For the past 2 years we have performed transvaginal ultrasonography in healthy women early in pregnancy. We have been delegated authority to prescribe mifepristone and misoprostol, to prescribe contraceptives, and to deliver patient care encompassing the abortion itself and follow-up visits.
- We have shortened the waiting times at the clinic; freed time for physician appointments; increased the number of medical abortions; and reduced the demand on surgical time and recovery unit beds.
- We can offer medical abortion to all healthy women who request it, and most can begin the abortion with the first visit.
Conclusions: - Midwives with adequate education have the capability to independently manage healthy women requesting an abortion early in pregnancy. Usually the problems are more of a psychosocial than medical nature. The abortion is not the problem, but often the solution to the woman’s problem.
- In the past 2 years we have become proficient in performing and assessing ultrasonography and detecting anomalies, whereupon we contact the attending physician.
It is important for midwives and physicians to collaborate in the care of these women. It must not become a matter of prestige.
Background: The failures of medical termination of pregnancy (MToP) can have serious consequences such as exceeding the legal age of abortion and the occurrence of fetal malformations related to the teratogenic action of misoprostol.
Objective: To study the correlation between a low-sensitivity urine pregnancy (LSUP) test associated to a self-performed questionnaire and the standard patient follow-up after MToP, consisting of a clinical examination, a blood hCG test and ultrasonography when needed. Methods: Prospective cohort study included women who came to their post abortion visit after MToP from March to August 2017. They performed a LSUP test and a self-performed questionnaire to assess their opinion on the completion of the abortion. Then a standard follow up was done by a doctor. A successful MToP was defined as a complete uterine abortion, with no the need for surgical intervention or for new abortive medication. Results: 133 women have been included in this study. The rate of successful MToP was 94.0%. Regarding failures there were two ongoing pregnancies (1.5%) and six retained products of conception (4.5%) treated either by a surgical procedure or with a new oral administration of misoprostol. Sensitivity of the womens opinion combined to the LSUP test was 100%, specificity was 89.6%, positive predictive value 38.1%, negative predictive value 100%, a Youden index of 0.89 and a kappa coefficient of 0.51. Conclusion: Given the extremely high efficacy of MToP, most women do not need a clinical follow-up to confirm pregnancy termination. Our data show that most women can ascertain their abortion outcome using a simple self-administrated questionnaire and a LSUP test.
Bojana Pinter, S.Baznik and T.Vovko, Department of Obstetrics and Gynecology,
University Medical Centre Ljubljana, Slovenia
Objectives: The aim of this study was to obtain a broader insight into social-economic, religious, and other characteristics of pregnant women having an induced abortion (IA), and into the reasons for induced abortion, use of contraception before and after IA, and to analyze women's attitude towards professional counselling before IA in the Ljubljana's region.
Design & methods: The study was based on two comparable questionnaires that were given to two groups of pregnant women: a study group of women that were having a first trimester IA at the Department of Obstetrics and Gynecology, University Medical Centre Ljubljana (323 subjects) and a control group of women in the first trimester of pregnancy that intended to give birth (60 subjects) and were attending out-patient clinics in the Ljubljana region. Participation in the study was voluntary and anonymous. The differences between the groups were analyzed using a chi-square test, and the correlations between individual characteristics were calculated using Pearson correlation coefficient. P values below 0.05 were regarded as significant.
Results: The average age was 28.8 ± 3.4 years in the study group, and 28.6 ± 7.0 years in the control group, the difference was not statistically significant (p=0.737). In the study group there were significantly more women that had finished primary school only than in the control group (17.9 %: 0.0 %; p<0.05), and fewer had achieved graduate (18.8 %; 6.7 %; p<0.05) or post-graduate education (2.2 %; 11.7 %; p<0.05). In the study group fewer women were employed (56.9 %; 80.4 %: p<0.05), and more of them unemployed (18.2 %; 5.4 %; p<0.05), and fewer lived with their spouses or family (55.5 %; 76.7 %; p<0.05). Women in the study group considered their socio-economic status significantly lower and fewer declared themselves as Roman-Catholics (66.3 %; 92.6 %; p<0.05). There was a significantly higher rate of barrier contraception use in the study group before the pregnancy. The main reasons for IA were current lack of wish for a child (48.7 %), financial and social reasons (35.3 %) and school or career (29.7 %). The majority (84.0 %) of women in the study group had professional counselling and 42.1 % of women in the study group would want such counselling.
