Misoprostol is an orally active prostaglandin
E1 analogue, which was ﬁrst licensed for the
prevention and treatment of NSAID-induced ulcers.
Because of its ease of use and strong uterotonic
properties, it quickly found uses in reproductive
health for the induction and treatment of abortion,
induction of labour and in the management of
postpartum haemorrhage. The manufacturer of the
original brand (Cytotec) was reluctant to encourage
its reproductive use for fear of a back-lash
from the antiabortion lobby. It therefore remains
off-label for reproductive health uses. This has
done little to stem enthusiasm for the drug with
protagonists pointing out that some of the most
important drugs in obstetrics (e.g. corticosteroids
to promote fetal lung maturity) remain off-label
for pregnancy use. Furthermore, the World
Health Organisation now considers misoprostol
an essential drug for a variety of gynaecological
indications. Clinicians are protected legally when
using it by the principle that doctors should act
according to ‘best practice’ as determined by
their peers. They should not be deterred by the
lack of licences, which were introduced to prevent
misleading claims by the pharmaceutical industry
rather than to guide clinicians’ prescribing. The
current situation is made easier by the widespread
production of generic misoprostol tablets, licensed
for reproductive health indications.
Janna Westerhuis MD, & Daan Schipper MD, medical director Bloemenhovekliniek, Heemstede, Holland
Since 1973, second trimester pregnancy terminations have been carried out using the D & E method introduced to us by Arnold Finks. This method has been subjected to adjustments by the introduction of prostaglandin induction with F2, Sulproston, E2 gel and now misoprostol. With the assistance of prostaglandin alone, a fully successful method has never been found within the reduced time frame of around 8 hours, which is dependant on the maximum time women can stay in the clinic (limit of 24 hours). Furthermore, it has always been strongly asserted in the Netherlands that attempts should be made to reduce the suffering of the woman during the abortion procedure as far as possible.
This is why there is still a great deal of emphasis placed on maintaining the skills and training of young doctors in this surgical technique. An approach has since been developed in Heemstede which occupies the middle ground between surgical abortion and procedures involving the use of medication.
The International Rescue Committee, a multi-sector humanitarian response organization, has embarked on an ambitious strategy to enhance the quality and reach of our programs to help our beneficiaries achieve key outcomes. A central pillar of IRC2020 is achieving gender equality, which requires improved sexual and reproductive health outcomes for women and girls. The global evidence demonstrating that the burden of unsafe abortion falls most heavily on poor women and girls in low resources countries, many of which are affected by conflict and natural disaster, led the IRC to develop a strategy to integrate safe abortion care (SAC) into our programs. This strategy has four main objectives:
As a result of this strategy, three IRC country programs offer safe abortion care and an additional 9 are developing strategies to do so. The IRC’s experience offers a road map and lessons learned for other organizations hoping to increase access to SAC and demonstrates that it is feasible to provide safe abortion care in humanitarian settings.
Ellen Wiebe, Canada
Background: About half of the women presenting for abortion in Vancouver are immigrants and most of these are from Asia. In previous studies of contraception and ethnicity, we found that the contraceptive practices and attitudes of immigrant women differ from those reported by other Canadian women. Specifically, we found that among Chinese and Korean immigrant groups in Vancouver, women expressed a deep suspicion towards hormonal methods of contraception, such as birth control pills, and were reluctant to use them. This study examined the experiences, attitudes and beliefs of immigrant women with regard to contraception in order to identify difficulties involved in accessing contraception in Canada. Our main concern was to understand more about the barriers for women accessing contraception prior abortion and if there were more barriers for immigrant women.
Method: This was a survey of women presenting for abortion using a questionnaire asking about women’s usage and experiences of both hormonal contraceptives and natural family planning methods, their attitudes towards medical contraceptive methods (hormonal and intrauterine), any barriers to contraceptive access they have encountered and the sources of information women rely on to make their contraceptive decisions. The site was an urban abortion clinic and the questionnaires were available in English, Chinese and Punjabi. Data was entered into an SPSS database for statistical analysis. The analysis included an examination of the differences in contraceptive practice, experience, and attitudes between immigrant women and other Canadian women, as well as a needs assessment.
Results: Of the 1000 subjects planned for this study, we have data on 143 at the time of writing this abstract. Of the 77 immigrants, 64% had previously used hormonal contraception compared to 94% of the 62 non-immigrants (p=<.001); 71% of the immigrants compared to 88% of the non-immigrants believed hormonal birth control was safe (p=.02); 25% of immigrants compared to 12% of non-immigrants had some problems accessing contraception; 30% of immigrants compared to 15% of non-immigrants had become pregnant “counting safe days” (p=.04).
Conclusion: More immigrants were using less effective methods of contraception when they got pregnant and they had more difficulties accessing contraception prior to the abortion. When the data is complete, we will be able to understand more about which groups of immigrants have the most difficulties. By determining the extent of inadequate information about contraception and barriers in access to contraceptive methods in immigrant women, we may be able to help plan solutions.
