Counselling: How do women
feel about it? One of the differences regarding abortion laws
worldwide, concerns the presence of a pre-
abortion counseling session. The necessity of
this counseling for women seeking ﬁrst-trimester
abortions has been extensively debated.
Professionals often hold strong opinions on this
issue while the opinion of clients themselves is
not heard. Our study, performed in Flanders (i.e.
the Northern part of Belgium), asked 971 women
how they experienced this session. Results
showed that despite initial resistance towards
the session and high decisiveness regarding
the abortion, women valued the counseling
and felt signiﬁcantly better afterwards. Besides
making an informed decision, non-directive
and client-centered counseling sessions - as
they are organised in Flanders - can have other
advantages for women seeking an abortion.
Examples of these are: the provision of correct
information about the procedure and its
consequences, the consolidation of an already
made decision, receiving emotional support for
the choices made… As a result, we support the
continuation of this pre-abortion counseling in
Flanders, in addition to the existing medical care.
Deciding on the method and location for induced abortion: a Flemish survey study
Joke Vandamme1, Ann Buysse1, Inge Tency2, Guy T'Sjoen1 1University of Ghent, Ghent, Belgium, 2KAHO Sint Lieven, Ghent, Belgium - email@example.com
Introduction The Belgian health insurance system prescribes that women who opt for medical abortion should stay at the abortion centre when using mifepristone and misoprostol. A lot of women currently decide for the more rapid surgical method under local anaesthesia. In this study, we map the process of deciding for one of the abortion methods along the different stages of information provision. Method. During a four month study period in four Flemish abortion centres, all Dutch-speaking adult women with a gestational period of less than 8 weeks were asked to participate. During the first visit, they were questioned about the sources they had consulted to get information on the abortion methods and were asked for their initial preference. Afterwards, they were shown a standardized videotape with accurate information on both methods and were asked for their preferences again. In a second video, women learned about the possibility of performimg the misoprostol phase at home and were questioned about their final preferences. Results. Preliminary results show that, when entering the abortion centre, the majority of women (>70%) preferred medical above surgical abortion. Most of the women (>60%) sought information on the official abortion centre website. However, one in three had visited other websites and one in four got information from external professionals. After the provision of standardized information, the percentage that prefers medical abortion drops to 50%. If the misoprostol at home option were available, only one in five would still prefer medical abortion with use of misoprostol in the abortion centre. Conclusion. Flemish women may have an inaccurate idea about the current medical abortion process. The misoprostol at home possibility would be a good alternative for the ones who would otherwise decide for the surgical method as well as for those preferring medical abortion.
Distress and dyadic coping when opting for induced abortion: an interactional analysis within couples
Joke Vandamme, Ann Buysse, Tom Loeys, Guy T'Sjoen University of Ghent, Ghent, Belgium - firstname.lastname@example.org
Introduction. For decades, the psychosocial literature on induced abortion has focused on women's coping mechanisms. To date, little attention has been paid to the ways of dealing with an abortion decision from the male partner's point of view and no study has questioned how couples deal with it together. In this study, we investigate bidirectional relationships between dyadic coping mechanisms and both partners' emotional distress associated with the abortion decision. Method. In four Flemish abortion centres, Dutch speaking adult women with a gestational length of less than 8 weeks and their accompanying partners were asked to participate in a study on abortion method preferences (N=232 and 59 respectively). Both partners filled out a questionnaire in which the Dyadic Coping Inventory (DCI; Bodenmann, 2008), the Positive and Negative Affect Scale (PANAS; Watson et al., 1988) and the Impact of Event Scale (IES; Horrowitz et al., 1979) were included. The DCI measured received and provided positive and negative support, delegated dyadic coping (taking over responsibilities), common dyadic coping (dealing with the distress together), and satisfaction with the dyadic coping. The PANAS measured the presence of positive and negative feelings since one learned about the unintended pregnancy and the IES examined the degree of avoidance and intrusion since that moment. The Actor-Partner Interdependence Model will be used to investigate actor and partner effects of dyadic coping mechanisms. Results. Preliminary analyses show that the negative support that is provided to the partner is significantly affected by the negative support received from that partner, both for the abortion-seeking women as for their male partners. Detailed dyadic analyses and results will be discussed in the presentation. Conclusions. Partners can strengthen each other in negative support interactions during the unintended pregnancy situation. Counsellors should investigate the bidirectional coping process in couples who decide on induced abortion.
Access to and reality of abortion in Europe
Marcel Vekemans, MD, Ob/Gyn, Medical Advisor, IPPF, London, UK.
