Edinburgh, 19-21 Oktober 2012: „Unwanted pregnancy - A fact of life“

  • 09:00-
    Legal/ethical aspects of abortion, Pentland
    • Bernard Dickens, CA
    • Sam Rowlands, GB
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      Going ForwardThe prevalence of contraceptive use and the
      abortion rate are very different among countries.
      We know that the abortion rate is high in
      countries where the prevalence of use a modern
      contraceptive method is low. Combined hormonal
      contraceptives (COC) are one of the most popular
      methods of birth control. This is a reliable form
      of contraception, having a theoretical failure
      rate of 0.1% and, due to problems related with
      compliance an actual failure rate of 2-3%. The
      pill use is very different among countries. It will
      be important to try to understand why these
      differences exist. Despite the safety of current
      COCs, fears of adverse metabolic and vascular
      effects and possible oncological effects remain.
      Misperceptions and concerns about side effects,
      especially those affecting menstrual cycle, fertility
      and body weight increase, are often reasons for
      discontinuation. Making contraception available
      is not enough to prevent abortion: women should
      be able to choose a contraception method that
      suits their personal expectations - only then
      will unwanted pregnancies be successfully
      avoided and the abortion rate will decrease. For
      contraceptive efficacy, a woman’s/couple’s free
      and informed choice is required.

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      The situation in Northern
      Abortion is legal in Northern Ireland but only in
      very restricted circumstances. Rape, incest and
      fetal abnormality are not grounds for an abortion.
      Women and girls resident in Northern Ireland with
      a crisis or unplanned pregnancy who decide to
      end their pregnancy have to travel to England
      and other European countries and pay for a
      private abortion. Despite being UK citizens they
      are not entitled to a free abortion in Britain unlike
      women resident in Britain. This presentation will
      explore the financial, practical and emotional
      consequences of this denial of sexual rights and
      the political dynamics which underpin this denial.

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      The Situation in the Republic
      of Ireland This presentation will set out the basis of
      abortion in law in Ireland and examine recent
      developments pertaining to the manner in which
      Ireland’s constitutionally enshrined ban on
      abortion operates. The application of international
      human rights norms and standards reveal the
      manner in which the ban – and the failure to
      attain legal clarity in relation to its operation –
      provides real opportunities for change. One
      such opportunity arose in the context of A, B,
      C v Ireland, the case taken to the European
      Court of Human Rights in which the Grand
      Chamber of the Court, in 2010, found a breach
      of the Convention in the case of C, due to the
      lack of clarity and the illusory nature of the right
      to access a termination under Irish law where
      there is a real and substantial risk to the life of
      a woman. The options available to the State to
      ensure compliance with the judgment will also be
      explored in this presentation.

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      Travelling for Abortion:
      A Framework for Future
      Advocacy and Research This presentation will discuss the ways in which
      the Irish Crisis Pregnancy Programme (formerly
      the Crisis Pregnancy Agency) has developed
      public governance of cross-border abortion
      care. In doing so my aim is to think more about
      the limits and potential of abortion travelling
      as an option for women living with restrictive
      abortion regimes. The governance of abortion
      travelling does seem to have the negative effect
      of consolidating the non-development of local
      lawful abortion services. But the Programme
      has also had the effect of providing publicly
      subsidised support for women who travel,
      enabling the reporting of extra-territorial abortion
      rates as national abortion rates, and of promoting

      abortion after-care on return. These public health
      measures, limited as they are, provide evidence
      of some public support for abortion use and may
      provide future resources for tackling domestic
      resistance to abortion provision.
      In analysing the Crisis Pregnancy Agency’s
      administration of an outward flow for abortion care,
      I identify its 4 key technologies of governance as
      the non-development of local abortion services,
      provision of support for exit, reporting of extra-
      territorial abortion rates, and promotion of aftercare
      on return. These technologies illustrate how state
      agencies may actively mobilise ‘the peripheral’
      as they claim to address local needs through
      participation in the regulation of cross-border
      healthcare. In so doing they configure a conception
      of the peripheral that does not want to become
      core and participates in transnational networks on
      its own terms. Secondly, this peripheralism is not
      constituted by the core, but cultivates dependency
      on core provision of healthcare in other
      jurisdictions. Thirdly, this peripheralism comes into
      being by focusing on marginal healthcare services
      (information, counselling, check-ups) on the fringes
      of abortion provision.