Conclusions: Pregnant women who decided on an IA had poorer socio-economic status, fewer of them were Roman-Catholics, and they used less efficient contraception.
Sexual behaviour and knowledge on contraception and STIs among Slovenian secondary-school students: differences regarding type of school
Bojana Pinter1, Tinkara Srnovrsnik1, Fani Ceh2 1Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia, 2The National Educational Institute, Ljubljana, Slovenia - firstname.lastname@example.org
Objective: To present the differences among secondary-school students on sexual behaviour and their knowledge on contraception and sexually transmitted infections (STIs), regarding type of school. Methods: The study was done on 969 randomly selected 3rd grade Slovenian secondary-school students of both genders by self-administered questionnaire in year 2012. Descriptive statistics and chi-square test were used. Results: Students were attending professional school, vocational school or gymnasium (12.6 %, 43.9 % and 43.5 %). Their average age was 17.5 +/- 0.7 years. Sexual intercourse have ever had was shown in 64.8 % of vocational-school students, 59.5 % of professional-school students and 47.2 % of gymnasium students (p < 0.001). Use of effective contraception (condom, hormonal contraception or double method) at last sexual intercourse was high (87.4 %) with no differences regarding type of school. Self-assessment of knowledge on different types of contraception revealed better knowledge among gymnasium students. Self-assessment of knowledge on STIs revealed poorer knowledge among vocational-school students. Vocational-school students were more likely to get information on sexuality from their parents and less likely from the internet than others; books and magazines were more often used by gymnasium students. Gymnasium students would more often use books and magazines, friend's advice or internet to get more information on sexuality. Sexuality education was most frequently performed in gymnasium (77.0 %) and least frequently in vocational school (64.7 %) but in the latter students were more satisfied with it. Conclusions: There were significant differences among secondary-school students in sexual behaviour and knowledge on contraception and STIs, regarding type of the school. Systematic sexuality education is needed to minimize the differences.
The importance of education on contraception
Bojana Pinter , MD, PhD. University Medical Center, Ljubljana -Slovenia
Family planning, sexual and reproductive health are essential components of individuals, couples and societies. Information on sexual and reproductive health and sexual education are very important in improving the knowledge and practice of contraception and thus in preventing unwanted pregnancies, which mostly end in induced abortions, and in preventing sexually transmitted infections (STIs).
The aim of sexual education is to change the sexual behavior with improving KAS (K–knowledge, A–attitude, S–skills) through education in sexuality, contraception, abortion prevention, avoiding risk-taking behavior and STIs (with HIV). Sexual education can be formal or informal, at school, in the family, by the media and through service providers. It needs broader approach than simply giving information and education on contraceptive and other preventive methods. Mechanical and organic bodily information are not enough as people, especially adolescents, are much more concerned about other aspects of love and sexuality: emotions, thoughts and anxieties should be addresses and discussed. Besides, training in communication skills is an important aspect of sexual education.
Innovative approach in sexual education could be as SPICES: S – stimulating, P – problem oriented, I – interactive, C – community based, E – extensive, S – students centered. Studies and practice have shown that “peer education” is one of the most successful approaches in sexual education. However, sexual education is only one part of a holistic approach to sexual health promotion and behavioral change, which develops through consecutive steps: awareness – knowledge - attitude – intention – behavioral change – sustained behavioral change.