In Europe, access to safe abortion is much easier than in the developing world, de jure and de facto. Legally, 81% of 59 developed countries (10%, in underdeveloped countries) allow induced abortion without restriction as to reason. Only 12% of the European countries (very small ones, except IRL and PL) restrict abortion to “physical risk to the pregnant wife”. Illegal abortion is not necessarily unsafe, or difficult of access, or entailing prosecution. And “legal” does not mean “safe”, or “easy to obtain” (P). Many European women still recourse to “abortion tourism” for discrete or second trimester abortions. But, de facto, Europeans are not equal concerning access to safe abortion, which depends on other than legal variables: availability of trained staff, restrictions on types of providers and facilities (in-, out-patient), dissuasive counselling, “experts” commissions, waiting periods (UK), permission from parents (I, DK) or husband (Turk), negative cultural/religious influences causing delays in care seeking, lack of trust in confidentiality, costs involved (social security reimbursement?), providers’ “conscientious objection” (I, D, Ö). Abortion services up to the full extent of the law should be accessible everywhere: health care providers are legally bound to this be it through referral. “Underserved groups” (adolescents, refugees, illegal immigrants) are targets for expanding our social role. Legal and other restrictions (and popes’ admonishments) do not eradicate induced abortion, as shown all over the world and throughout human history. Nor do prevention, such as modern and emergency contraception, sex education, abstinence vows and ignorance-only education. In the US, 60% of 1.3 million abortions per year are contraceptive failures. The 1991 Tbilissi recommendation “From Abortion to Contraception” has not been fully implemented.
A lack of staff trained in abortion techniques (medical, counselling) is alarming. Young professionals might be less motivated. Most have not seen women die after induced abortion. Training is not given enough attention. Also, better pain control and post-abortion contraception, and more humane attitudes, are needed. More training “Centres of Excellence” could be developed (and train providers from the underdeveloped world, where 13% of the maternal mortality, 220 deaths every day, is due to unsafe abortion). In (mainly Eastern) Europe, there remain 600 deaths/year after unsafe abortion, related to high incidence of abortion in some countries, use of less safe techniques (vacuum should replace curettage), and, at times, poor quality of care.
Advocacy for less restrictive laws and for keeping alive adequate laws remains necessary, in front of the anti-choice movement. The battle is never won for ever. Decriminalization (“l’avortement hors du code pénal!”) is an option: leave this medical issue to the private sphere, abortion being a normal, natural part of reproductive life.
Thanks to the commitment of governments, NGOs, and international organizations (the European Union has shown commitment to the respect of the women’s rights), access to safe abortion is quite satisfactory in Europe, but not everywhere and not for everybody. Continuous efforts are needed to improve the situation and to defend the progress made.
Who is afraid of a woman’s right to self-determination?
Marcel Vekemans, MD, Ob/Gyn, IPPF Central Office, London, UK
For the species survival, new human life has to be protected: we all are “pro-life”.
However, humans can interfere with procreation, using abstinence, contraception,
abortion, infanticide, assisted reproduction. Decisions have to be made; limits have to be
set for health, financial, and ethical considerations. Societal organizations, religions and
individuals all want to interfere and take decisions based on tradition, cultural values and
beliefs, family and community goals, legality, religion, morality, philosophy, power, and
ambiguous “natural laws”. By definition, those who set limitative norms are opposed to, or
concerned by, a woman’s right to self-determination. With regard to abortion, the issue is
not about protecting life. This is easy to show: most so-called “pro-lifers” do not actively
oppose the death penalty, war, or environmental degradation, nor do they support
contraception and universal access to health care, or do they fight neonatal death (4
million mostly preventable deaths yearly, globally), or infant killing diseases such as
The issue in patriarchal societies is to guarantee a man’s paternity (“sola mater certa est”)
by controlling the female reproductive function and sexuality, imposing prenuptial virginity,
arranged marriages, dowry systems (a reason for sex selection), absolute fidelity and
harsh punishment of female adultery, confinement of women in-house, and abstinence-
only education. Contraception is made difficult accessing, violence against women (up to
“honour killing”) is used, women are humiliated by lower wages, genital cut-ting, denial of
general education. Traditional patriarchal systems are still protected by laws,
governments, judicial systems, religions, and by most men and women. However, more
and more leaders and governments understand that the death toll related to unsafe
abortion is not acceptable, and that imposed child-bearing is a serious denial of women’s
rights. Traditions being slow to reverse, many governments, parliamentarians, judges,
international and professional organizations, and most men and women, are still afraid of a
woman’s self-determination. Only for one-self, if confidentiality is ensured, is the right to
self-determination almost universally accepted.
Why safe abortion and contraception is a necessity for society
Marcel Vekemans (IPPF)
IPPF, London, United Kingdom
In traditional medicine, doctors know best. In the field of contraception and abortion, we health care providers indeed can easily prove that safe abortion is better than unsafe abortion, that contraception is better than unwanted pregnancy, that high contraceptive use decreases abortion rates, that access to safe legal abortion decreases maternal mortality and morbidity, and that huge cost savings for health systems can be made by eliminating unsafe abortion. Have we been able to convince all societies?