  • 10:30-
  • 11:30-
    W06 Workshop: Ultrasound in abortion care, Tinto
    • Christian Fiala, AT
    • Matthew Reeves , US
    W07 Hot topic: Late term abortion, Pentland
    • Marge Berer, GB
    • André Seidenberg, CH
    W08  Interactive workshop: providers as targets and causes of abortion stigma, Carrick
    • Thea Schipper, NL
    • Anne Vérougstraete, BE
    W09 ICMA/EEARC Session: Unsafe abortion in Eastern Europe, Harris
    • Rodica Comendant, MD
    • Gabriele Halder, DE
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      Dr. Comendant holds a PhD as an obstetrician
      gynaecologist. She is the Director of the
      Reproductive Health Training Center (RHTC)
      of Republic of Moldova, and since 2005 has
      served as the Coordinator of the International
      Consortium for Medical Abortion. In this capacity,
      she successfully supported the development of
      the ICMA regional networks in Latin America,
      Asia, and Eastern Europe. Additionally, Dr.
      Comendant is the National Coordinator of Safe
      Abortion Programme of the Reproductive Health
      Strategy of Republic of Moldova, an attendant
      Professor of the Department of Obstetrics and
      Gynecology of State University of Medicine
      and Pharmacy of Moldova, a regional and
      international trainer in safe abortion methods,
      a senior consultant for Gynuity Health Project,
      USA, and a consultant for the WHO Strategic
      Assessment of Abortion in several countries.
      ICMA: global, regional and national networking to
      reduce the burden of unsafe abortion
      In spite of increased attention to sexual and
      reproductive health and rights, and particularly
      to maternal mortality, in spite of the development
      of effective technologies to make abortion very
      safe, pregnancy-related deaths and unsafe

      abortion remain a major public health problem in
      largeparts of the world.
      There are many organisations working worldwide
      to improve women’s access to safe abortion
      services – through advocacy, law and policy
      reform, capacity building, service delivery, training,
      information sharing and networking. Everyone
      feels there is a growing need to link together and
      combine the efforts towards ensuring the right to
      safe abortion in all the countries. It was agreed an
      international movement is needed to challenge the
      growing threat posed by conservative political and
      religious forces who are seeking to turn the clock
      back, block efforts to improve laws and provide
      services, and exclude abortion from maternal
      mortality reduction and family planning initiatives.
      This is why representatives of several dozen
      NGOs from all world regions, consulted and
      called together by the ICMA and it’s four affiliated
      regional networks (ASAP, EEARC, CLACAI and
      ANMA), in 2011-12, decided to launch the
      International Campaign for Women’s Right to
      Safe Abortion in April 2012, which after only a few
      months has been endorsed by more than 620
      groups and individuals all over the world.

    W10 ESC session, Ochil
    • Johannes Bitzer, CH
    • Anibal Faúndes, BR
    • Kristina Gemzell-Danielsson, SE
  • 12:45-
    Lunch session 3: Emergency Contraception, Tinto
    • Elisabeth Aubény, FR
    • Teresa Bombas, PT
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      Bridging Hormonal emergency contraception prevents
      between one half and two thirds of pregnancies.
      Traditional on-going methods of contraception are
      far more effective. A consultation for emergency
      contraception (EC) should therefore be regarded
      as an opportunity to provide women with an
      on-going method of contraception which will
      prevent pregnancy more effectively than repeated
      use of EC. The on-going method is best started
      immediately to prevent pregnancy immediately
      including those resulting from further acts of
      unprotected sex in the cycle in which EC was
      used (so-called bridging).
      In most European countries most women now
      get EC from pharmacies over (or behind) the
      counter. Pharmacists are unable to provide
      on-going effective contraception without a
      doctor’s prescription and a mystery shopper
      study undertaken in Edinburgh demonstrated
      that most pharmacists give little or no advice
      about bridging. Even when EC is issued by a
      health professional who can provide an on-going
      method, a disappointingly low number of women
      are provided with an effective bridging method.
      Strategies to enhance bridging from EC to an
      effective on-going method need to be developed
      and tested.

