Authors

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Patimat Abakarova

MD, PhD, member of RSOG, Researcher of the Out-patient Department of the RC Ob/Gyn &P, Russia


Speeches:

Dina Abbas


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    Medical abortion with mifepristone + misoprostol at 13 – 22 weeks: how long between the mifepristone and the misoprostol?

    Dina Abbas1, Nguyen thi Nhu Ngoc2, Jennifer Blum1, Nguyen thi Bach Nga3, Huynh Kim Chi4, Roxanne Martin1, Beverly Winikoff1 1Gynuity Health Projects, New York, NY, United States Minor Outlying Islands, 2Center for Research and Collaboration in Reproductive Health, Ho Chi Minh City, Viet Nam, 3Hung Vuong Hospital, Ho Chi Minh City, Viet Nam, 4Huynh Kim Chi, Binh Duong Hospital in Obstetrics and Newborn, Binh duong Province, Viet Nam - dabbas@gynuity.org

    Objective: To compare a regimen that initiates misoprostol dosing at the same time as mifepristone to a regimen where misoprostol is started 24 hours after mifepristone for termination of pregnancy of 13 – 22 weeks. Method: Double blinded randomized placebo controlled trial where participants received mifepristone either 24 hours before, or at the same time as, misoprostol (repeat doses of 400 mcg buccal every three hours). If abortion was not completed within 48 hours after induction with misoprostol the participant received standard care. Results: 504 women were enrolled in Vietnam. 87.1% of women who received the two drugs simultaneously experienced complete uterine evacuation within 24 hours after induction with misoprostol, compared to 95.1% of women who received misoprostol 24 hours after mifepristone. At 48 hours, this increased to 96% in both study arms. The mean misoprostol treatment duration and total misoprostol doses received was significantly lower in the group that received the misoprostol 24 hours later 9.13 vs. 14.66 (p=.000) and 3.47 vs. 5.44 (p=.000) respectively. Mean duration of the process, defined as receipt of mifepristone to complete abortion, was significantly shorter for women who received the drugs simultaneously 14.66 vs. 33.37 (p< 0.0001). In both groups the side effect profile was similar and overall satisfaction was high (>98%). Results will be presented by gestational age group (13 – 16; 17 – 22 weeks). Conclusion: Preliminary findings suggest that taking mifepristone and misoprostol simultaneously significantly lowers clinical efficacy at 24 hours; results in a longer mean misoprostol treatment duration; and requires more misoprostol doses. However there may be trade-offs as the simultaneous regimen significantly shortens the total time of the overall process and may require fewer clinic visits in some settings. The study provides evidence that allows providers and women to choose among two viable second trimester medical abortion regimens.


Marie Adamo


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Martine Aeby-Renaud


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    How involved are partners in teenage girls’ abortions?

    Martine Aeby-Renaud1, Geneviève Sandoz1, Gaëlle Aeby2 1Hôpital universitaire de Genève, Unité de Santé Sexuelle et de Planning Familial, Genève, Switzerland, 2Collaboration, University of Lausanne, Lausanne, Switzerland - martine.aeby-renaud@hcuge.ch

    Voluntary termination of pregnancy is an important issue, in particular for teenage girls. However, less attention is paid to their partners, to who they are, whether and how they get involved in the process. This study investigates the involvement of male partners in the process of voluntary termination of pregnancy (VTP) for teenage girls up to ages 18 inclusive, who consulted with the "Sexual Health and family planning unit (USSPF)" (Geneva, Switzerland) in 2013. The final sample is composed of 43 teenage girls. Ages range from 15 to 18 years old. Prior to their pregnancy, around two thirds of the teenage girls had used one or more contraceptive methods. They mentioned male condoms (81.4%), emergency contraception (32.6%), the pill (30.2%), withdrawal (18.6%), calendar method (2.3). Nevertheless, 37.2% of them had not yet used any method. The great majority of teenage girls were in a relationship (86%). For the rest of them, it was either a one-night stand (9.3%), or sex with a friend (4.7%). The duration of relationships ranged from 2 months to 4 years. Age of partners ranged from 15 to 28 years old. On average, partners were older than the teenage girls with a mean of 2.91 years difference in age. Most of the partners were informed about the pregnancy (90.2%). Concerning their involvement in the VTP process, analyses were restricted to couples. We considered three variables: attendance at USSPF (yes: 41.7%), giving support (yes: 88.6%), and agreement with the VTP (yes: 93.9%). In summary, results showed that the majority of teenage girls were in a stable committed relationship that lasted at least several months. Partners were involved in the VTP process and provided support. Therefore, counsellors should more actively associate them in the VTP process for better prevention of contraceptive failure and experience of VTP.


