Access in different countries and current status
Elisabeth Aubény, gynecologist, President French Association for Contraception, Hopital Broussais, Paris. Co-founder and Past President of Fiapac
The early medical abortion method is authorized in Europe in many countries. The authorized method, in France(since1989), Austria, Belgium, Denmark, Holland, Germany, Spain, Switzerland, Slovenia (since 1999), until 49 days of amenorrhea, is Day 1: mifepristone 600 mg taken at the abortion center with the patient going home immediately afterwards, Day 3: misoprostol 400 µg taken orally, followed by medical supervision for 3 hours in the center; Day 10-15: check-up visit. In Sweden (1993) in U.K,(1994) this method is authorized until 63 D.A. with gemeprost, as prostaglandin, taken vaginally. But among these countries, the use differs from one country to another. It is used in Sweden and Switzerland more than 50 %, in Belgium, France and Finland around 30 %, it is used in Holland and U.K, around 15 % and less than 5 % in others authorized countries. The use of medical abortion in a country depends of many factors: length of legal authorization, price of the abortion and its reimbursement by assurance to the patient, fee of doctors paid by assurance, but also reticence of doctors to change their habits for a method they don’t know exactly. In the future ameliorations can be bring to this method specially used without any hospitalization, practice by trained general practitioners in their on practice. Women who have the possibility to choice this method are very satisfied. It is our medical duty to propose it.
Emergency contraception, can it be handed out without medical prescription?
E. Aubény, gynecologist, President French Association for Contraception ,
Hopital Broussais, Paris. Co-founder and Past President of Fiapac
Levonorgestrel can be used in emergency contraception (EC) at a dose of 1.50 taken in oneintake. This progestin has no contra-indications, and its efficacy is greatest when taken very quickly after unprotected intercourse (95% success rate if taken within 24 hours). Taking into account these facts, in 1999 the French government approved the sale of levonorgestrel emergency contraception on a non-prescription basis in pharmacies. This makes its use easier and quicker as pharmacies are widespread and have on-call service. Since that time, many other countries have authorized this distribution without medical prescription in Europe :(Albania, Belgium, Estonia, Denmark, Finland, Latvia, Lithuania, Netherlands, Portugal UK) and outside Europe. In Norway and Sweden the product is available over the counter in pharmacies : the user does not need to ask a pharmacist for the product. In France the product can also be directly delivered for free by high-school nurses to pupils and by pharmacists to minors. Since these decisions, the product has been widely used. In France and in the U.K. 80 000 women use it per month. In others countries, sales of levonorgestrel EC pills keep increasing. Post-marketing surveillance of EC has not detected any unexpected side effects in any country. Women use EC properly; they do not use EC as a regular contraceptive method (focus group study), and in France sales of birth control pills continue to increase. Even so, many women who have unprotected intercourse do not use EC because they do not think they are at risk of pregnancy. E.C is under utilized, an information process must be increased.
The International Federation of Professional Associates of Abortion and Contraception (FIAPAC) is an association created in 1996 through the joint efforts of three national abortion associations (Belgian, French and Dutch).
The association is governed by French law for non-profit organizations (law of 1901). It’s Headquarters are located at Hôpital BROUSSIAS in Paris.
It is open to any medical or para-medical professional of abortion and contraception. Membership to FIAPAC for these professionals can be obtained through the approbation by the General Assembly of their demand following proposal by the Executive Committee.
The objectives of the FIAPAC are:
- to allow for all women to decide freely whether they want to keep their pregnancy or not,
- to put at their disposal the best abortion techniques available and to accompany them in this difficult moment,
- to facilitate access to a quality contraception method they choose to use.
It is for this reason that the FIAPAC thinks it is important for professionals working in the abortion and contraception fields, who come from different backgrounds, to meet and exchange ethical viewpoints on the legal problems encountered, as well as on their techniques.
The FIAPAC thus organizes a congress every year. Three have already taken place (Amsterdam - 1997, Brussels - 1998, Maastrich - 1999), with a simultaneous translation in two languages allowing for everyone to participate and exchange information.
To summarize, the FIAPAC is a meeting place for professionals of abortion and contraception who think that women are responsible for themselves, and who think that they are free to decide what is best for themselves in the event of an unwanted pregnancy.
Is monthly bleeding optional?
Elisabeth Aubeny, MD, Paris, France
Since prehistoric times women have endured menstruation, whether they liked it or not.
The timing of the bleeding was not necessarily predictable nor could it be modified.