Societies are a heterogeneous mix of formal and informal groups, of diverse “communities”, and of individuals with divergent opinions. Forces are exerted in various directions. Concerning abortion and contraception, opposition to liberal attitudes comes from different sides, as influenced by traditions, social and economic pressures, convictions, religions, patriarchy, conservatism, fundamentalism, etc… As a result attitudes, behaviours and legislations vary hugely between countries, and over time. The claim that safe abortion is unacceptable in a society as a whole is a myth, as shown by the fact that abortions occur everywhere. But countries with restrictive abortion laws and/or limited access to contraception are evidence that significant parts of a society can refuse to accept or endorse our simple truth that “access to contraception and safe legal abortion is best”.
Demographic concerns also intervene: governments favour population expansion (to be strong, politically and economically; to have a powerful army; to avoid ageing of the population) or limitation (to avoid famine, impoverishment, exhausted resources, pollution), or remain unconcerned.
Pro-choice activists need to harness two opportunities: the diversity of societies and the ability to influence the development of laws and policies.
Access to safe legal abortion and to contraception is a basic human right, but very often essential prerequisites to exert these rights are lacking. Most importantly, almost everywhere education about reproductive health and sexuality remains problematic, despite efforts started a century ago. We still need to ensure, especially in the developing world, easy access to a well-developed health care system, equal status of women and men (a fundamental prerequisite for exerting women’s rights), and the elimination of gender exploitation and violence (zero tolerance).
We still need to convince many societies of the importance of contraception and safe abortion, and/or of taking action to make the services accessible.
How will we be able to secure the right for abortion? Around the world, in a lot of countries where abortion is legal, women have great difficulties to have access to abortion. A few countries have regulations that state CO is not permitted for health care providers working in the field of reproductive health (Sweden, Finland, Iceland).
Is this an actual solution for other countries? In most countries, individual CO is written in the abortion law and in medical law, and in Belgium, abortion providers agree to this.
Which woman wants to be treated by a team that has a negative feelings towards abortion? Anti-choice health care workers obliged to work in the field of abortion could make it a traumatic experience!
In countries where CO is permitted, our actual fight should focus on the following:
The state should ensure that abortion services are available in each region (in hospitals or in outpatient facilities) and make sure women know where to go. Public hospitals should offer an abortion service if they want to keep their state funding. Public hospitals should not have the “right” of conscience. Objector status of doctors should be public and quick referral to an abortion service mandatory. Providers, who work in abortion services, should choose to do so (conscientious commitment) so that women are treated with respect and empathy.
Doctors performing abortions should not be discriminated and should be dismissed from other tasks who need to be taken over by conscientious objectors. Women’s rights movements should encourage feminists to become doctors and young doctors to perform abortion and be proud to do so. We need to do a charm offensive to show that working in abortion care permits rich human encounters with women grateful to be able to decide about their future life.
Fears: sterility, sexuality, bleeding, infection
Anne Verougstraete MD
Gynaecologist; Brussels, Belgium
-Sjerp-Dilemma: Family Planning and Abortion Centre: Vrije Universiteit Brussel
-Hôpital Erasme: Université Libre de Bruxelles
What is the influence of fear of “sterility”on contraception use and abortion?
Is there a risk of sterility after induced abortion?
Is there an increased risk of spontaneous abortion, preterm delivery, stillbirth, ectopic
pregnancy, placenta praevia …. in a subsequent pregnancy?
Are women with short-term complications after induced abortion more at risk to have
problems in a subsequent pregnancy?
Is there a link between induced abortion and breast cancer??
What is the influence of sexuality on contraception use and abortion? What about
contraception use and sexuality? And what about sexuality after abortion?
What is the risk of bleeding and infection after abortion? What can we do about it?
The actual knowledge and evidence will be discussed.
How frequently is it done? Possible reasons for the huge regional differences
Anne Verougstraete (Belgium)
Sjerp-Dilemma-VUB: Family Planning and Abortion Centre: Vrije Universiteit Brussel; Hôpital Erasme: Université Libre de Bruxelles (Obstetrics), Belgium
Surgical abortion is a very safe procedure and with local anaesthesia it is safer than with general anaesthesia. This has been repeated by WHO (2003), the RCOG (2004) and ANAES (2001).
In Europe, there are huge regional differences in the anaesthesia used for surgical abortion, and in a given region, some hospitals perform the procedure only under local anaesthesia and others only under general anaesthesia. It seems very unlikely that these differences reflect the choice of women!
Possible reasons for the regional differences:
Conclusion. Local anaesthesia is, medically speaking, safer than general anaesthesia. With a proper technique (priming of the cervix, local anaesthesia and oral painkillers) and a good accompaniment, it is accepted by most women. Ideally, women should have the right to choose which anaesthesia they want for their abortion. In the workshop we will discuss how it is in your region, and the reasons why.