The majority of sexual education programs have some positive effects upon some outcomes (such as greater knowledge), but only some of the programs actually result in some behavioral change as: delay in the initiation of sex, increase in condom or contraceptive use, reduction of unprotected sex among youth and reduction of unwanted pregnancy and induced abortion rates. The studies show that effective sexual education programs:
- include a narrow focus on reducing sexual risk-taking behaviors that may lead to STIs or unintended pregnancy (e.g. delaying the initiation of sexual intercourse, using protection)
- use social learning theories as a foundation for program development
- provide basic, accurate information about risks of unprotected intercourse and methods of avoiding unprotected intercourse through experiential activities designed to personalize this information
- include activities that address social or media influences on sexual behavior
- reinforce clear and appropriate values to strengthen individual values and group norms against unprotected sex
- provide modeling and practice in communication and negotiation skills.
The studies also show that sexual education programs do not increase any measure of sexual activity.
Sexual education in Slovenia
Because most youth are enrolled in school for many years before they initiate sex and when they initiate sex, schools have the potential for reducing adolescent sexual risk-taking. Unfortunately, the practice in many European countries, as in Slovenia, is that there is no formal sexual education nor in primary nor in secondary schools. The study on sexual behavior of secondary-school students in Slovenia has shown, that the majority of students get the information on sexuality from friends, parents and different sources together and that the school is less important source of information. In the absence of formal sexual education other sources of information (e.g. internet, journals) could provide youths with minimal information. However, more cooperation on national level should be established to introduce formal sexual education in schools.
The suggestion made by the Population Council is that rather than dual protection, what many young and adult people need is “triple protection” against unintended pregnancy, STIs and infertility (which is possible consequence of STIs in women and men). Triple protection can be achieved by ABC approach: A – abstinence, B – being faithful and using contraception, C – condom use.
Effective sexual education programs can be an effective component in a larger initiative to reduce the unintended pregnancy, STIs and infertility risks in youth and adults
An update on unwanted pregnancy from Slovenia - with special focus on adolescents
Bojana Pinter Division of Ob/Gyn, University Medical Centre, Ljubjana, Slovenia - email@example.com
Background: In Slovenia abortion has been permitted on request from 1977. The liberalization of the law was a consequence of improvements in vacuum aspiration technique in 1964 at the Dept. of Ob/Gyn in Ljubljana, Slovenia. This technique had been successfully presented to the world's professionals at IPPF conference in Santiago, Chile, in 1967 and evaluated in the American-Yugoslav joint project "Abortion study Ljubljana" in 1971−1973. Content: Abortion rates in Slovenia have decreased in the last thirty years: in 1980 the abortion rate was 40.3/1000 women aged 15−49 years, in 2012 8.7/1000. Among adolescents aged 15−19 years abortion rates decreased from 25.3/1000 in 1980 to 5.8/1000 in 2012. A decrease in unwanted pregnancies was evident in spite of an increase in sexual activity of adolescents. According to representative studies on sexual behaviour of Slovenian secondary-school students in the years 1996, 2004 and 2012 the percentage of sexually active students aged 17 years increased from 45% (male) and 44% (female) in 1996 to 53% (male) and 57% (female) in 2014. The decrease in abortion rates is in correlation with an increase in use of effective contraception (condom, hormonal contraception or double method): from 75% in 1996 to 85% in 2012, and a decrease in students using no contraception: from 19% in 1996 to 7% in 2012. In addition, contraception is widely accessible through outpatient Ob/Gyn services and fully covered by general health insurance. In the last twenty years the knowledge on contraception among providers has increased. In spite of the fact that sexuality education in schools is not mandatory, pupils and students get some information through special programmes held in schools. In addition, the media, on the subject of contraception, mostly work in collaboration with professionals. Conclusions: The decrease in abortion rates in Slovenia is the result of accessible services and increased knowledge of contraception among providers and users.
Monitoring the Abortion Process: Home Use Of Misoprostol in the United States
Eric Schaff, MD
Professor of Family Medicine and of Obstetrics and Gynecology
University of Rochester School of Medicine
New York, USA
The United States medical abortion experience has been unique. Frustrated with not having mifepristone, U.S. researchers explored the combination of methotrexate and misoprostol for medical abortion in the mid-1990s. The experience was mixed because the regimen often took several weeks to be successful. But, it provided abundant opportunity to explore different approaches to medical abortion.