Comparing side effects of hormonal contraceptives in East Asian and Caucasian
Ellen R Wiebe MD, Konia Trouton MD, Amy Fang,
University of British Columbia, Vancouver BC, Canada
Introduction: Our previous studies in East Asian women have found that they perceive oral
contraceptives to be dangerous and to have too many side effects. The purpose of this
study was to compare side effects and discontinuation rates in East Asian and Caucasian
Method: This was an observational cohort study of usual care. Chinese, Korean and white
Caucasian women were recruited at two urban freestanding abortion clinics. These women
were given one package plus a prescription of Alesse, Tri-Cyclen, Yasmin or Evra.
Questionnaires in Chinese and English asked about the side effects and/or reasons for
Results: Out of the 212 women recruited, there is follow-up data on 161. There were 65
Caucasians and 96 Asians. These two groups of women were similar with respect to age
(mean 25 years), education (mean 14 years) and obstetrical history (mean 0.2 births),
except that the East Asian women had had more abortions than the Caucasian women.
There was a significant difference in the discontinuation rates; more East Asian women did
not start or quit after taking just a few pills in the first month (40% vs 17%). There was
more acne in the Caucasian women (22% vs 7%). There was more nausea in the East
Asian women (20% vs 7%).
Conclusion: In women who decided to use hormonal contraception after an abortion, rates
of discontinuing or not starting hormonal contraception were higher in East Asians
compared to the Caucasians. Side effects were different in the two groups, indicating there
might be different brands that would be more suitable for East Asians than for Caucasians.
Objectives: The purpose of this pilot study was to ensure that the insertions and early expulsion rates were acceptable in order to plan a larger trial with the IUB.
Methods: This was an observational pilot case series. The inclusion/exclusion criteria were similar to those for non-study patients receiving IUDs. Women aged 18-50 requesting intrauterine contraception were enrolled. Exclusions included recent pelvic inflammatory disease, genital malignancy and anaemia. The main outcome measure was expulsion by the 6-8 week follow-up visit. Ease and pain of insertion as well as complications and side-effects were also recorded.
Results: 50 women had IUBs inserted between January and April 2014 by a single clinician in Canada. Only 6 (12%) had had a previous birth and 16 had had previous IUDs. There were no failed insertions and 43 (86%) insertions were found to be "easy". The mean pain score for insertion was 5.3/10. There were 32 follow-up visits 6-8 weeks post-insertion by May 2014. There were 8 expulsions (one post medical abortion and accompanied by a "gush of blood"), there was one removal for pain and bleeding and no other complications.
Conclusions: Including the first study of 15 women, there are now data on 65 insertions with no problems, so the insertion technique and equipment for IUBs can be considered acceptable. The early expulsion rate appears too high and may require some change in design. The lack of other complications warrants further studies with this innovative product.
How can we best train primary care providers to
Wiebe, E; Trouton, K; Malleson, R
University of British Columbia, Canada
The purpose of this study was to determine how best to train
primary care providers (PCP) to insert IUDs. This was a mixed
method study with interviews and questionnaires of family
physicians and nurse practitioners who presented for training in
three different settings: at a 1-hour workshop, a one-on-one
20 minute training at an exhibit booth or a 4-hour session in-
clinic with patients. Questionnaires were completed at the time of
the training and a convenience sample was interviewed 2–
12 months later. The interviews were audio-taped and transcribed.
On-going theme analysis was done and the interview guide was
changed to explore some themes in more depth in subsequent
interviews. A total of 71 PCPs completed questionnaires at the
time of IUD insertion training and 19 of these were interviewed
2–12 months later. The questionnaires revealed a signiﬁcant lack
of knowledge and skills; for example, 52% had inserted no IUDS
in the past and 65% had never recommended an IUD to women
<21 years of age. In the interviews, 16/19 PCPs said the training
allowed them to start or to increase IUD insertions and 7/19 were
now taking referrals from other clinicians. The barriers they
identiﬁed included the lack of numbers in primary care, lack of
support by colleagues and lack of equipment. Many said they
would like more support after the training. From this study, we
now have more information about how to improve knowledge
and skills training and support for PCPs who wish to insert IUDs
in their practices.
Is there a place for observing fertile periods?
Ellen Wiebe (Canada)
Willow Women’s Clinic, 1013-750 West Broadway, Vancouver, BC V5Z 1H9, Canada
In abortion clinics we see many women who conceived while taking hormonal contraception, usually the “pill”. It is important to understand why these women have failed contraception in order to help with them with their choices for the future.