Anne Verougstraete, Gynaecologist, Family Planning and Abortion Centre Vrije Universiteit Brussel,
Hôpital Erasme Université Libre de Bruxelles (Obstetrics), Brussels, Belgium
Heath care providers usually advise women to wait until the next menses before starting hormonal contraception. The idea is to avoid the use of hormones in a beginning undetected pregnancy. An alternative is to start hormonal contraception immediately with a back-up birth control method for the first seven days. For long-acting methods (implants and injectables), the necessity of doing a pregnancy test after 2-3 weeks should be evaluated.
When women come for contraceptive advice, their motivation to start a method is high and the risk of an unwanted pregnancy may also be high. We therefore should have good reasons to delay the start of the chosen contraception. The advantages, disadvantages and management of quick start of oral contraception, patch, vaginal ring, implant and injectable will be discussed.
Extended use of hormonal contraception is becoming more common. A woman can chose continuous
use or insert a break every 3 or 4 months in the following situations: at the woman’s choice, headaches or migraine during the hormonal free interval, painful or heavy withdrawal bleeds, absent withdrawal bleeds, endometriosis, premenstrual syndrome, suspicion of decreased efficacy for any other reason.
The advantages, disadvantages, management and risks will be discussed. Quick start and extended use of hormonal contraception should be offered and discussed with women.
Special aspects: Minors, Virginity Anne Verougstraete(B)
Gynaecologist working in SJERP-DILEMMA VUB (family planning and abortion centre of the Flemish Free University in Brussels) and in Cesar De Paepe Hospital in Brussels.
Premarital virginity for girls is an important value in traditional Moroccan and Turkish culture and for a majority of men and women. This value seem to have more importance when the educational level is low. Most of the second-generation Moroccan boys in Brussels want to marry a virgin, and most girls agree.
The girls who have premarital sex usually bear the blame for having said “yes” and often carry the entire responsability if they get pregnant.
Due to conflicting norms and values, migrant girls may have more difficulties to use contraception properly.
In most families male dominance is the traditional norm and the girls have usually integrated the feminine role model since childhood. It is therefore often more difficulties for them than for European girls to be assertive and persuade unwilling boys to use condoms.
So the girls who break the traditional rules are not only more at risk for unwanted pregnancy but also for acquiring STI and HIV.
The selfesteem of the girls who lost their virginity is often low and they may be very anxious about their chances in future life.
In the workshop, the following topics will be discussed:
How do we deal with minor migrant girls who want an abortion?
What about parental consent??
Is it a good idea to use mifepristone and misoprostol??
Specific contraception counseling??
Specific psychologic support??
Should we do virginity repair???
if we do:
- which technique do we use?
- which recommendations can we make to providers dealing with a demand of virginity repair?
Pain and abortion: women’s perspective, including cultural aspects
Anne Verougstraete1 1-Sjerp-Dilemma-VUB: Family Planning and Abortion Centre: Vrije Universiteit Brussel, Brussels, Belgium, 2-Hôpital Erasme: Université Libre de Bruxelles (Obstetrics), Brussels, Belgium - email@example.com
Surgical abortion: Surgical abortion is a very safe procedure and with local anaesthesia it is even safer than with general anaesthesia. In Europe, there are huge regional differences in the anaesthesia used for surgical abortion, and in a given region, some institutions perform the procedure only under local anaesthesia and others only under general anaesthesia. It seems very unlikely that these differences reflect the choice of women! A growing number of women choose "not to be there" at the moment of the abortion, while others prefer to be in control even if this means they will feel some pain.
Given the choice, many women appreciate emotional support during the surgical abortion procedure; some may want respect for a desired scheme (silence, music etc). Recently hypnotic techniques have been introduced in medical care: it is now used in emergency medicine, during interventional radiology, diagnostic procedures and surgical treatments. In some hospitals breast cancer operations and thyroid operations are performed under local anaesthesia and hypnosis so that general anaesthesia is not needed. There is growing interest in also using hypnosis during abortion procedures to reduce anxiety and pain, in women who desire it.
Medical abortion: Most women prefer home use of misoprostol but it is important to maintain the option to reside in the medical setting for those who wish. At home, women appreciate the possibility to have personal phone support or support by mobile phone messages in order to better manage pain and bleeding by reducing anxiety and stress. Conclusion: Woman-centred care should respect pain management and some rituals women wish for their abortion. In a lot of settings, women do not have this choice!
Conscientious objection in Italy: is a ban the solution?