Lessons from Methotrexate Medical Abortions
We learned early on with methotrexate abortions, that vaginal misoprostol was more effective than oral misoprostol. We also learned that repeating the misoprostol dose was necessary, safe and increased the effectiveness rates. We had to monitor the medical abortion with ultrasound because at two weeks, despite a history of bleeding, as many as 15-20% of pregnancies had not been expelled and the decision to perform an aspiration completion depended on the results of the viability of the pregnancy by ultrasound. And lastly, we learned that women could have a medical abortion safely at home as long as they had access to emergency medical care, if needed. Women also found home use of misoprostol highly acceptable.
Abortion Rights Mobilization Trials
In 1996, the Abortion Rights Mobilization (ARM), a non-profit advocacy group in New York City, contracted with the University of Rochester medical abortion researchers to coordinate trials with mifepristone. We applied the information learned from the U.S. experience with methotrexate, i.e., use of vaginal misoprostol, home administration of misoprostol, a repeat dose of misoprostol if needed, and routine ultrasound monitoring.
Over the following four-year period, the ARM trials have enrolled 7000 women in seven multicenter trials. These trials have recently come to a halt as the commercial product has come to market.
Summary of ARM Trials
In 1966, the first ARM trial used mifepristone 600 mg and vaginal misoprostol. It was an open label, non‑randomized, prospective trial at one site, up to 56 days gestation. The first follow up occurred within the first 7 days. There were 166 subjects with a 97% effectiveness up to 8 weeks. Four percent of subjects used a second misoprostol dose, 34% bled prior to misoprostol, and 11% did not require misoprostol. There were no transfusions, but there was 1 hospitalization related to bleeding.1
The second trial in 1997 used mifepristone 200 mg and vaginal misoprostol and was an open label, non‑randomized, prospective trial at 7 geographically diverse sites. There were 933 subjects with a 97% effectiveness up to 8 weeks pregnant. 2% used a second misoprostol dose and there were no transfusions and no hospitalizations.2
The third trial in 1998 extended the gestational age to 9 weeks pregnant using mifepristone 200 mg and vaginal misoprostol at 15 geographically diverse sites. Women used home misoprostol. There were 1137 subjects and 308 between 56‑63 days gestation. The regimen was 97% effective up to 8 weeks, 96% after 8 weeks, and 2% uses a second dose of misoprostol. There were one transfusion and two hospitalizations.3
The fourth ARM trial randomized misoprostol at 1, 2, or 3 days after mifepristone 200 mg. Again, it was an open label, prospective trial at 15 geographically diverse sites. There were 2255 women enrolled up to 8 weeks pregnant. The regimen was 98% effective at 1 and 2 days, and 97% effective at 3 days (2% used a second dose). There were no transfusions and 2 hospitalizations.4
We have had another trial completed comparing mifepristone 200 mg and Oral vs. Vaginal misoprostol at 24 hours. We used two doses of oral misoprostol 400 mcg two hours apart on day 2 up to 63 days pregnant. There were 1168 women enrolled. The effectiveness at first follow up was 89% in the oral group and 97% in vaginal group, ( p<0.001). In oral group, the regimen was 90% effective up to 7 weeks and 88% effective between 8‑9 weeks gestation. After a second vaginal dose of misoprostol was used, the overall effectiveness, 94% in oral group, 99% in vaginal group. There was more diarrhea with oral 33% v 18% vaginal misoprostol,( p<.001 ). There were no transfusions and no hospitalizations.
A sixth completed trial of 1000 women is still being analyzed to determine whether experienced US clinicians report that they need routine ultrasound.. Preliminary results show that about 57% of the time, clinicians report that ultrasound is not indicated. Ultrasound was reported to be indicated in about 22% of the time and “not indicated but desired” in the remaining 21%.
We have just finished our seventh trial which was a randomization of oral v vaginal misoprostol after mifepristone 200 mg at 48 hours up to 9 weeks pregnant. We used two doses of oral misoprostol 2 hours apart. There will be about 750 subjects enrolled. The results are pending. Low dose mifepristone and one dose of oral misoprostol 400 mcg after 49 days was not effective and the study was amended. There was 1 transfusion.