Often women blame themselves or are blamed by others for the failure because they missed a pill or were not “compliant”. A study using computerized pill packages showed that over 60% of women who did not get pregnant missed at least one pill each month. Therefore, missing one or two pills in a cycle does not explain the failure. The most important risk factor for oral contraceptive failure is a previous failure according to a study of 769 women who presented for an abortion saying that they had taken all their pills. Anecdotally, it was observed that many women presenting for abortion had conceived early in their cycles. Our hypothesis was that there is a subset of women having contraceptive failure because they ovulate early and therefore their method of contraception is ineffective.
We did a retrospective chart survey of data we normally collect in our abortion clinics, i.e., the LMP dates, whether the cycle is regular and the last period normal, the gestational age of the pregnancy and what form of contraception was used during the month of conception. We reviwed 913 charts reviewed of women presenting for an abortion with an intrauterine pregnancy of less than 63 days gestation as determined by endovaginal ultrasound and who said they were “sure” of the date of their last normal menstrual period. Their mean age was 28.4 years with a range of 14 to 47 years. The mean gestational age was 42.3 days with a range of 32 to 63 days. About half were white Caucasians and most of the rest of Asian descent. The mean cycle day of conception was 14.6 with a range of 1 to 40 and the mode was 15. There were 26/99 (26.3%) of women using cyclic hormonal contraception who conceived before Day 10 of their cycle compared to 100/679 (14.7%) using all other forms of contraception. (p=.004). There were no other differences in day of ovulation with respect to age, ethnicity.
Conclusion. There is an important subset of women who ovulate early and therefore the usual pattern of hormonal contraception may have a higher failure rate for these women.
Knowledge and attitudes about contraception and abortion in women of five countries: US, Canada, UK, France and Australia.
Ellen Wiebe1, Lisa Littman3, Janusz Kaczorowski2 1University of BC, Vancouver, Canada, 2University of Montreal, Montreal, Canada, 3Mount Sinai, New York, USA - email@example.com
Objectives: The purpose of this study was to answer the following questions: 1. Do anti-abortion women differ from pro-choice women in their knowledge about health risks associated with abortion and contraception? 2. Which countries and demographic characteristics are associated with lower knowledge about abortion and contraception risk? Methods: We surveyed an on-line sample of women aged 18-44 from US, Canada, UK, France and Australia (at least 200 per country) in January 2013 using Survey Monkey Audience panel. The survey asked demographics, attitude to abortion and knowledge about risks of IUDs and abortion vs births. For the purpose of this study, women choosing the response, "Abortion should be allowed for ANY reason, because no one should be forced to continue a pregnancy" were categorized as "pro-choice" and those choosing one of other responses were categorized as "anti-choice". Results: Within two days, 1117 surveys were completed: 233 in Canada, 223 in the US, 230 in the UK, 221 in France and 210 in Australia. Almost half (47.1%) of the participants were classified as pro-choice because they indicated that women should be allowed to have an abortion for any reason in the first 3 months: 38.7% in Canada, 37.1% in USA, 42.0% in UK, 68.7% in France and 53.6% in Australia (p<.001). Women classified as having anti-choice beliefs were more likely to provide incorrect answers to all 10 knowledge questions about abortion and contraception (p=<.001). There were few differences in knowledge between the women from different countries. Conclusions: Women from these 5 countries were similar in terms of their knowledge about the risks of abortion and contraception. The majority of women gave incorrect answers to the knowledge questions. Women classified as anti-choice, in all five countries, were more likely to overestimate the risks of both abortion and contraception.
Misconceptions about termination of pregnancy
risks in pro-choice and anti-choice women having
Wiebe, E1; Littman, L2
1 University of BC, Canada;2 Mt Sinai School of Medicine, USA
Misinformation that exaggerates the risks and sequelae of
pregnancy termination is common. The purpose of this study was
to answer the following research question: Do anti-choice women
having a termination of pregnancy (TOP) differ from pro-choice
women having TOPs in their knowledge about health risks
associated with TOP? This was a questionnaire survey of women
having TOPs in an urban free-standing TOP clinic. The
questionnaire was given to women when they arrived for their
ﬁrst clinic appointment and asked about women’s knowledge,
attitude to TOP, where they received their information as well as
demographics. Women with anti-choice attitudes were compared
to pro-choice women with respect to their knowledge of risks. In
228 completed questionnaires (94% response rate), 75% of
surveyed women said that one ﬁrst trimester TOP had greater or
equal health risks compared to childbirth, 7% said that TOPs
increases the risk of breast cancer, 29% said TOP increases the
risk of depression and 26% said that TOP increases the risk of
infertility. When asked about their attitude to pregnancy
termination, 35% women said that there were reasons why some
women should not be allowed to have a TOP. These anti-choice
women were more likely to believe that TOP caused infertility
(40% vs. 17%, P = 0.001) and more likely to believe that women
had more depression after a TOP than childbirth (39% vs. 25%,
P = 0.03). From this study, we concluded that misinformation
about the risks of TOP is common in women having a
termination and anti-choice women have more misconceptions
about the risks than pro-choice women.