Silvana Agatone

s.agatone@libero.it


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    IUD insertion immediately post abortion
    Silvana Agatone M.D.,P.Facco M.D, M GiovanniniM.D. M.Carlos MW T.Malatesta MW,
    P.Proietti MW, Operating Unity for voluntary abortion, Obstetrics and Gynaecology
    Deparment, S:Pertini Hospital Rome Italy
    To evoid recurrent abortion and to provide an acceptable and fast contraception, from the
    year 2005 we started to insert 100 IUD (MLCu 3,75) immediately after uterine aspiration
    for the termination of pregnancy of less then 12 weeks duration.
    A control by ultrasound was carried after 1 and 3 months from the insertion.We had 3
    expulsion and 2 cases of metrorraghia, so that the response rate was 95%.
    No pregnancy,perforations o cases of pelvic inflammatory deseases were recorded.We
    concluded that insertion of IUD immediately post abortion is an acceptable contraceptive
    solution


Marjorie Agen


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    A national campaign to de-stigmatize abortion in France: why?

    Danielle Gaudry, Marjorie Agen, Shiva Bernhard Le Planning Familial, Paris, France - d.gaudry001@wanadoo.fr

    Abortion and contraceptive methods are a fundamental part of Human Rights: women have a right to choose whether to be pregnant or not. WHO guidelines about safe abortions demonstrate that the legalization and improved safety and accessibility of abortion are essential for women's health: postabortion deaths disappear, postabortion complications, including accidental infertility, are reduced. In the August 2011 report to the UN "Right of everyone to enjoyment of the highest attainable standard of physical and mental health" the Special Rapporteur considers "the impact of criminal and other legal restrictions on abortion conduct during pregnancy; contraception and family planning and the provision of sexual and reproductive education and information. Some criminal and other legal restrictions in each of those areas, which are often discriminatory in nature, violate the right to health by restricting access to quality goods, services and information. They infringe human dignity by restricting the freedoms to which individuals are entitled under the right to health, particularly in respect of decision-making and bodily integrity." It is violence against women to oblige them to stay pregnant when they don't choose to be pregnant. In French society, as well as other European countries, the model of pregnancy and maternity in a heteronormative family is prevalent. Traditionalists, in the "la manif pour tous" movement, dream about a social standard where women are the complement of men and where equality between the sexes doesn't exist. The rejection of the Estrella report by the EU parliament and the "one of us" initiative have demonstrated easily that "obscurantism is at our doorstep" (Veronique Keyser). Some official decisions recently taken in France, including the 100% refund for abortion and the change of law on the reference to distress, are positive signs, and the campaign in Luxembourg for instance, contribute to lifting the taboo on the right to abortion. Many hospitals and abortion centres however have disappeared since 2001, with governmental budget cuts resulting in the merger of French hospitals. Women are obliged to wait two to three weeks for an appointment, often traveling 60 to 80 km to access surgical or medical abortion. These facts are real difficulties in the exercise of the right to abortion. For these reasons, it is critical to provide a communication platform to women, their relatives, and medical professionals, to allow a debate about abortion without prejudice or guilt. So, the Planning Familial has created a website where everyone can improve abortion rights, by answering a questionnaire, monitoring social networks and forums, sharing the poster and the site address. More than 1,000 questionnaires have been completed to date, since April 2014. We would like to present the site "l'avortement, un droit à defendre" to the FIAPAC.