1. A 200 mg dose of mifepristone with vaginal misoprostol is as effective as the 600 mg standard mifepristone dose. Effectiveness rates with vaginal misoprostol have ranged from 96-98%.
2. With the use of vaginal misoprostol, we have demonstrated high effectiveness rates above 95% up to 9 weeks gestation.
3. A repeat dose of misoprostol in women with a persistent gestational sac at first follow up in the first week, was both safe and might improve effectiveness. A randomized trial of a repeat dose of misoprostol in initial non-responders would help to answer this question. Since there are few (5%) women who do not respond initially, it would require a large sample.
4. Vaginal misoprostol provided increased flexibility in the regimen and could be given 1, 2 or 3 days after mifepristone with effectiveness rates above 95%.
5. Home use of misoprostol is safe. Only 2 women out of 7,000 have needed an emergent aspiration curettage within 4 hours of using misoprostol, i.e., the time period when medical observation is required in France. Four transfusions occurred in these 7000 women (<0.1%). Of note, they all were delayed ranging from 1-3 weeks after using mifepristone.
6. Ultrasound dating of the pregnancy and confirming the abortion is highly accurate. It allows women to return earlier for evaluation, as soon as one day after using misoprostol, at a time when the serum hCG may still be elevated and the uterus has not fully involuted. It can also allow an early ectopic pregnancy to be detected. The French experience has demonstrated that ultrasound need not be routine.
From these studies, we conclude that the best regimen is mifepristone 200 mg in women up to 9 weeks pregnant (by ultrasound) followed 24-72 hours later by vaginal misoprostol at home, with a repeat dose of misoprostol in initial non-responders.
1. Schaff EA, Stadalius L, Eisinger SH, Franks P. Vaginal misoprostol administered at home
after mifepristone for abortion. J Fam Pract 1997;44:353‑360.2.
2. Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low‑dose mifepristone
200 mg and vaginal misoprostol for induced abortion. Contraception 1999; 59:1‑6.
3. Schaff EA, Fielding, SL, Eisinger SH, Stadalius LS, Fuller L. Low‑dose mifepristone
Followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception
2000; 61:41‑ 46.
4. Schaff EA, Fielding SL, Westhoff C, Ellerston C, Eisinger SH, Stadalius, LS, Fuller L.
Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion (< 56 days gestation): a randomized trial. JAMA 2000;284(15):1948‑1953.
Tatiana Popovitskaya, Reproductive Health Alliance, Kyrgyzstan
Co-author: Galina Chirkina
For a long time abortion has been used as the main method of contraception in Kyrgyzstan. According to independent research, 7 out of 10 pregnancies end in an abortion. Young people under the age of 19 account for more than 200 abortions each year. This takes into account only the officially recorded and reported abortion figures. 70% of all abortions are still performed using dilation and curettage (D&C) contributing to the high level of post-abortion complications. The systematic underreporting of abortion figures is another sore point. Research performed by the Reproductive Health Alliance Kyrgyzstan (RHAK) showed that only one in 8 abortions performed in governmental clinics is registered and private clinics do not report their abortion figures.
According to the official figures of National Statistic Committee of Kyrgyz Republic the number of abortions has increased, especially amongst young people between 13 and 19 years of age*. At the same time we can see that the rate of contraceptive use by adolescents also decreased during the last 5 years by 1.8 times.
Several barriers to reproductive services influence the choices for adolescents in Kyrgyzstan:
- Adolescents have limited access to quality information and there is no sexuality education
- Adolescents have limited access to information on contraceptives and to contraceptives
- Adolescents are victims of violence based on tradition and violence within families and communities**
- Lack of quality of abortion care in the country; in 70% of the cases abortions are performed by D&C
- Lack of governmental commitment towards adolescents’ reproductive health
RHAK has played an important role in recognizing the need of young people to be able to access quality reproductive health services and has implemented several strategies to improve the reproductive health of young people in Kyrgyzstan. RHAK is now operating their own clinics providing high quality abortion services.