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      IUD for EC
      Dr. Linan Cheng
      Shanghai Institute of Family Planning Technical Instruction, The International Peace
      Maternity and Child Health Hospital, China Welfare Institute, Shanghai, PR China
      Emergency contraception is defined as the use of a drug or device as an emergency
      measure to prevent pregnancy after unprotected intercourse. From this definition it follows
      that methods of emergency contraception are used after coitus but before pregnancy
      occurs, and that they are intended as a back up for occasional use rather than a regular
      form of contraception.
      The first report by Lippes in 1976 indicated an effectiveness of >95% within 5 days of
      unprotected intercourse. Askallani 1987 first compared Cu-IUD (Cu-T 200) insertion with 

      expectant management in women requesting emergency contraception within 4 days of
      unprotected intercourse. There was a significantly higher number of pregnancies in the
      expectant management group (RR: 0.09, 95% CI 0.03 to 0.26). The comparative
      effectiveness of inserting an intra-uterine device has not been adequately investigated.
      Whereas it might be difficult to conduct randomized controlled trials of intra-uterine devices
      with other interventions with the woman as unit of randomization, cluster randomization
      might overcome this problem. Although there are many barriers to using intra-uterine
      devices for emergency contraception, data from nonrandomized studies that were all
      conducted in China suggest that inserting Copper-IUDs for emergency contraception could
      be effective in preventing unintended pregnancy (3 pregnancies/1470 women, failure rate:
      0.20%). These findings are in line with the findings of the Askalani trial that compared IUD
      insertion with nothing. In the review of the efficacy of the IUD used in emergency
      contraception by Trussell and Ellertson a meta-analysis of 20 published papers of post-
      coital IUDs showed a failure rate of 0.1%from more than 8400 insertions.
      The postcoital insertion of an IUD is an option that can be used up to 5 days after the
      estimated time of ovulation and can be left in the uterus as a long-term regular
      contraceptive method.

  • 14:00-
    W11 Workshop: Advances in 1st trimester surgical abortion, Pentland
    • Rodica Comendant, MD
    • Andreja Štolfa Gruntar , SI
    W12 Workshop: Conscientious objection, Harris
    • Kelly Culwell, US
    • Maria Francès- Kircz, NL
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      Examples from Italy


      The Italian  law  no.194 approved  in 1978, is often considered one of the most advanced inWestern Europe. An abortion may only be carried out in a public hospital and there are no special abortion clinics inItaly. The conscience clause is partially responsible for many of the difficulties in availability of services. The Article 9 provides for the non-participation of staff of any level who work in hospitals and do not want to participate in abortions for reasons of conscience. The objectors are freed from activity specifically directed to the interruption of pregnancy but not from assistance before or after the abortion. It is the responsibility of the hospital to ensure the procedure is efficient and the Region is responsible for the to the provision of the services. This brings to remarkable differences  from one region of the country to another. For example the Region of Emilia Romagna, where social and medical facilities are easily available, offers better services with access to medical abortion. Conscientious objection is a major limiting factor in the implementation of the law. According to the Secretary for Health’s last report, at a national level nearly 71 % of  the  gynaecologists  are conscientious objectors  and in some regions this percentage reaches 80-85%. Medical abortion has been approved since 2009, but only within 49 days of amenorrhea, in spite of the European mutual recognition procedure. In all cases, with only two regional exceptions , a compulsory hospitalization is requested. So far the medical procedure is not readily accessible in all localities. Restrictions in access to abortion and lack of having the choice between a medical or a surgical procedure are currently the major problems.

    W13 Hot topic: Sequelae of abortion: myths and facts, Carrick
    • Jean-Jacques Amy, BE
    • Sam Rowlands, GB
    W14 WHO session: Update on evidence based guidelines  , Tinto
    • Marc Bygdeman, SE
    • Anna Glasier, GB
    W15 Free communications, Ochil
    • Lena Marions, SE
    • Allan Templeton, GB
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      Termination of pregnancy services in Pakistan –
      a confiscated right
      Ali, SM; Rizvi, A; Mahmood, N; Khanum, A
      Rahnuma, Family Planning Association of Pakistan- an affiliate of
      Objective: The aim of the study was to highlight the various
      factors which control women’s right to access to termination of
      pregnancy (TOP) services.
      Methods: Data from 400 women aged 18–60 years seeking TOP
      and general services from clinics of the Family Planning
      Association of Pakistan (FPAP) in Lahore and Karachi was
      obtained through a structured questionnaire over 3 months and
      descriptive analysis of data was done using SPSS version 17. The
      questionnaire was administered by clinic counsellors and covered
      key themes of knowledge on access to safe TOP, TOP-related
      stigma, reasons for seeking TOP service, decision-making on
      family size and demographic data.
      Results: During the study it was found that a majority of the
      TOP clients (59.8%) coming to six service delivery points had a
      family monthly income of less than PKR 10 000. The average age
      of TOP clients was 30 years (SD 6). Similarly, the average number
      of children of TOP clients was 3 (SD 1.9). A large number of
      TOP clients (39.5%) were illiterate and only 5% of TOP clients
      had 16 years of education while 33.7% of their husbands were
      illiterate and 4.2% had 16 years of education. When knowledge of
      clients on the legal status of TOP was assessed it was found that
      out of 400 clients, 49.3% considered TOP to be illegal. The
      knowledge level between general clients and TOP clients was also