Aubert Agostini


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    LS01.1

    Cervical priming before surgical abortion

    Aubert Agostini, Alexandra Ohannessian
    La Conception Hospital, Marseille, France

    Legal abortions are an international public health issue, with one in five pregnancies worldwide resulting in the decision to terminate. Accordingly, in 2008, 43.8 million elective abortions were performed, for a mean of 28 per 1000 women aged 15 to 44 years, with nearly 8.5 million complications. These complications can be life-threatening and are responsible for 13% of the annual international maternal mortality.
    Surgical abortion requires mechanical dilatation of the cervix. This cervical dilatation is the source of the principal complications of abortions including cervical laceration, uterine perforation with a risk of wounding adjoining organs, haemorrhage and, finally, the long term risks of cervical incompetence, late miscarriage and preterm delivery.On the other hand, when cervical dilatation is not adequate at the moment of aspiration, it can also cause other short-term complications: ongoing pregnancy and infection that can affect fertility. Cervical preparation has shown benefits in terms of cervical dilatation and reduction of intraoperative bleeding as well as a reduction in the incidence of complications. Misoprostol and mifepristone are the two substances recommended for cervical preparation during the first trimester.

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    MYA study: Observational study on cervical preparation prior to surgical abortion in real life conditions

    Aubert Agostini1, Philippe David2, Virginie Rondeau3 1Assistance Publique Hôpitaux de Marseille, Service Gynécologie, Hôpital de la Conception, Marseille, France, 2Service Gynécologie Obstétrique, Clinique Jules Verne, Nantes, France, 3INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France - aubert.agostini@ap-hm.fr

    Background: More than 200,000 abortions are performed yearly in France. Guidelines are available for medical and surgical abortion. However, clinical practices on surgical abortion and particularly on cervical preparation are not well known and not sufficiently documented. Study objectives: The main objective is to describe the different surgical abortion procedures especially the methods used for cervical preparation prior to surgical abortion including mechanical dilatation, therapeutic regimen, prescribed medications and conditions of administration. The secondary objectives assess the investigator's satisfaction with cervaical preparation, patient's feedback on surgery and identify associated factors with the chosen method of cervical preparation. Design: MYA is an observational, prospective study set up, in real-life conditions, in centres with at least 50% of their activity in surgical abortions and with a high number of abortions per year (N >500). In total, 132 centres were invited and 40 centres agreed to take part in the study from December 2013. A cohort of 600 women (older than 18 years) undergoing a surgical abortion at less than 14 weeks’ gestation, is expected. Women are enrolled during the visit prior the surgery after giving their oral consent. Data collection and outcome measures: Data will be collected by the investigator on 3 occasions: enrollment visit, during surgery and at the follow-up visit usually planned 3 weeks after surgery, including safety data. Patients will be asked to complete a questionnaire on acceptability one week after surgery. Cervical preparation will be described by the method used: medication prescribed or not, dosage and type of administration, interval between the medication administration and surgery and the rationale of this therapeutic regimen. Descriptive statistics of all variables will be performed to analyze the results. Conclusion: This study aims to provide additional information on the procedures of cervical preparation particularly for Western countries where these medical practices are poorly documented.

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    FC30

    Mifepristone and misoprostol for cervical ripening in surgical abortion between 12 and 14 weeks of gestation: a randomised controlled trial

    Alexandra Ohannessian1, Karine Baumstarck2, Julia Maruani1, Emmanuelle Cohen-Solal1, Pascal Auquier2, Aubert Agostini1
    1Department of Gynecology and Obstetrics, La Conception Hospital, Marseille, France, 2Department of Public Health, Self-perceived Health Assessment Research Unit, Aix-Marseille University, Marseille, France

    Objective: Misoprostol and mifepristone are the two substances recommended for cervical preparation during first-trimester surgical abortions to decrease intraoperative bleeding and complications. The objective of the study was to evaluate whether the combination of mifepristone and misoprostol for cervical preparation in an elective surgical abortion between 12 and 14 weeks of gestation can reduce blood loss in comparison to misoprostol or mifepristone alone.
    Method: A randomised controlled trial was performed in Marseille, France between May 2013 and May 2014. Women requesting a surgical abortion under general anesthesia between 12 and 14 weeks of gestation numbered 198, randomised into three groups: one group received 400 mcg oral misoprostol three hours before surgery; one 200 mg oral mifepristone 36 hours before surgery; and the other both treatments. The main outcome was the quantity of intraoperative bleeding. Secondary outcomes were duration of intervention, ease of dilatation and complications.
    Results:  The quantity of intraoperative bleeding differed significantly between the groups (p=0.001): 222 mL+/-64 in the combination group, 329 mL+/-129 in the misoprostol group, and 276 mL+/-119 in the mifepristone group. The combination was associated with a shorter operative duration (p=0.001): 5 minutes +/-2 in the combination group, 7+/-5 in the misoprostol group, 7+/-3 in the mifepristone group. A hemorrhage was observed for 5 of 55 women (9%) in the combination group, 13 of 51 (25%) in the misoprostol group, and 9 of 56 (16%) in the mifepristone group (p=0.08). No cervical laceration or uterine perforation was reported.
    Conclusion: The combination of mifepristone and misoprostol in cervical preparation for elective surgical abortions between 12 and 14 weeks of gestation significantly reduced blood loss in comparison to misoprostol or mifepristone alone.