Pain management in abortion
Ellen Wiebe MD,
University of British Columbia, Vancouver BC, Canada
Adequate pain control during abortion remains an important challenge in abortion practice.
Pain control methods include general anesthesia, conscious sedation using a narcotic
(usually fentanyl) and sedative (usually midazolam), local anesthesia, oral analgesics,
misoprostol and „verbal anesthesia“. A survey of 640 women from a random sampling of
National Abortion Federation clinics found that the average pain score on an 11-point
scale was 4.65 for abortions performed using conscious sedation and 5.2 for abortions
performed under local anesthesia.
There is evidence that a number of specific techniques and drugs reduce the pain of an
abortion procedure including: buffering the pH of the local anesthetic, using a deep
injection technique, injecting slowly, pre-operative ibuprofen and cervical preparation with
misoprostol. Different surgeons have different pain scores using the same medications
and basic techniques indicating that actual surgical technique also affects the pain scores.
Anxiety and depression scores are highly corelated with pain scores and various methods
of reducing anxiety such as music, low lights, distraction, relaxation techniques etc can be
One of the greatest challenges facing a medical director of an abortion clinic is changing
the behaviour of the doctors working within that clinic to improve patient care and
specifically to reduce the pain experienced during the abortion procedure.
Ellen Wiebe MD, Lori Brotto PhD, University of British Columbia Vancouver, Canada
Objectives: To determine the rate and characteristics of women who reported mood and/or sexual side effects with previous hormonal contraceptives. Three cohorts were compared: women presenting for abortions, for IUDs or for primary care.
Method: Women presenting for abortions or IUDs at an urban women’s clinic were given a questionnaire in the waiting room asking if they have ever used hormonal contraception in the past and, if yes, whether they ever had problems with sexual or mood/irritability side effects from hormonal contraception. Women age 15-50 presenting for primary care at family doctors offices were given the same questionnaires. Descriptive statistics were prepared to discover the rate of these side effects and compare the women who had or did not have these side effects. The three cohorts were compared.
Results: There were 1243 women who completed questionnaires; 77% (954) had previously used hormonal contraception and 169 of these were from primary care, 560 were abortion patients and 221 were IUD patients. Of the ones who had previously used hormones, 51% (482) said they had at least one mood side effect on at least one brand and 38% (358) said they had at least one sexual side effect on at least one brand. Self reported ethnicity in these women was: White/Caucasian 66% (663), East Asian 17% (161), South Asian 8% (71), other 9% (88). The three groups of women who had used hormonal contraception were similar except that the primary care group were older (p<.001) and had a higher proportion of Caucasians (p=.009). The 289 women who had never used hormonal contraception were less likely to be Caucasian (p=<001), more likely to have children (p=.003) and had less education (p=.001).
Women presenting for abortion and primary care had similar rates for all side effects but women presenting for IUDs had higher rates of mood side effects (p=.002). Women who complained of sexual side effects were more likely to also complain of mood and physical side effects (p=<.001). Women who complained of mood side effects were more likely to be younger (p=.03), unmarried (p=<.001), nulliparous (p=<.001) and presenting for an IUD rather than primary care or abortion (p=.002). Women complaining of sexual side effects were more likely to have more education (p=.03), be unmarried (p=.02) and nulliparous (p=.004). Caucasian and South Asian women complained about more hormonal side effects than East Asian women (p=.001).
Conclusion: Women have a high reported rate of sexual and mood side effects from previous hormonal contraception. These rates are similar to two studies which found sexual and mood side effects the most important reasons women discontinued hormonal contraception.
The feasibility of offering medical abortions by telemedicine: two years’ experience
Ellen Wiebe1 ,2, Cheryl Couldwell2 1University of BC, Vancouver, Canada, 2Willow Women's Clinic, Vancouver, Canada - firstname.lastname@example.org
Objective: To describe the results of our programme of providing medical abortions by telemedicine. Methods: We did a retrospective chart review May 2012 - May 2014. Women saw a physician and counsellor by Skype videoconferencing for screening, information and consent. They went to a local laboratory for hCG tests for initial screening, the day of the medication and one week later. The medications were couriered or a prescription was faxed to a local pharmacy. At the follow-up visit by Skype we discussed her experience and her blood test results. If the hCGs had fallen by 80% in one week, we told her the abortion is completed and she needed no further follow-up. If she needed more medication, surgery or further blood tests, we arranged these. See www.willowclinic.ca. Results: In 24 months we saw 23 women for medical abortions by telemedicine and 65 were seen in clinic for the first visit and booked for telemedicine follow-up. Of the 88 women, three women were lost to follow-up (3.4%), four had surgery (4.5%) and 14 (15.9%) needed another follow up (more misoprostol or just another hCG). During that time, we saw 3757 women for the usual in-clinic medical abortions. Conclusions: This method of providing telemedicine abortions is feasible in our setting and may improve access to abortions. The main innovation in this programme is that the patients were in their own homes using their own technology (a computer or smart phone) and yet we provided the same physician and counseling services as we did in our clinic. Most women prefer to come to the clinic.