Silvio Viale Sant'Anna Hospital, Turin, Italy - firstname.lastname@example.org
In Italy abortion can be performed only in public hospitals and only by gynaecologists working in public hospitals. In Italy you cannot obtain an abortion at outpatient clinics. So conscientious objection is the bottleneck of the service. According to the latest available data, in 2011 the number of public gynaecologists was 5,036 of which 3,490 were objectors (69.7%) and 1,546 were non-objectors (30.7%). Given that in 2011 there were 111,415 abortions, we can say that the mean annual number of abortion for each non-objector gynaecologist was 72. For comparison it is to be observed that the average annual number of deliveries for each gynaecologist was 110. The actual situation varies greatly by region, with the mean ratio of 60 abortions for gynaecologists in northern regions and 112 in southern regions, but in general has changed little over the last few years. In 1998 total gynaecologists were 5,285, of which 3,338 were objectors (64%) and 1897 non-objectors (36%), with 138,357 abortions and 73 for each non-objector. Both the number of abortions and the number of non-objectors have gone down together. Since we cannot expect a change in the law in order to allow abortions at outpatient clinics and by other categories of doctors, we must ask ourselves if 1,546 is a sufficient number for the needs. There is one non-objector gynaecologist for every 7,189 women aged 15-44 years, with an abortion rate of 9.4 per 1,000. Probably the answer lies in reducing the number of departments of obstetrics, that in Italy are nearly 600, and deciding to perform abortion in the biggest ones. The answer is to establish an annual threshold of at least 1,000 abortions with more then 50% of non-objectors in these departments. The author does not think that the answer is to ban conscientious objection.
Death after medical abortion not linked to mifepristone
Silvio Viale Sant'Anna Hospital, Turin, Italy - email@example.com
The death of a woman of 36 years with no previous known medical condtions after a medical abortion in Turin last April 9 attracted great attention in the media, . The headlines were "death after RU486", but the first report of the medical examiner appointed by the coroner said that RU486 was not responsible for the death . The protocol was mifepristone 600 mg on the first day and gemeprost 1 mg on the third day. On the third day ketorolac 30 mg IM for pain was also administered together with methylergometrine maleate 0.2 mg IM to reduce blood loss. Shortly after the expulsion the woman developed shortness of breath and loss of consciousness followed by cardiac arrest. The first cardiac arrest occurred at around 12:30 and the woman died at 22:45 in the ICU. From the first evidence the autopsy did not reveal any relevant items. Unfortunately, this is not the only death that has occurred in Italy in 2014 after an abortion. Two other women died recently after an abortion. One woman died in Nocera Inferiore, near Salerno, from abdominal bleeding after surgical abortion in a woman with myomas and previous caesarean section. The other woman died in Turin from acute liver failure two days after a surgical procedure for missed miscarriage. In the first case the media interest was mostly local. In the second case the media didn't known about it. These three deaths remind us that there is no zero-risk in pregnancy and that, though rare, it is possible to die during an abortion procedure even in countries with advanced health care systems. Regarding the death after medical abortion that occurred in Turin, we can say that mifepristone is not responsible in any way.
Medical treatment of abortion and missed miscarriage: what's the difference in results?
Silvio Viale San'Anna Hospital, Turin, Italy - firstname.lastname@example.org
Objectives: We have compared the efficacy of medical treatment for abortions in women with missed miscarriages. The protocol was mifepristone 600 mg orally + gemeprost 1 mg vaginally two days after, eventually repeated once. Women didn't stay in hospital between mifepristone and gemeprost. Methods: Since April 2011, when mifepristone became available in Italy, until April 2014 we have performed 3545 medical abortions up to 7 weeks. Later we started to offer medical treatment also for blighted ovum and missed miscarriage up to eight weeks of development, regardless of the true gestational age. As at April 2014 we have performed 423 medical treatments of missed miscarriages and blighted ovum. Results: The overall success rate of medical management of abortion and missed miscarriage was 96.3%, with 147 surgical procedures out of 3968. For abortion the success rate was 96.5%, with 125 surgical procedures out of 3545. For missed miscarriage the success rate was 94.8%, a little less, with 22 surgical procedures out of 423. If we keep out the 32 cases in which the curettage occurred for failure in expulsion, 22 abortion and 10 missed miscarriage, the overall success rate rises from 96.3% to 97.1%. By doing the same for abortions and missed miscarriages we found that the success rate rise in both cases, from 96.5% to 97.1% for abortions and from 94.8% to 97.1% for missed miscarriage. Consequently, the rate of curettage drops from 3.5 to 2.9% for abortions and from 5.2 to 2.9% for missed miscarriages. Conclusions: The only significant difference is that medical treatment of missed miscarriage has a fourfold risk of failed expulsion compared to medical treatment of abortion, 2.4% versus 0.6%. With a success rate of 94.8% the medical regimen with mifepristone and gemeprost can be a routine alternative to surgical management of early fetal demise.