The Safe Abortion and Family Planning clinics in Bishkek (capital city) and Karakol were established under a Safe Abortion Action Fund project and further supported by IPPF EN through the GCACI project and SALIN+ project. The main goal of the clinics is to increase access to high quality information and services on abortion and family planning for young girls and women, especially poor, marginalized, socially excluded and underserved groups. The doctors were trained in safe abortion methods using Manual Vacuum Aspiration (MVA) and trained on providing pre - and post abortion counselling and contraceptive services. Clients can receive contraceptive services in the clinic and young people receive all services free of charge.
RHAK is recognised as the leading expert on safe abortion in the country and has delivered government sponsored training to a total of eight governmental clinics of family medicine and three maternity hospitals.
Besides medical services the RHAK clinics are also involved in prevention activities like information campaigns aimed at young people, open – door days, group consultations or discussions with students and schoolchildren which the aim to further reduce barriers to accessing services provided by RHAK clinics.
RHAK believes and proves that an NGO can be a good promoter of safe abortion and can successfully train service providers, assess the quality of care, increase the knowledge of the population as well as the medical and business community, support and develop safe abortion pilot clinics and projects, join forces
with key partners for advocacy and promotion of safe abortion.
*The official rate of abortions in the age group from 13 to 19 in 2009 was 3,6 for 1000 girls, in comparison with 2008 –3,0 and 2005 - 2,9 for 1000 girls.
**An example of such a violent tradition is bride napping or bride kidnapping also known as as marriage by abduction or marriage by capture.
Title: The experience of use of medical abortion for HIV-infected women at home in Ukraine
Women with HIV have a right to decide about their reproductive choice. There is no reason why HIV positive women cannot use medical abortion. HIV positive women may be at higher risk of reproductive tract infections from retained products of conception, but this may occur with medical or surgical abortion.
The aim of our study was to assess the efficacy and acceptability of home administration of misoprostol for early medical abortion up to 63 days of amenorrhoea for HIV-infected women.
Methods. This case-control study included 68 cases of medical abortion in HIV-infected women who did not receive antiretroviral therapy. About 20% of women lived in the rural regions. Among of them 10 (14.7%) of women had previous cesarean sections Medical abortion was used the first time in 89.7% of women, the second time – 8.9%, the third time – 1.4%. About 2% of women came back to the hospital after misoprostol because they were worried (25% of them had previous cesarean section).
Results. The method was effective in 95.5% of cases. Three failures (4.5%) were recorded which included incomplete abortion (1.5% of cases), heavy bleeding (1.5% of cases), continuing pregnancy (1.5% of cases). In case of complications we performed vacuum-aspiration. We did not have cases of serious infections after medical abortions. The complete abortion has occurred after taken of misoprostol in the first 3 hours in 46.9% of cases, after 6-9 hours – in 49.4% of women, at the third day – in 2.6% of women and at the fifth day – in 1% of women.
Our study shows very high results of success and minimal complications of medical abortions in HIV-infected women at home (95.5% of cases). More than 80% of women were satisfied. Our data suggest that the use medical abortion at home is the safe effective alternative to surgical abortions for all women.
Even as the climate for sexual and reproductive health funding and research has become more tolerant, abortion in humanitarian settings remains under-studied. Systematic reviews have documented significant limitations of funding for abortion-related research as well as evidence gaps on both the need for and provision of safe abortion in humanitarian settings. Additionally, many implementing and research institutions lack the networks, skills and/or time to conduct challenging research in this complex environment. Evidence is needed to generate and sustain interest, document the scope of the problem, and ultimately to help promote an agenda for bridging this gap and turning research into action to meet women’s abortion care needs. This presentation will discuss the evidence gaps, types of needed research, promising partnerships, funding, and describe examples of on-going research and documentation.