Hormonal contraception has changed all that. For the first time in mankind’s history, it is
possible to manipulate the timing of menstruation and even to stop it altogether. Some pills
have been especially designed to be taken continuously for 3 months or even for a full
year thereby reducing the number of withdrawal bleeds experienced over time. Long term
progestogen contraceptives can, theoretically, give women a break from menstruation for
3 to 5 years. However these regimens are often associated with frequent episodes of
breakthrough bleeding. So research continues in order to try to improve these
methods.But what do European women think about these new options?A survey in 1980
showed that, in U.K, like in many countries, the majority of women wanted to have monthly
menstruation. Recent surveys in Europe indicate that women’s attitudes to menstruation
are changing. In 1999 a survey from Holland found that only 35% of women wanted to
menstruate once a month, and 31.1 % of women of 25 to 34 years would prefer never to
menstruate; in a German survey from 2004 35% of women between 25 to 35 years wanted
a monthly menstruation and 37% would have preferred never to menstruate; in 2005 in
France only 11% of women wanted to menstruate, while 75 % thought that it was a burden
and 57 % would take a pill which would stop menstruation; in 2006 an Italian survey
showed that 50 % of women without menstruation–related symptoms would like to change
the rhythm of their menstruations. So a majority of women would like to modify the timing
of their menstrual periods. The motivation for the changed of attitudes include: the fact that
there less medical problems associated with lack of menstruation, the women feel they
have a better quality of life, with better hygiene and a reduction of blood loss. However a
large minority of women still prefer to have menstruation each month because this
reassures them that they are not pregnant, they think that menstruation is a natural
phenomena, that it allows elimination of “bad blood”, that is a sign of feminity and they are
afraid of the adverse effects of hormones. However it seems that at the beginning of the
21st century, more and more women would prefer to have control over whether or not they
menstruate. In the next years menstruation will probably become entirely optional.
Austria: only in hospitals
Germany: not available under study
Holland: judged not useful
Spain: price not yet defined
Switzerland: RU486 = poison so forbidden
Reminder of the law. 75% of cost paid back.
A week to think over before taking MIFEPRISTONE as well as a psycho-social
counselling session. Ultrasound between D10 D14 if there is a doubt. Result: 98.5% success rate. Continued pregnancy 1 0/00.
Doctors are badly paid.
Abortions are carried out by doctors in their private surgeries with out time given
to think it over. The Church puts pressure on the public hospital system.
40 000 abortions per year.
Only one public hospital prescribes MIFEPRISTONE.
Consultations take place by phone. There is a lack of information.
Success rate of 97%.
Choice of method:
The method is perceived as being less aggressive, "natural.
It represents 14% of the legal abortions in 1990 and 30 to 40% in 1998.
The choice is made in relation to how early in pregnancy the request is made.
A non-surgical method with the possibility of the partner being present.
The question as to whether the method should be available up to the 63rd day is
The discussion showed the advantages that would arise from "de-medicalising
this method and using it at home (defended by A. BUREAU France) up to the
49th day of amenorrhe.
It was accepted that studies must be carried out to reduce the dose of
MIFEPRISTONE to 200mg and to look into different protocol.
This third seminar ended after a series of rich and formative exchanges on the
practices of the different participants.
A change in the statutes was decided by the founder members. From now on the
F.I.A.P.A.C. , for democratic and voting reasons, is no longer an association of
associations but an association of individual members. The membership fee for
2000 is 250 F.
It was decided to meet again in Paris for the 4th seminar on 24th and 25th
Where should medical abortions take place?
Elisabeth Aubény (France)
10, rue du Docteur Lancereaux, 75008, Paris, France
Medical abortion takes places in 2 stages: the administration of mifepristone which inter00:rupts the pregnancy then, 48h later, the administration of a prostaglandin which results in expulsion of the uterine content. Where should these two medicines be provided and taken? Mifepristone is currently bought by the doctor and taken by the woman in his presence. Why should the woman not buy mifepristone herself at the pharmacy with a medical prescription and then take it, like any other medicine, at home? Fear of a black market? Prostaglandins. The regimen for Misoprostol administration varies from one country to another. In many countries administration of misoprostol takes place in a hospital centre, followed by a 3h monitoring period due to fear of serious adverse events including and haemorrhage at the time of expulsion. Experience shows that, for pregnancy of less than 49 DA, this precaution is not medically necessary with a regimen of mifepristone 600 mg + oral misoprostol 400µg. For this reason in Sweden and France the administration of misoprostol “at home”is now authorised. Studies have demonstrated that this approach is also possible up to 63 DA but with a different regime: mifepristone 200 mg + misoprostol 800µg by vaginal or buccal route. This technique is authorised in Sweden and practiced in the USA (900,000 cases) without related problems. This “at home” administration of misoprostol allows avoidance of one consultation and thus simplifies the method. It is very well accepted by the women who chose it: greater intimacy and confidentiality. However, certain women prefer to be in a medical environment at the time of administration of misoprostol and during the hours that follow. It is important that women are able to choose between the two options. From 63 DA until the end of the first trimester medical abortion is not legally authorised anywhere. However, it is sometimes used. In this case, it is essential that the women take misoprostol in hospital and that they are monitored until expulsion has taken place as bleeding may be heavy and pain must be actively managed. Also at these later gestations products of conception are more visible and must be disposed of appropriately. When using gemeprost, this requires to be stored in a freezer, and the administration must take place in a hospital centre.