      observed as 62% of general clients considered TOP to be illegal in
      Pakistan while 36% of clients, who had availed themselves of TOP
      services, considered it illegal. Out of 200 TOP clients, 54.2%
      associated stigma with TOP by not telling others that they had
      sought TOP services. The reasons for seeking the TOP service
      were: cannot afford another child (28.4%), mothers’ health
      concerns (27.9%), last child too young (18.9%), contraceptive
      failure (16.9%), too many children (5.5%), unmarried (1.9%) and
      separation from husband (0.5%). Out of 400 clients, 47.2% were
      not asked about their wish to have children and 48.2% were not
      involved in the decision about birth spacing. Moreover, the need
      for family planning had not been met by 18% of TOP clients as
      they had used TOP services more than once.
      Conclusion: Controlled access to family planning services, stigma
      attached to TOP and low educational and economic status are the
      factors which interfere with the right of women to seek TOP
      services. Moreover, there is also a need to further study this
      phenomenon and better understand how each of the factors
      (stigma, low education etc) affects access to and uptake of safe
      TOP services.

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      Fatal flaws in a recent meta-analysis on
      termination of pregnancy and mental health
      Steinberg, J; Trussell, J; Hall, K; Guthrie, K
      Office of Population Research, Princeton University, USA
      Similar to other reviews within the last 4 years, a thorough review
      by the Royal College of Psychiatrists, published in December 2011,
      found that compared to delivery of an unintended pregnancy,
      termination of pregnancy (TOP) does not increase women’s risk
      of mental health problems. In contrast, a meta-analysis published
      by Coleman in September 2011 in the British Journal of
      Psychiatry claimed to find that TOP increases women’s risk of
      mental health problems by 81% and that 10% of mental health
      problems are attributable to TOP. Like others, we strongly
      question the quality of this meta-analysis and its conclusions.
      Here we detail seven errors in this meta-analysis and three
      significant shortcomings of the included studies because policy,
      practice, and the public have been badly misinformed. These
      errors and shortcomings render the meta-analysis’ conclusions
      invalid. In this case there was a complete failure of the peer-
      review process and editorial oversight.

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      First Tri deaths: the hidden patterns
      Troncoso, E1; Schiavon, R1; Freyermuth, G2;
      Ramirez, G2
      1 Ipas; 2 Observatorio de Mortalidad Materna, Mexico
      In Mexico, public health sector information systems have
      significantly improved their record keeping and allow us to know
      that termination of pregnancy (TOP) mortality accounts for
      around 10% of maternal deaths in the last 10 years. Given the
      high mortality ratio, maternal deaths are analysed carefully every
      year in the Ministry of Health. The goal of this project was to
      better understand the 2010 TOP related mortality files.
      During 2010, 9.27% of maternal deaths were due to TOP
      (92 cases). Almost 75% of deaths were among women aged 15 to
      34 years, younger than those dying from other causes. Twenty-six
      percent were single compared with 15% for the other causes.
      Ninety percent of women received health care before the death.
      The quality of the information of the TOP cases was poor,
      regularly a maternal mortality case was 11 elements for the
      comprehensive analysis into their file. In the case of TOP deaths,
      only 66% of the files had verbal autopsies, 23% a necropsy report,
      and no one had an official declaration. In some cases, women
      were not aware of their pregnancy, and the diagnosis did not
      consider pregnancy.
      Despite the interest in maternal mortality, TOP has not been
      adequately addresed in the current framework and more questions
      remain after the revision of the files. TOP-related deaths require
      an adequate response from the health systems.