Abigail Aiken


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    Do as we say, not as we do: experiences of unprotected intercourse among Society of Family Planning fellows

    Abigail Aiken1, James Trussell2 1University of Texas at Austin, Austin, Texas, USA, 2Princeton University, Princeton, New Jersey, USA - araa2@utexas.edu

    Objectives: Despite our role in preventing unintended pregnancy and STI transmission, very little is known about reproductive health professionals’ own experiences of sexual risk-taking. We examined the prevalence and circumstances of unprotected intercourse among Society of Family Planning (SFP) fellows in the United States. Methods: A link to an anonymous online survey was sent via email to 477 SFP fellows. Within the first week, 321 (67%) responded, and we expect around an 80% total response rate. We asked whether respondents had ever and in the past year had unprotected vaginal intercourse when not intending a pregnancy, and if so, how many times, under what circumstances, and at what age the first time. We then asked about unprotected vaginal, anal, or oral intercourse ever and in the past year under three different scenarios: 1) partner not known to be infection-free, respondent infection-free; 2) partner known to be infection-free, respondent not infection-free; 3) partner known to have an infection, respondent infection-free, including the number of times, applicable circumstances and age the first time. Results: Among respondents so far, 46% have ever had unprotected vaginal intercourse when not intending pregnancy; 35% more than 10 times, and 13% in the past year. Sixty percent have had unprotected vaginal, anal, or oral intercourse with a partner not known to be infection-free; 38% more than 10 times, and 22% within the past year. Eight percent have ever had unprotected intercourse with an infection-free partner when they themselves had an infection, and 5% have ever had unprotected intercourse with a partner known to have an STI. Conclusions: Preliminary results suggest that despite a high level of medical knowledge, risk-taking with respect to pregnancy and STIs is common among reproductive health professionals.

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    The Irish abortion referendum represented an historic moment for reproductive rights in Ireland. Strikingly, the overwhelming “Yes” vote from Irish voters was echoed and supported by a broad spectrum of Irish politicians. This presentation will describe the critical role played by scientific evidence in shaping the policy conversation and influencing the opinions of politicians. We will discuss both quantitative and qualitative findings about how women in Ireland access abortion and their experiences both traveling abroad to clinics and self-managing using online telemedicine. Looking ahead, we will also examine elements of the new legislation Irish politicians are drafting to grant access to abortion up to 12 weeks gestation. Finally, since the political spotlight has now turned to Northern Ireland, where abortion laws remain among the strictest in the world, we will preview new research examining women in Northern Ireland’s decision-making and experiences around abortion and discuss strategies for how this research might help support change. 

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    CS07.1

    Measurement of unintended pregnancy and its importance for predicting negative life impacts.

    Abigail Aiken1 ,2
    1University of Texas at Austin, Austin, TX, USA, 2Princeton University, Princeton, NJ, USA

    Unintended pregnancy is a key public health metric for gauging efforts to improve women’s reproductive health. Research has demonstrated complexity in women’s intentions, desires and emotional orientations towards pregnancy, as well as the propensity of each to change over relatively short periods of time. Yet current approaches to preventing unintended pregnancy and improving pregnancy outcomes are narrowly focused on the ideal that all women must form timing-based intentions regarding whether/when to have a(nother) child and then specifically plan either to achieve or to avoid pregnancy. In reality, many women hold ambivalent, indifferent or incongruent attitudes towards pregnancy, while others do not find planning meaningful in the context of their lives or may be unable to attain normative ideals regarding readiness for pregnancy and parenthood. Moreover, the main public health and clinical rationale behind preventing unintended pregnancy is that it necessarily results in adverse health and social outcomes. The evidence for such negative outcomes, however, is mixed and many studies suffer from serious methodological limitations. We review cutting-edge research examining pregnancy intentions, feelings and desires from women’s perspectives, as well as the evidence linking intentions to both negative and positive life impacts. We conclude by examining how shifting our emphasis from preventing unintended pregnancies to preventing truly undesired pregnancies could advance reproductive justice and result in more woman-centreed policy and practice.