Ellen Wiebe, Canada
Most of the common complications of surgical abortion (such as incomplete abortion leading to bleeding, pain and infection, missed ectopic pregnancy, and failed abortion) can be avoided if the procedure has been verified to be completed. The National Abortion Federation Clinical Practice Guidelines state that “either tissue exam or ultrasound must be used to confirm evacuation” in all cases but that tissue exam should be used when no fetal pole has been seen by ultrasound pre-op and also in second trimester cases. This presentation will go through the practical details of verifying completion of the abortion through tissue examination, post- and intra-op ultrasound as well as using serial beta HCG measurements for cases with inadequate tissue.
Women’s perceptions of viewing ultrasound before
termination of pregnancy: comparing ﬁrst and
Wiebe, E; Trouton, K
University of British Columbia, Canada
Objectives: The purpose of this study was to gain a better
understanding of women’s choices, perceptions and experiences of
viewing the ultrasound before having a ﬁrst or second trimester
termination of pregnancy (TOP).
Methods: A questionnaire was offered to women prior to their
ultrasound asking if they wished to view it. For women who chose
to view the ultrasound, a second questionnaire asked them about
their experience. Women in the ﬁrst trimester (up to 12.0 weeks
by ultrasound) were compared to those in the second trimester.
Results: There were 234 women who completed the ﬁrst
questionnaires: 172 ﬁrst trimester and 62 second trimester. Of the
ﬁrst trimester patients, 50% (86) and of the second trimester
patients 47% (29) wanted to see the images (NS). More second
trimester women were unsure about how they would feel about it
(P = 0.01). There were 77 ﬁrst trimester and 27 second trimester
patients who completed the second questionnaire. When asked if
viewing the ultrasound made it harder emotionally, 21% (16/77)
of the ﬁrst trimester patients and 44% (12/27) of the second
trimester patients said ‘yes’ (P = 0.01).
Conclusions: About half of the women in this study wanted to see
the ultrasound before the TOP. Second trimester patients were
more likely to be unsure about what to expect and were more
likely to ﬁnd it harder emotionally. It is important that we
prepare our second trimester patients more carefully for the
experience of viewing the ultrasound.
Women’s perceptions of viewing ultrasounds before and products of conception after an abortion
Ellen Wiebe (Canada)
Willow Women’s Clinic, 1013-750 West Broadway, Vancouver, BC V5Z 1H9, Canada
Introduction. Anti-choice organizations often use pictures of ultrasounds and products of conception in their campaigns. In the past, it was common for staff at abortion clinics to prevent women from seeing the ultrasound pictures (US) before the procedure or the products of conception (POC) because they thought it would upset them unnecessarily. In recent years, it has been more common to offer the choice. There have been no reports published on women’s perceptions of seeing POC at the time of their abortions. There is only one report about US showing that many women want to see US and concluding that women should be offered a choice. The purpose of this study was to offer women the choice to view US and POC and discover what the experience was like for them.
Data-Collection Methods. This was a questionnaire study of women presenting for abortion. Before the ultrasound and procedure, women answered questions about whether they wanted to see the US and POC and what they expected to see and feel. Those women who chose to view the US and/or POC were asked about their perceptions afterwards.
Summary of Results. There were 311 women who answered the first questionnaire about ultrasound and 214 (68.8%) chose to view. Women were more likely to choose to view if they were younger (p=.04), had no children (p=.001) or were East Asian (p=.03). Of the women who chose not to view the US, 43% expected that it would make it harder on them emotionally compared to 10.2 % of the women who chose to view. After viewing the US, 209 women answered the second questionnaire and 34 (16.2%) said they found it harder emotionally. Of 452 women who answered the first questionnaire about POC, 123 (27.2%) wanted to view. There were 117 women who answered the follow-up questionnaire about viewing POC and 18 (15.4%) said it was harder emotionally. Comments included “it made it easier”, “I thought I would see more”.
Conclusion. Offering women the choice to view the ultrasound and the products of conception after first trimester termination allows women opportunities to explore personal preferences. For most women who choose to view, it is a positive experience and may improve the quality of services for abortion care.