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      Our love affair with misoprostol over the last
      20 years
      Herbert, WY
      The Queen Elizabeth Hospital Pregnancy Advisory Centre, Australia
      TheQueen Elizabeth Hospital Pregnancy Advisory Centre in
      Adelaide, South Australia is agovernment-funded clinic established
      in 1992,providing over 2500 surgical terminations eachyear.
      Four papers published over the last 20 years document our
      implementation of misoprostol use, showing significant
      improvements in service delivery, as well as reduction in
      complication rates.
      Our first study published in 1999 showed that adding
      misoprostol to osmotic dilators at 17–20 weeks of gestation to
      increase passive dilatation of the cervix, markedly reduces the risk
      of perforation of the uterus.
      Our second study published in 2009 compared the outcomes
      of four different peri-operative misoprostol regimens for first
      trimester surgical terminations. Compared to no misoprostol
      regimen, the regimen of 200 lg of oral misoprostol 3 hours
      pre-operatively plus 200 lg of misoprostol vaginally at the end of
      the surgical procedure showed: 90% reduction in difficult cervical
      dilatations, 60% reduction in rate of D&C treatment of retained
      products of conception and 71% reduction in incidence of
      women requiring post-operative contact for concerns.
      In 2011, our third study demonstrated that adding 200 lg of
      oral misoprostol 3 hours before two tablets sublingually every
      half-hour for three doses at 13–16 weeks of gestation further
      reduced difficulty of the operation.
      In 2002, we adopted medical management with misoprostol,
      as first-line treatment for retained products following surgical
      termination. Our study published in 2009 showed that the
      regimen of 200 lg of misoprostol orally or sublingually three
      times a day for six doses was 93% effective, and reduced the
      D&C rate by 79.6% from 1.18% to 0.24%.

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      Regional differences in surgical intervention
      following medical termination of pregnancy
      provided by telemedicine
      Gomperts, R1,2; Jelinska, K1,2; Sabine, S1,2;
      Gemzell-Danielsson, K1,2; Kleiverda, G1,2
      1 Women on Waves; 2 Department of Obstetrics and Gynaecology,
      Karolinska Institutet, Stockholm, Sweden
      Objective: Analysis of factors influencing surgical intervention
      rate after home medical termination of pregnancy (TOP) by
      women in countries without access to safe services using the
      telemedical service ‘Women on Web’.
      Design: Cohort study.
      Setting: Women with an unwanted pregnancy <9 weeks pregnant
      who used the telemedicine service of Women on Web between
      February 2007 and September 2008 and provided follow-up
      Sample: Women who used medical TOP with a known follow up.
      Methods: Information from the online consultation, follow-up
      form and emails was used to analyse the outcome of the TOP.
      Main Outcome Measures: Ongoing pregnancy, reason for surgical
      intervention, perceived complications and satisfaction.
      Results: Of the 2323 women who did the medical TOP and had
      no ongoing pregnancy, 289 (12.4%) received a surgical
      intervention. High rates were found in Eastern Europe (14.8%),
      Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in
      Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%;
      P = 0.000). More interventions occurred with longer gestational
      age (P = 0.000). Women without a surgical intervention more
      frequently reported satisfaction with the treatment (P = 0.000).
      Conclusions: The large regional differences in the rates of
      reported surgical interventions after medical TOP provided by
      telemedicine cannot be explained by demographic factors or
      differences in gestational length. It is likely that these differences
      reflect different clinical practice and local guidelines on
      (incomplete) abortion rather than complications that genuinely
      needed surgical intervention. Surgical interventions significantly
      influenced womens’ views on the acceptability of the TOP.

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      Safety and effectiveness of termination services
      performed by doctors versus midlevel providers: a
      systematic analysis
      Ngo, T1,2; Park, MH1,2
      1 Marie Stopes International; 2 London School of Hygiene & Tropical
      Medicine, UK
      Objective: We review the evidence that compares the effectiveness
      and safety of termination of pregnancy (TOP) procedures
      administered by mid-level providers (MLPs) versus doctors.
      Methods: We conducted a systematic search of published studies
      assessing the effectiveness and/or safety of TOP provided by MLPs
      compared to doctors. The Cochrane Central Register of
      Controlled Trials, EMBASE, MEDLINE and Popline were searched
      for trials and comparison studies. The primary outcomes were:
      (i) incomplete or failed TOP and; (ii) measures of safety (adverse
      events and complications) of TOP procedures administered by
      MLPs and doctors. Odds ratios and their 95% confidence intervals
      (CIs) were calculated for each study.