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    FC04

    Safety and effectiveness of medical abortion outside the formal healthcare setting: do women seek timely care for potential complications?

    Abigail Aiken1 ,2, Rebecca Gomperts3, James Trussell1
    1Princeton University, Princeton, NJ, USA, 2University of Texas at Austin, Austin, TX, USA, 3Women on Web, Amsterdam, The Netherlands

    Objectives: Medical abortion provided outside the formal healthcare setting is an important option for women in countries where abortion is illegal or highly restricted. Yet very little is known about its safety and effectiveness. We address this important knowledge gap using high-quality data from a setting where women commonly rely on this pathway to abortion.
    Methods: We examine outcomes and complications among 1,234 women in Northern Ireland (representing 79% follow-up) who conducted medical abortion through Women on Web between March 30th 2009 and December 31st 2012. Women used a regimen of 200mg oral mifepristone and 1200mcg buccal misoprostol (with additional misoprostol provided if required).
    Results: At the time of consultation, 77% reported gestational age under seven weeks, and 23% between seven and nine weeks. Abortions typically occurred between five and 21 days later (women were strongly discouraged from performing abortion after 12 weeks gestation). Virtually all women (99.0%) were able to end their pregnancies and 95.1% were able to do so without surgical intervention. Three women (0.2%) required a blood/blood product transfusion and 23 (1.9%) were given antibiotics. Nine percent of women reported bleeding lasting more than two hours soaking more than two maxi pads per hour; fever >39C or purulent discharge; or pain persisting several days postabortion. Among women reporting these possible symptoms of serious complications, 97% sought timely medical care (the other 3% suffered no harm). Among women not reporting a potentially serious complication none received treatment for one.
    Conclusions: Despite a variety of gestational ages (including some beyond nine weeks) and the likely possibility that some providers performed surgical intervention and prescribed antibiotics unnecessarily, findings show that medical abortion provided outside the formal healthcare setting is highly effective and safe. Crucially, women are able to self-identify potentially serious complications and seek appropriate and timely medical assistance.


R. Ben Aissa et al.

slii.accounting@planet.tn


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    Reproductive health women rights in Tunisia

    R. Ben Aissa, N. Abedrabo, F. Temimi, M. Ben Attia, E. Hsairi, N. Gueddana (Tunisia)

    Office national de la famille et de la Population Tunisie, Tunisia

    Women’s rights are a part of human rights and reinforce gender equality and then economic development and at term reduction of poverty.

    Reproductive rights in Tunisia, according Cairo conference in 1994, as been facilitated by an enabling legal framework and a political will and are one of the foundations of the socio-economic development plan.

    The presentation is related to: Women’s rights, right to education for girls, rights to contraception and reproductive health services, right to abortion, right to a safe maternity, women’s rights against violence, and rights for youth to a safe sexuality.