FAQ, Frequently Asked Questions in abortion care
Ellen Wiebe1, Philippe Faucher2 1University of BC, Vancouver, Canada, 2Hôpitaux Universitaires Est Parisien, Paris, France - email@example.com
Women presenting for abortion come with questions, both voiced and unvoiced. They often believe misinformation about exaggerated risks of infertility and depression and many are worried about pain. Abortion providers want to choose the best protocols and to relieve the unnecessary anxiety and pain. In this session we will address four issues. 1. Pain control: How can we best relieve the anxiety about pain and the pain of medical and surgical abortions? We will discuss the use of local and general anaesthesia, intravenous sedation, oral medications and non-pharmaceutical methods of pain control. 2. Antibiotic prophylaxis: What is the evidence about preventing endometritis in medical and surgical abortions? We will present the number needed to treat (NNT) with antibiotic prophylaxis in order to prevent each case of endometritis so that we can make the best choices for our patients. 3. Reproductive outcome: What is the actual risk of infertility (including Asherman's syndrome), miscarriage, premature delivery and abnormal placental insertion after abortions? We know these risks are low, but we need to address the anxieties of our patients as well as our colleagues. 4. Long-term sequelae: What are the actual risks of psychological problems and of breast cancer after abortions? There has been so much bad science on these topics and we need to assess the validity of the evidence. We will also address the issue of how to communicate this evidence effectively to our patients and our colleagues.
National guidelines on Rhesus (Rh) testing and treatment with Rh (anti-D) immune globulin (RhIg) for spontaneous and induced abortion vary between countries. Rh alloimmunization (also called isoimmunization) may harm subsequent pregnancies, but there is a lack of evidence that this occurs in early gestations. We should stop testing Rh status and administering RhIg to women having an induced or spontaneous abortion at early gestations if this is shown to be unnecessary, because this interferes with access to abortion and incurs extra cost. In the Netherlands, the policy is to not treat Rh-negative women having medication-induced or spontaneous abortions under 10 weeks’ gestation and surgical abortions under 7 weeks’, while in Canada all Rh- negative women are treated. We compared the clinically significant Rh alloimmunization rates in Canada and the Netherlands to determine whether the Dutch policy could be safely adopted by other countries. National guidelines from Canada and the Netherlands were obtained for the period of 2006 to 2015, and public databases were consulted to obtain national rates of abortions, births, Rh negativity, and the number of women with clinically significant perinatal antibodies. For Canada, the total fertility rate was 1.56, the abortion rate was 1.9%, and the Rh negativity rate was 13.0%. For the Netherlands, the total fertility rate was 1.66, the abortion rate was 1.2%, and the Rh negativity rate was 14.5%. In Canada, out of 573,206 samples tested in pregnant women, 0.0043% had clinically significant perinatal antibodies. In the Netherlands, out of 1,816,457 samples tested, 0.0040% had clinically significant perinatal antibodies.
This provides evidence that the Dutch policy of not treating Rh-negative women having medication-induced or spontaneous abortions under 10 weeks’ gestation and surgical abortions under 7 weeks’ can be safely adopted by other countries.
Psychosocial background factors and mental health-consequences of
induced abortion in Austrian women
Erika Baldaszti and Beate Wimmer-Puchinger
Ludwig Boltzmann Institute for Women’s Health Research, Vienna, Austria
Objective:The aim of this study was to gain knowledge about the role of psychosocial conditions, contraceptive use, partnership and sexuality in the decision-making process about unplanned pregnancies of Austrian women seeking abortion. Furthermore aspects of choosing medical or surgical abortion and the prevalence of post-abortion depression are addressed.
Materials and methods:350 women who underwent surgical abortion and 227 women choosing medical abortion answered a questionnaire after abortion; as controls 400 women continuing pregnancy answered after week 12 of gestation. A follow-up questionnaire was administered three months after abortion.
Results:Women who decided to terminate pregnancy were found to have more often instable partnerships. At the time of conception 40% of women undergoing an abortion had not used any contraceptive method, of those who did, 50% had used condoms; dissatisfaction with contraception was high. Comparing the medical to the surgical method of abortion satisfaction of women with both procedures is high. Depression score assessed by means of HAD Depression Scale was not increased at time of abortion or three months after. At time of abortion half the participants felt sure about their decision for termination of pregancy, three months after abortion two thirds of the women had the feeling that the decision for abortion was right.
Conclusions:Once more our results indicate that prevention of abortions is a matter of making contraceptives more accepted and easily obtainable for all groups in society. All women surveyed in this study decided to terminate pregnancy after a thoroughly reflexion about the basic conditions of their life. This can be seen as the main reason that mental health consequences after abortion like feelings of guilt, fear or depression were within a normal range.
Alternative ways for follow up Women who choose outpatient medical abortion
are typically given an appointment for a follow up
visit several days to two weeks after they have
used the medications. Yet almost no women
require intervention or additional treatment at
such follow up visits. Providers and women have
sought safe ways to reduce the number of women
who need to return to the clinic. This presentation
discusses strategies to reduce the need for
universal return visits, including telemedicine, use
of various electronic media, and the development
and promise of semi-quantitative pregnancy tests,
including data from recent research.