      Results: Two prospective cohort studies (n = 3821) and two
      randomised controlled trials (RCTs) (n = 3821) were included.
      Three thousand seven hundred and forty-nine women underwent
      a procedure administered by an MLP and 3893 women underwent
      a physician-administered procedure. Three studies used surgical
      TOP with maximum gestational ages ranging from 12 to 16+
      weeks; a medical TOP study had maximum gestational ages up to
      9 weeks.
      There was no difference in incomplete/failed TOP for
      procedures performed by MLPs compared to doctors in RCTs of
      surgical (OR: 2.00; 95% CI: 0.85, 4.68) and medical TOP (OR:
      0.69; 95% CI: 0.34, 1.37). One prospective cohort study showed
      increased odds of incomplete/failed TOP among MLPs versus
      physician groups (OR: 4.03; 95% CI 1.07–15.28).
      None of the included studies found a difference in the odds of
      overall complications between provider groups.
      Conclusions: Based on this evidence, there is no indication that
      procedures performed by MLPs are less effective or safe than
      those provided by physicians.

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      Task sharing in post-termination of pregnancy care
      at district level in Uganda; healthcare providers’
      perception on safe TOP, post-TOP care and
      contraceptive counselling – an exploratory study
      Allvin, MK1; Paul, M1; Gemzell-Danielsson, K1;
      Kiggundu, C2
      1 Department of Obstetrics and Gyanecology Karolinska Institutet,
      Stockholm, Sweden; 2 Mulago University Hospital, Kampala, Uganda
      Background: Termination of pregnancy (TOP) is restricted in
      Uganda and poor access to family planning results in unwanted
      pregnancies forcing women to have unsafe TOPs and thus posing
      a great burden on the Ugandan health system. Post-TOP care is
      implemented and unofficial task shifting is taking place as a
      pragmatic response to the workload.

      Objective: To explore the healthcare providers’ perception on
      post-TOP care, with regard to professional competences, medical
      and surgical methods, contraceptive counselling and task shifting/
      sharing in post-TOP care.
      Methods: In-depth interviews (n = 27) with healthcare providers
      participating in post-TOP care were conducted in seven health
      facilities in the Central region of Uganda. Data was organised
      using thematic analysis with an inductive approach.
      Results: Post-TOP care was perceived necessary, however
      controversial, and together with poor conditions it provoked
      frustration, mainly among the midwives. Task sharing was
      generally implemented and midwives were identified as the main
      providers. Different uterine evacuation skills were recognised and
      midwives would sometimes perform interventions not approved
      by hospital guidelines, due to absence of doctors. Misoprostol was
      rarely used or accessible at district level, however those with
      experience perceived it efficient and safe. An overall demand and
      need for further training was identified.
      Conclusions: Developing policies and service guidelines in order
      to implement evidence based use of misoprostol in post-TOP care
      as well as provision of in-service training is recommended.
      Implementation of official task shifting in post-TOP care would
      further be a systematic approach to improve quality of care and
      accessibility of services in order to reduce TOP-related mortality
      and morbidity.

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      Training midwives and doctors in post-termination
      of pregnancy care in Gabon and Cameroon
      Alblas, M; Ndembi, AP; Pheterson, G; Mbia, C;
      Mekui, JE
      Middle Africa Network for Women’s Reproductive Health: Gabon,
      Cameroon and Equatorial Guinea
      The NGO Middle Africa Network for Women’s Reproductive
      Health: Gabon, Cameroon and Equatorial Guinea – GCG is
      devoted to research, education and training to understand
      obstacles to better health care. This presentation focuses on one
      central part of the mission: training midwives and doctors in
      post-termination of pregnancy (TOP) care, mainly manual
      vacuum aspiration. After a needs assessment initial field trip in
      2009 it became clear that the morbidity and mortality among
      women due to unsafe TOP is high in rural areas in Northern
      Gabon, southern Cameroon and eastern Equatorial Guinea.
      When complications from back street TOP arise, women arrive
      late (or never) for emergency hospital care because they know
      TOP is illegal and highly stigmatised, and often they have no
      money either for transport to the hospital or for the medical aid
      they need. If a doctor is present, he/she can do a sharp curettage
      under general anesthesia, but this is expensive and in the more
      rural areas often there is no doctor. Pregnancy and birth are
      typically the domain of midwives, but they are not trained in
      treating TOP-related complications since procedures such as MVA
      or misoprostol use are not institutionally recognised, and only
      doctors perform D&Cs.
      Recently one of our trained midwives has been appointed by
      the Ministry of Health to train all the midwives in the country in
      post-TOP MVA. In the last 3 years this network has made a

      significant first step in demonstrating that also in a country where
      TOP is illegal, one can build capacity, mobilise attitude change
      and enlist institutional support.