Marijke Alblas

malblas@iafrica.com


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    Comparison of the safety and satisfaction of first trimester abortions performed by
    physicians and mid-level providers using MVA in South Africa
    Marijke Alblas
    Hoffman M*, Harries J*, Morroni C*, Beksinka M**, Kunene B**, Warriner I.***
    * Women’s Health Research Unit, University of Cape Town, South Africa
    ** Reproductive Health Research and HIV Unit, Durban, South Africa
    *** World Health Organization, Geneva, Switzerland
    Background: In countries where legislation permits the termination of early pregnancy,
    limited resources, including available trained personnel, often restrict access to safe
    abortion services. In some countries in order to improve access, trained mid-level
    providers (nurses, midwives and physician assistants) perform first trimester abortions.
    This WHO collaborative study was conducted in South Africa and Vietnam to evaluate the
    safety and effectiveness of first trimester abortions performed by mid-level providers
    (MLPs) as compared to those performed by physicians. The South African component of
    the study will be presented.
    Methods: A randomised controlled equivalence trial was conducted between September
    2003 and June 2004 in four Marie Stopes International clinics in South Africa. All women
    seeking a first trimester abortion were invited to participate in the study. Eligibility criteria
    included: gestational age of no more than 12 weeks, age 18 years or above, and
    willingness to return for a follow-up visit, or to have a telephone, home or outside clinic
    interview. Women were randomly assigned to a mid-level provider or physician for the
    abortion and were followed-up by study staff 14 days later. The primary outcomes of
    interest were complications occurring within two weeks of the abortion procedure. These
    complications, immediate or delayed, were clinically verified. Patients’ satisfaction with the
    service was assessed.
    Results: Six physicians and six MPLs participated in the study. A total of 1160 women
    consented to participate, 581were randomised to a physician and 579 to a mid-level
    provider. Six women withdrew from the study and one was lost to follow up. There were
    no complications among the physicians and eight (seven retained products and one
    infection) among the mid-level providers. Measures of equivalence of complication rate 

    between providers was 1.4% (95% CI 0.4-2.7) This was well below the a priori margin of
    equivalence which was set at 4.8%. More than 96% of women reported satisfaction with
    quality of care.
    Conclusion: Overall the quality of care was excellent and there was no difference
    between physicians and mid-level providers. The complication rate was low and met the
    criteria for equivalence. Given appropriate training and in a supportive environment MLPs
    provide first trimester MVAs as safely as physicians.

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    The efficacy, safety and acceptability of medical and surgical second trimester

    termination of pregnancy in Cape Town, South Africa

    Marijke Alblas, Independent Consultant, South Africa

    Co-authors: Kelly Blanchard, Ibis Reproductive and Health SA, Debbie Constant, Women's Health Research Unit University of Cape Town, Daniel Grossman, Ibis Reproductive Health SA, Jane Harries,

    Women's Health Research Unit University of Cape Town, Naomi Lince, Ibis Reproductive Health SA

    To examine efficacy, safety and acceptability of two 2nd trimester abortion techniques used in South Africa: medical induction (MI) with misoprostol alone and dilation and evacuation (D&E).

    In February-July 2008, we enrolled 304 adult women undergoing abortion at 13-20 weeks at 5 hospitals around Cape Town in a cross-sectional, observational study. 220 underwent D&E with misoprostol cervical priming (up to 3 doses) and paracervical block, and 84 underwent MI. Information was obtained about the procedure and immediate complications, and women were interviewed after recovery.Data were analyzed using SPSS v14.

    Median age was 25 years, median parity 1, and median education grade 12. Median gestational age was different between D&E and MI clients (16.0 weeks vs. 18.1 weeks, p<0.001). D&E was more effective than MI (99.5% vs. 50.0% of cases completed on-site and without unplanned surgical procedure, p<0.001). Complications were common (43.8% D&E vs. 52.4% MI, p=0.2). Fetus was expelled prior to procedure in 43.3% of D&E cases. In addition to incomplete abortion, there were 3 MI cases with blood transfusion, 1 hemorrhage without transfusion and 1 fever. 98.8% MI and no D&E clients needed overnight stay. Most women were somewhat-very satisfied with their experience (95% D&E vs. 95.9% MI). More D&E clients compared to MI reported moderate-extreme physical pain (75.7% vs. 59.5%, p=0.007) and moderate-extreme emotional discomfort (49.8% vs. 33.8%, p=0.017).

    D&E was more effective, required shorter hospital stay and had fewer severe complications. Second trimester abortion services can be improved in South Africa by expanding D&E training, altering the cervical priming protocol for D&E, improving pain management, and introducing mifepristone.

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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.


Inas Alhamdani

irhfpa@yahoo.com


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    In Iraq “illegal termination of pregnancy” still happens!