Misoprostol alone for abortion
Beverly Winikoff, MD, MPH,
Gynuity Health Projects, New York, USA
In places where mifepristone is unavailable, misoprostol has emerged as an important
basis of alternative medical abortion regimens. Both methotrexate + misoprostol and
misoprostol alone have been used successfully for this purpose. While it appears that
regimens of methotrexate + misoprostol may be more effective than misoprostol alone,
other considerations have made misoprostol alone a more commonly used alternative
outside of established services. The most effective regimens of misoprostol alone for early
first trimester abortion have efficacy >85% and < 90%. Misoprostol may also be used
alone for induction of abortion after 63 days’ LMP. So far, the vaginal route has been the
most widely studied and commonly used route of administration for this indication, but it is
likely that other routes, such as buccal and sublingual misoprostol, will have similar
efficacy. This presentation will discuss the efficacy, safety, and side-effects of such
alternative medical abortion regimens, as well as issues of cost. The role of non-
mifepristone medical abortion will be explored in circumstances where abortion services
are poor or non-existent as well as in circumstances where abortion services are well-
developed but mifepristone is unavailable.
How do women manage antibiotic pills after medical abortion?
Laura Frye, Erica Chong, Beverly Winikoff Gynuity Health Projects, New York, USA - firstname.lastname@example.org
Is it time to move away from routinely giving doxycycline to medical abortion patients? Objectives: Routine provision of antibiotics following medical abortion is common, yet practitioners and professional societies differ on the utility of this practice. Our study compares the side-effects experienced by women who were prescribed doxycycline following medical abortion to those who were not and assesses the adherence to one regimen. Methods: 581 women seeking medical abortion were enrolled in this prospective, observational study in nine study sites. They were recruited from 1) clinics that routinely prescribe a seven-day course of doxycycline (Doxy Arm) and 2) clinics that do not routinely prescribe any antibiotics (No Doxy Arm). Seven to fourteen days following the administration of mifepristone, women were asked to self-administer a computer-based survey. The survey asked about side effects experienced (both arms) and adherence to the regimen (Doxy Arm only). Results: Self-reported adherence to the doxycycline regimen was moderate: 44% reported missing at least one dose and 34% stopped taking the doxycycline before 7 days. There was a trend toward increased nausea in the Doxy Arm (48% vs. 41%; p=.06) and a statistically significant difference in vomiting (25% vs. 19%; p=.03). A small but noteworthy number of women were confused about various aspects of the different medicines they received or were prescribed, including misunderstanding the purpose of a medicine, claiming to not have received a drug despite medical chart confirmation and noting costs of filling prescriptions that were not received. Implications: In the absence of robust evidence that prescribing 7 days of doxycycline following medical abortion is effective at reducing serious infections, these data can assist in deciding whether routine provision is the most appropriate strategy. Given the limits of any patients' ability to follow multiple and varied instructions, it is worth considering the impact of adding doxycycline, especially when it is frequently advised to be taken with an anti-emetic.
Sexual Education Measures in the Framework of the Vienna Women’s Health Programme
Angelika Wolff , Project Management, Vienna Women’s Health Programme
In general, there has been a downward trend in teenage pregnancies in Vienna and also in Austria. In 2002 the number of children born to mothers under 20 years of age dropped by 2,000 compared to 1993. All in all, however Austria ranks only fourth-last in a European comparison of birth rates of women under 20 years of age. Austria does not yet have a comparable countrywide programme.
The Vienna Women’s Health Programme deals with health promotion for girls and young women. Experience has shown that health promotion must start as early as possible. Gender-related measures in schools are therefore of vital importance. Sexual education and information for young people helps to prevent unwanted pregnancies, abortions and psychological stress, caused by teenage motherhood. On the one hand, it is important to close the information gap in boys who still know little or nothing about the female body, ovulation days, the female cycle, etc. On the other hand, it is important to promote empowerment in girls and convince them to be self-determining, not let themselves be pushed, insist on contraception, etc.
Initiative – Youth Information Fair
Information events on the issue of adolescent sexuality are a measure provided for students, teachers, pedagogues, youth workers, parents, school physicians, etc. The information fairs, which have taken place so far, reached up to 1,000 young people. The evaluation data has shown that this form of knowledge transfer has proved of value.
 Source: Statistics Austria
Home abortion. Experiences of women and their partners
Marianne Wulff, Anneli Kero, Katarina Bergström, Ann Lalos (Sweden)
Department of Clinical sciences, obstetrics and gynecology, Umeå University, 901 87 Umeå, Sweden
Background.At Umeå university hospital in Sweden 34% (2007) of all medical abortions were homeabortions. A team of counsellor, nurse as well as a gynaecologist will take care of the abortion seeking woman/couple and offer the opportunity to choose between medical abortion (when early in pregnancy) or surgical abortion. If medical abortion is preferred by the woman, she can do it at home if she wants to and if she fulfils certain criteria (not being too young or immature, not suffering from heavy dysmenorrhoea, not being alone at the time for abortion and not living too far from the hospital). The aim of the study was to gain deeper knowledge about experiences, opinions and reactions among women who choose homeabortions and among their partners present when the abortion took place.