Efficacy and tolerance of emergency contraception with levonorgestrel in a dose of 1.5 mg (Escapelle)
Vera Prilepskaya, Elmira Dovletkhanova, Patimat Abakarova, Elena Mezhevitinova Federal State Budget Institution "Research Centre for Obstetrics, Gynaecology and Perinatology", Ministry of Healthcare of the Russian Federation, Moscow, Russia - firstname.lastname@example.org
Objectives: To assess efficacy and tolerance of levonorgestrel-containing contraceptive Escapelle in women for emergency contraception. Materials and Methods: We investigated 35 women, aged from 18 to 39 (mean age 23.4+/-1.1) coming to the Centre for emergency contraception. All women visited the Centre during 48-96 hours after the moment of unprotected sexual contact. Nineteen women (54.3%) had the 1st phase of menstrual cycle, 16 (45.7%) had the 2nd phase. To exclude contraindications for hormonal contraception we conducted examinations (clinical, ultrasound, pregnancy test). One dose of Escapelle containing 1.5 mg of levonorgestrel was indicated to all patients. Results: Efficacy of Escapelle made up 97.2%. Pregnancy occurred in one case (2.8%) that was associated with the time period of more than 96 hours since the intercourse. In the 1st group 11 (58%) out of 19 women were noted to have menstruation delay, 5 had heavy periods (26.3%). In the 2nd group five women (31.2%) had menstruation delay for 3-5 days, shortening of the cycle was found in four (25%) women, heavy periods were in two (12.5%). Side-effects were registered in six women (17.1%). Out of them sickness was noted in four (11.4%), vomiting in one (2.8%), breast tension in one case (2.8%). Conclusion: Escapelle is a highly efficient and well-tolerated method of emergency contraception. Taking into account the fact that side-effects in the form of menstrual cycle disorders were found more often in women using Escapelle during the 2nd phase of the cycle it is necessary to recommend planned hormonal contraception. Efficacy decreases with the time period since the unprotected intercourse.
This paper reflects on findings from several recent studies on abortion in Scotland. These have examined experiences of earlier/later abortion, more than one abortion, and of working in abortion provision. Together they constitute a rich body of data illustrating manifestations of abortion stigma; feelings which abortion may evoke (such as shame, disgust), and ways in which stigma is resisted/rejected. Qualitative secondary analysis of these data highlights that negative attitudes toward abortion continue to prevail - and to shape experiences of those seeking and providing it – but that positive accounts also emerge and merit further attention. Foregrounding positive accounts contributes to understanding of abortion stigma, and of what alternative orientations to abortion might look like, in a way that is grounded in women’s lived experiences. Our analysis also suggests that, even in a context where it has been safely, legally provided for 50 years, women who have undergone abortion nevertheless find it difficult to escape cultural narratives which position it as highly negative and taboo. Our findings point to the need to further address abortion stigma and negativity head-on, and to collaboratively shift the narrative towards abortion positivity.
Challenges and barriers to accessing safe abortion services in Nepal
Mahesh Puri (Nepal)
Center for Research on Environment Health and Population Activities (CREHPA), Kusunti, Lalitpur, P.O. Box 9626, Kathmandu, Nepal
Abortion was broadly legalized in Nepal in 2002, and the policy implemented in 2004. Before legalization, abortion was treated as a criminal offence resulting in the imprisonment of women. Law and provision of services are necessary but not sufficient to guarantee access. The legal reform has certainly created a new paradigm requiring the framing of right-based polices and programmes by the government to be implemented in collaboration with non-governmental organisations and donors. Universal access to information and safe abortion services has the potential to significantly reduce the country's maternal mortality and morbidity. This paper examines the post legalisation challenges and barriers to accessing safe abortion services in Nepal. There are many obstacles those must be overcome before Nepalese women will be able to exercise their rights. Some of the major barriers and challenges are lack of knowledge about the law especially among rural women, inadequate access to safe and legal services, low economic status and high abortion fee, poor supportive environment including societal, cultural and religious attitudes, including stigma and not supportive attitude of rural men for women’s absolute rights to abortion and sex selective abortion. Due to all of these reasons, unsafe abortion continues to prevail in the country despite the four years of safe abortion service expansion. The prevention of unsafe abortion practices in the country and creating enabling environment for women and couples to access legal and safe abortion services as outlined in the safe abortion service procedure are daunting task and requires strategic interventions.