Vacuum aspiration before 7 weeks
Mike Vidot, Clinica El Sur. Sevilla. Spain
Until now pharmacological termination of pregnancy has been considered the method of
choice in pregnancies below 7 weeks. In our experience surgical vacuum aspiration is also
a safe and alternative method which can be used before 7 weeks, as long as a proper
preoperative surgical assessment is performed. This technique has numerous advantages
compared to the pharmacological method. It is as safe as the pharmacological method, but
with more advantages for the patient. The procedure is immediate, less cost effective for
both the clinic and the patient, reduces the psychological effects that an unwanted
pregnancy can cause, gives the patient the opportunity for immediate contraception after
termination of pregnancy and can be implemented in countries whereby anti-
prostaglandins are not available.
Why abortion is performed in Spain until 26 weeks
Mike Vidot, MD, Clinica El Sur, Sevilla, Spain
In Spain abortions can be performed based on a law of indications (Decree 9/1985; article
417), which has not been modified in posterior reforms of the Penal Code of Conduct.
This law states that abortion will not be pursued in Spain if it is practiced by a doctor or
under his or her supervision when certain circumstances are given:
- A pregnancy which results in a serious risk for the mothers’ physical and psychological
health, diagnosed by a specialized physician, without gestational age limits.
- Pregnancies resulting from rape can be performed up to 12 weeks.
- Pregnancies up to 22 weeks when the foetus presents a high probability of having
physical and psychological alterations certified by 2 different specialized physicians.
These physicians under no circumstances should be the ones who perform the
Hence, that’s why we think that in Spain we can consider that induced abortion is not
voluntary, but a necessity derived from a situation.
Also the WHO defines health as: a state of physical, psychological and social wellbeing,
not the mere absence of diseases.
Based on these 2 aspects (without gestational age limits where the mothers health is
concerned and the definition of health by the WHO), in Spain, the private specialised
clinics in abortion, interpret that if there is a criteria which estimates that a pregnancy is of
high risk for the mothers health, this can be performed without a gestational age limit,
understanding that an unwanted pregnancy alters the psychological and social welfare and
that her health is at risk.
On the other hand WHO in its Technical Resolution 461 defines abortion as ¨the
interruption of pregnancy before its viability¨.
The clinics of ACAI (Association of Accredited Clinics for Voluntary Interruption of
Pregnancy) interpret that according to WHO, as soon as foetal viability is given, it is not an
abortion and that the law could not be applied. Hence, based on the fact that foetal viability
is considered from 25 to 26 weeks onwards, pregnancies with healthy foetuses up to 26
weeks can be interrupted if there is a psychiatric report certifying that there is a risk for the
mothers mental health. Also, estimating that abortion is the best option in such cases
pregnancies are interrupted beyond 26 weeks when a foetal malformation is not
compatible with extra uterine survival or human dignity. In such cases a certificate of none
viability signed by 2 different obstetricians is required. This legal interpretation of the law
has not been questioned judicially until now.
This has converted Spain in a destination for abortion, mostly from the European
countries with Voluntary Interruption of Pregnancy laws which complicate the access of
women who are more than 12 weeks pregnant or those countries which have restrictive
laws regarding abortion above 22 weeks.
The Private Specialized Abortion Clinics have assumed also abortions which are not being
performed in Spanish public hospitals. They only accept those with foetal pathology until
22 weeks, pregnancies derived from rape or which puts in danger the mothers’ health.
The proposal of postpartum contraception is one of the recommended practices in the management of patients with childbirth (CNGOF recommendations post-partum 2015). Contraception should be chosen by the patient after a detailed explanation of the different contraceptive methods that can be considered based on her antecedents. Currently in France, contraception mainly proposed in the postpartum is the use of a micro progestin pill. Internationally, there are many countries offering post-delivery IUDs to women who wish to perform well on efficacy, tolerance and compliance. Patients are very often satisfied with being able to return home without having to worry about contraception. This technique is not yet part of practices in France. Firstly, we propose to evaluate the practices in France and the knowledge of the midwives and gynecologist-obstetricians and then we will present some result in a tertiary maternity unit.
Different strategies to legalize abortion: Successes and lessons from Portugal
Duarte Vilar (Portugal)
A short history of the politics on abortion in Portugal before 2007 will be presented, stressing the importance of the political instance in producing and maintaining restrictive laws and in denying access to legal abortion services, and explaining the main reasons and actors that were involved in this process.
Some of the main moral and political debates occurred in the context of the 2007 Referendum will be presented.
The new legislation issued from the referendum process and the pro choice victory in 2007 will be presented an analysed on its limits and also in its positive and innovative aspects.
An overview on 15 months of legal abortion in Portugal will be done, presenting the gains on women’s health and also the main current constrains to the right to legal abortion.
Duarte Vilar, Sociologist, APF Executive Director, Portugal
Co-author: Elisabete Souto, Psychologist, Help Line Opções Coordinator
In July 2007, following the pro choice victory in the Referendum of February 2007, the majority of the Portuguese Public hospitals, 3 health centers and 3 private clinics started to provide safe abortion cares.
This enormous change effectively provided an easy access of Portuguese women to safe and legal abortion cares. In 2009 19572 legal abortions were performed.