Subjects and methods.Telephone interview by the counsellor in the abortion team using a semi-structured questionnaire with 41 questions, most of these being open-ended. Interviewed were: 100 women and 25 partners. Most women were interviewed one week after the abortion. Quantitative data were analysed using SPSS -programme and the open-ended qualitative data were analyzed using content analysis.
Results.The mean age was 32 years and the majority was married or cohabiting. Pregnant for the first time were 18 women and almost half (45) had had an abortion earlier. The women wanted to do the abortion at home because of a wish of: “control and integrity”, “not having to respond to other people”, “becoming more peaceful when in your own environment”, “not making the process so dramatic”. The overall experience of the homeabortion was that it was “as expected or easier than expected”. The day of mifepristone however, was for many women filled of strong emotions, often paradoxical feelings, and a waiting to the day of prostaglandin and the expulsion of the fetus. That day were dominated by physical symptoms such as nausea, pain and bleeding. Women expressed with emphasis that they would recommend homeabortion to other women. Regarding the partners present during the day of the abortion, they were present because: “it felt natural” or “because she asked for it . Theirreflexions included feelings of “contribution”, “involvement” and “I had a greater role than I would have had at the hospital”.
Conclusions.When having the opportunity to choose homeabortions, the vast majority of women 26-45 years who chose this type of care felt healthier, freer and more empowered having done the abortion at home. They experienced the abortion “as expected or easier than expected” and would strongly recommend it to other women. Their partners were satisfied too, mostly due to the opportunity to be involved to a greater extent than if being at the hospital.
New law about abortion in Switzerland
Danielle Wyss, Family planning counsellor in Lausanne, PLANeS – Swiss Foundation for Sexual and Reproductive Health.
Since 2002, Switzerland has a new regulation about abortion, called « régime du délai ». Abortion is legal within the first 12 weeks of pregnancy. Before an abortion is performed the doctor has to inform and counsel the woman and give her the addresses of specialized counselling centres where she can receive more information and help. Young women under the age of 16 have to visit a counselling centre before an abortion can be performed. The costs of the abortion are covered by the health insurance.
First experiences in Switzerland with this new law will be presented, i.e. the fact that the decriminalisation has – according to statistics – not increased the number of abortions. Nevertheless, prevention should be developed, particularly in regard to migrant women, and the collaboration with doctors should be reinforced. Furthermore, the first consequences of this law on the implication of family planning centres will be discussed.
Abortion request during adolescence and management of confidentiality. A challenging issue
Danielle Wyss, J.-C. Suris, S.-C. Renteria (Switzerland)
Mutidisciplinary Unity for Adolescent Health (UMSA) and Family Planning Clinic, Psycho-social Unit, Department for Obstetrics and Gynecology, Centre Hospitalier Universitaire CHUV, 1012 Lausanne, Switzerland
Introduction. The right for adolescents to access to confidential health services, including requests for abortion, is broadly recognized by the United Nations Convention on the Rights of the Child. It is widely approved and applied by reproductive health professionals, provided that the capacity to discern of the young person is deemed sufficient. This study focuses on the challenges due to the request for confidentiality towards the holders of parental authority in this context, and on the consequences of the different ways of taking care of it.
Objectives.To determine whether the situation of minor consultants asking for confidentiality differs from the others and to assess the risks of assuming confidentiality regarding the continuity of follow-up, the contraceptive compliance and the risk of a new unplanned pregnancy.
Material and methods.Retrospective study of 174 female aged less than 18 years who consulted a specialized unit for adolescents or a family planning center with an abortion request between 2003 and 2006. The sample was divided into two groups depending on whether confidentiality was requested or not. For the groups «without» (N=104) and « with »(N=70) a request for confidentiality, we compared the socio-demographic, relational and medical factors related to the decision and the medical and psycho-social follow-up post abortion.
Results.Adolescents «with» a request for confidentiality are more likely than those « without» to be of foreign nationality, especially from Africa or South America (59.4% versus 37.1%). They are more likely to be studying (80% versus 62.1%) and they more often live with both parents (47.1% versus 33.7%); they have more frequently a partner of about the same age (72.1% versus 57.3%) and are less ambivalent before the decision to abort (94.3% versus 83.7%). There was no difference between the two groups regarding the relationship with the parents, the age of the pregnancy, the experience with hormonal contraceptives before the pregnancy, the follow-up post abortion or the occurrence of a new unexpected pregnancy in the following year.
Conclusions. It seems to be more difficult for adolescents living in “intact” families or integrated in an educational or professional track to talk to their parents about their unexpected pregnancy. If the request for confidentiality is made in the setting of a specialized unit for adolescents with an explicit therapeutic agreement and closely scheduled follow-ups, it does not appear to have negative consequences on the compliance with follow-up or the risk of a subsequent unplanned pregnancy. In these circumstances, the assumption that recommends the ability to guarantee the care of adolescents in sexual and reproductive health matters in respect of confidentiality is compatible with the responsibility of caregivers vis-à-vis these underage patients, on the short and medium-term.