  • 15:30-
  • 16:00-
    Medical abortion 1st trimester
    • Christian Fiala, AT
    • Anne Vérougstraete, BE
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      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.

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      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.

    • close

      Increasing access to safe
      abortion servicesMedical abortion with mifepristone and a
      prostaglandin analogue was developed into a
      safe and effective method for induced abortion
      in the 1980’s. Today the prostaglandin analogue
      of choice is misoprostol and medical abortion
      is a safe option for termination of pregnancy
      at all gestational lengths. However, several
      barriers remain that limit global access to safe
      abortion services. Simplifying medical abortion
      could potentially contribute to increased access
      and acceptability. Possible approaches include
      the option to self-administer misoprostol at
      home. Another possibility is task sharing with
      midlevel providers to allow these health care
      professionals to be more involved with the care
      of healthy women undergoing medical abortion.
      This possibility is likely to have major impact
      to increase access to safe induced abortion in
      countries were medical resources are scarce. A
      simplified treatment regimen may also include
      home self-evaluation of complete abortion, an
      option which is currently being investigated.

    • close

      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.

    • close

      About 15% of pregnancies
      terminate spontaneously in the
      first trimester .The majority of these miscarriages
      are unrecognized clinically.. As the levels of
      progesterone fall expulsion of the products of
      conception occur spontaneously and resumption
      of cyclical ovarian activity with 2-3 months.
      Modern methods of medical abortion using
      mifepristone and a prostaglandin simulate closely
      the mechanisms which occur in spontaneous
      abortion suggesting that it is likely that the
      majority will resolve spontaneously without further
      intervention(Baird 2002) . Blockage of the action
      of progesterone with mifepristone results in
      powerful uterine contractions which together with
      an increased sensitivity to prostaglandin leads to
      expulsion of the fetus and placenta.(Baird 2002).
      Extensive research over the last 30 years has now
      identified a simple regimen (Mifepristone followed

      by misoprostol) which is highly effective(on-
      going pregnancy<1%), is free from serious
      side effects and does not require sophisticated
      facilities(WHO2003). Several studies have shown
      that abortion can be safely delivered by relatively
      unskilled health workers (mid-level providers
      MLP) who have been trained to follow an agreed
      protocol of treatment(Shannon &Winnikoff 2009
      Warriner et al2011). By devolving provision of
      abortion to MLP the access to abortion should
      be greatly widened. As predicted in the original
      report of medical abortion with mifepristone and
      gemeprost that “this combination would have
      particular application in countries where skilled
      medical and surgical experience are in short
      supply” (Rodger & Baird 1987 )

  • 17:30-
    • Sharon Cameron, GB
    • Sam Rowlands, GB
    • close

      Future perspectivesThe current situation in abortion care should be
      improved on two levels: medical and social. On
      both levels the focus needs to be the pregnant
      woman rather than external factors.
      On the medical level we need to give more
      autonomy to the woman coming for an abortion.
      The procedure still is very much controlled by
      the medical system and women are forced to
      follow the rules. There is a huge potential for
      more autonomy especially in medical abortion,
      which will be done at home in the future, only
      the drug needs to be bought in the pharmacy
      or drugstore, just like the pregnancy test. This is
      already reality for example in India.
      Also we urgently need better means to effectively
      control pain associated with the medical and
      surgical procedure and for medical abortion we
      need to reduce duration of bleeding.
      Equally important are improvements on a social
      level: real self-determination. Women and couples
      need the legal framework to freely decide on a
      pregnancy and as well all necessary means to
      execute their decision. We have made a huge
      progress from archaic interdiction of abortion to the
      current legal status. However there still are many
      paternalistic remnants when it comes to abortion.

  • 18:15-