The new situation also implicated a change in the role of APF (the main NGO of S&RH&R in Portugal) taking into consideration our profile – we don’t provide clinical services and we work mainly on information, education training and advocacy. Since 2007, we have developed a large training program to service providers and we still are the main providers of training on abortion in the country.
At the same time, we have used our Helpline OPÇÕES as an observation post on the implementation of the law, and the quality of services. In fact, more than 1000 women contacted the help line and it was possible to use their testimonies to better understand eventual problems and barriers in the provision of legal abortion cares, all over the country. This continuous information flow permitted updated information and the identification of new issues to be worked along the training activities.
Another strategy is the dissemination and debate of research results with service providers. In this field,
APF produced a first qualitative research based on the women testimonies collected through OPÇÕES helpline and a quantitative and qualitative research on abortion recidivism will be presented in the beginning of 2011.
Also we have to say that APF, as an NGO always was and continues to be a network of service providers that use the NGO as a free space of discussion of their practices and problems.
Finally, APF produced a set of educational materials that have been provided to the NHS and, thus, to service providers, as a tool to be used with the women that attend the abortion services.
High failure rates of medical termination of pregnancy after the introduction to a large teaching hospital
D. Vitner, R. Machtinger, M. Baum, M. Goldenberg, E. Schiff, D.S. Seidman (Israel)
Department of Ob. & Gyn., Sheba Medical Center, Tel-Hashomer, affiliated to Sackler School of Med., Tel-Aviv University, Tel-Aviv, Israel
Background. The outcome of all 349 women who chose to undergo medical termination of pregnancy in a tertiary medical center during 2000-2003 was studied.
Methods. The success rates in two time periods (2000-2001 and 2002-2003) were compared in order to assess the effectiveness of medical abortion with mifepristone and misoprostol after its introduction to a large academic tertiary medical center.
Results. The success rates were overall disappointing and significantly declined over time (87.0% vs. 79.3%, p=0.029).
Conclusions. The continuing relatively high failure rate is probably due to the difficulty in defining clear sonographic criteria for treatment failure, and the complexity of a follow-up program implemented at a large teaching hospital by a broad staff with widely varying experience and knowledge of the new procedure.
Cervical priming – where is the evidence?
Helena von Hertzen (WHO), Geneva
Cervical priming before surgical abortion is especially beneficial for women with cervical anomalies or previous surgery, young women and those with advanced pregnancy, as they have a higher risk of cervical injury or uterine perforation. WHO Scientific Group, therefore, recommended routine priming for durations of pregnancy over 9 completed weeks for nulliparous women, for women younger than 18 years old and for all women with durations of pregnancy over 12 completed weeks.
Recent research, however, suggests that all women (and doctors performing the procedure) benefit from routine priming, especially when misoprostol is used. The use of laminaria seems to be outdated, as in comparative studies more complications were seen after laminaria than after gemeprost. Further, gemeprost has been shown to be associated with more side-effects and complications when compared to oral (0.4 mg) or vaginal (0.2 mg) misoprostol, although cervical dilation, operation time or bleeding are similar. Only the use of mifepristone can compete with misoprostol in efficacy and low rate of side effects, but its high price and the long interval required between the treatment and procedure makes it less attractive.
The optimal dose of misoprostol is 0.4 mg: lower doses are less effective and higher doses do not give any advantage, they only cause more side effects. The appropriate interval between misoprostol administration and vacuum aspiration is 3 hours, because shorter intervals are not sufficient for full priming effect, even if the dose is increased. Oral, sublingual and vaginal routes of administration of misoprostol have been compared, sublingual administration may give somewhat better results compared to oral administration, but has more side effects, but when compared to vaginal administration there does not seem to be a difference in efficacy, but in some studies women have reported more side effects after sublingual administration.
Cervical priming prior to surgical abortion
Helena von Hertzen (WHO)
Cervical priming before surgical abortion is especially beneficial for young women and for those in the advanced stages of pregnancy, with cervical anomalies, as they have a higher risk of cervical injury or uterine perforation. When the use of laminaria was the main method to prepare the cervix, the WHO Scientific Group on Medical Methods for the Termination of Pregnancy recommended routine priming for durations of pregnancy of over 9 completed weeks for nulliparous women, for women younger than 18 years of age and for all women with durations of pregnancy of over 12 completed weeks.
This recommendation may need to be review, as recent research suggests that all women may benefit from routine priming of the cervix with misoprostol: a WHO study involving 4791 women demonstrated that routine priming of the cervix with two misoprostol tablets of 200 µg administered vaginally 3 hours prior to vacuum aspiration in pregnancies of up to 12 weeks, decreased the need for further dilatation of the cervix, shortened the time to complete the procedure and significantly decreased the rate of incomplete evacuations. The use of laminaria now seems outdated, as comparative studies report more complications after laminaria than after prostaglandins.
The optimal dose of misoprostol is 400 µg: lower doses are less effective and higher doses only produce more side effects. The appropriate interval between vaginal misoprostol and vacuum aspiration is 3 hours; shorter intervals are not sufficient for full priming effect, even if the dose is increased. The interval may be shortened to 2 hours when misoprostol is administered sublingually. Only the use of mifepristone can compete with misoprostol in efficacy and low rate of side effects, but its high price and the long interval required between the treatment and procedure render it less attractive.
Cervical priming – the evidence
Helena von Hertzen, MD, WHO, Geneva,
Cervical priming before surgical abortion is especially beneficial for women with cervical
anomalies, for young women and for those with advanced pregnancy, as they have a
higher risk of cervical injury or uterine perforation. When the use of laminaria was the main
method to prepare the cervix, WHO Scientific Group recommended routine priming for
durations of pregnancy over 9 completed weeks for nulliparous women, for women
younger than 18 years old and for all women with durations of pregnancy over 12
This recommendation may need to be reviewed as recent research suggests that all
women may benefit from routine priming of cervix with misoprostol: a WHO study including
4791 women demonstrated that routine priming of cervix with two misoprostol tablets of
0.2 mg administered vaginally 3 hours prior to vacuum aspiration in pregnancies of up to
12 weeks decreased the need for further dilatation of the cervix, shortened the time to
complete the procedure and significantly decreased the rate of incomplete evacuation. The
use of laminaria now seems to be outdated, as comparative studies report more
complications after laminaria than after prostaglandins.
The optimal dose of misoprostol is 0.4 mg: lower doses are less effective and higher doses
only cause more side effects. The appropriate interval between misoprostol administration
and vacuum aspiration is 3 hours, because shorter intervals are not sufficient for full
priming effect, even if the dose is increased. Oral, sublingual and vaginal routes of
administration of misoprostol have been used. Only the use of mifepristone can compete
with misoprostol in efficacy and low rate of side effects, but its high price and the long
interval required between the treatment and procedure make it less attractive.
Summary of current evidence
Helena von Hertzen, MD, WHO, Geneva
During the last ten years the use of misoprostol has escalated in the area of reproductive
health due to its many advantages compared to other prostaglandins, and a substantive
scientific evidence has accumulated suggesting that misoprostol is safe and effective for
various indications, provided the dosage is correct. However, with very few exceptions,
misoprostol has not been licensed for use in obstetrics and gynaecology and this has left
many doctors unsure of their position regarding the use of an off-label drug.
Depending on the indication the strength of scientific evidence varies: experts will agree
e.g. on the benefits of misoprostol compared to other available options for labour induction
and medical abortion. Consequently, misoprostol has been included in the complementary
list of WHO Essential Medicines Library: 25 microgram tablet for the induction of at-term
labour; and the termination of pregnancy of up to 9 weeks (200 microgram tablets) to be
used after mifepristone pretreatment.
More research results may be needed to assess whether evidence-based guidance can be
given regarding other indications. Clinicians agree that cervical priming prior to vacuum
aspiration, or other gynaecological procedures, has become easier thanks to misoprostol.
In addition to the sequential regimen with mifepristone, misoprostol may be used alone to
induce abortion in settings where mifepristone is not available, provided a somewhat lower
effectiveness is acceptable. Misoprostol may also be useful in the treatment of incomplete
abortion, intrauterine fetal death, or in the prevention, and perhaps also in the treatment, of
postpartum haemorrhage, but experts need to agree whether there is enough evidence to
recommend its routine use for these indications.
Where is the evidence : results from clinical trials
Helena von Hertzen , MD, DDS,
Since 1990 Medical Officer, UNDP/UNFPA,WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
Managerial responsibility for the research initiated and carried out by the Research Group on Post-ovulatory Methods for Fertility Regulation, and for the research on breast-feeding with emphasis on its birth spacing effect.
The absolute efficacy of emergency contraception (EC) can only be investigated in placebo controlled trials. As such trials have never been undertaken, we do not know with certainty how effective emergency contraceptive pills are. It is evident that the copper IUD is very effective when used for EC, as there were no pregnancies among nearly 2000 women who had a copper IUD inserted after unprotected intercourse.
Different hormonal EC regimens have been compared in large randomized controlled trials (RCT), which constitute a sound tool to estimate a difference between treatments if properly conducted. It should be noted, however, that comparison of pregnancy rates between trials is subject to bias as women's characteristics and eligibility criteria usually differ. The main outcome in efficacy trials of EC is the occurrence of pregnancy, which is a rare event even if no EC is used: it has been estimated that even without treatment only some 8% of women would become pregnant after one act of unprotected intercourse. Thus, the trial size has to be large enough to provide power for treatment comparisons. Such large RCTs have demonstrated that both levonorgestrel and mifepristone are more effective and better tolerated than the regimen of combined oral contraceptives.