    Inas Alhamdani, Taghreed Alhaidari (Iraq)

    Al Elwyia Maternity Teaching Hospital and College of Medicine, Baghdad University, Baghdad, Iraq

    Background. 55.000 unsafe abortions take place all over the world, with 95% in developing countries and with more than 200 maternal deaths per day. In the Arab World 5% of all maternal deaths are due to unintended abortion related complications. The 2003, the UNFPA reports showed that Iraq has an increase in spontaneous and unsafe abortions but with no data on the exact number of illegal terminations.

    Aim. To assess how wide the problem is, throughout a survey performed in 2007 at one of the big maternity centers in Baghdad; that is Al Elwyia Maternity Teaching Hospital.

    Methodology. The current work presents an observational longitudinal study, including 322 women who present cases of illegal termination of pregnancy from a total of 3100 women who terminated their pregnancy before 24 weeks of gestation for any indication during the year 2007. All those women had a direct interview with special questionnaire, clinical examination was conducted thereafter.

    Results. Out of the total 3100 women admitted for termination of pregnancy, 322 were confirmed to have illegal termination. That represents 10. 4% of the total. Most of the patients (62%) were between 20-30 years old, with 69.9 % already having children. The most common mode of termination was the combined medical and surgical method, which has been performed by medical or paramedical staff (86,9 %). In 93.7 % of cases, pregnancy was confirmed by ultrasound. Failed contraception due to improper pills intake represents 53% of the cases. Decision for termination was taken by the wife herself in 64% of cases; mainly due to financial reasons. The most common presentation was septic abortion (86%), with 89.4% requiring 1 to 3 units of blood transfusion.

    Conclusion and Recommendations. Illegal termination of pregnancy is still an ethical, religious and medical problem all over the world, including our country. The main determining factor for termination of pregnancy amongst those women seemed to be the fact that it was unwanted and/or unplanned; either due of inappropriate timing, problems in the relationship itself, or due to social and economic implications, which are important issues in Iraq. The main problems encountered were improper contraceptive use in spite of very good awareness and/or the desire to use, as well as the abuse of misoprostol (which is not yet  approved in our country) by pregnant women and paramedical staff . There is a real need for thorough attention to update our national family planning and access to contraception policy, in order to meet the emerging social demands.There is also an urgent need to integrate abortion care related services into the overall reproductive health care, as part of a broader and safer motherhood plans.


Syed Mustafa Ali


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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
    IPPF
    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.


Maria Jesus Alonso


Speeches:

Nathalie Ambassa

nathalieambassa@yahoo.com


Speeches:
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    Paracervical block versus intracervical injection for pain management during first-trimester surgical abortion under local anaesthesia

    Nathalie Ambassa, K. Bourzoufi, Francis Collier (France)

    Orthogenics and medicine of the couple department, Hôpital Jeanne de Flandre, CHRU Lille, France

    Objective.Two different local anaesthesia techniques are commonly used for pain relief during first-trimester surgical abortion: paracervical block (PCB) or intracervical injection (ICI). The superiority of one technique versus the other has not been clearly established. In practice, the choice between these two techniques is made empirically, according to specific habits of each centre or each practitioner. This prospective observational study compared the effectiveness and acceptability of these two techniques to reduce pain during first-trimester surgical abortion following cervical priming with misoprostol.

    Patients and methods. Two-hundred and forty-nine women undergoing suction evacuation up to 12 weeks gestation were randomized into two groups: (ICI) 5 mL of 2% lidocaine injected at the 4 and 8 o’clock positions of the cervix; (PCB) 10 mL of 1% lidocaine injected at the 4 and 8 o’clock positions of the vaginal vault. Using a 0-10 scale, women rated pain associated with local anaesthetic administration, cervical dilatation and during and after suction evacuation. Pain scores, post-operative analgesic demand and satisfaction levels were compared among the two groups.

    Results.Pain levels during local anaesthetic administration were significantly lower (p<0.0001) in the paracervical group (2.1±2.1) than in the intracervical group (3.9±2.4). There were no statistically significant differences in the pain scores during cervical dilatation and suction evacuation. Post-operative demand for analgesics was significantly (p=0.0286) higher in the intracervical group. There was no difference between the groups concerning the global satisfaction of the patients (p=0.2489).

    Conclusion. The paracervical block is less painful and at least as effective against the pains related to the cervical dilatation as the intracervical injection. Therefore, the paracervical block seems to be the technique of choice in first-trimester surgical abortion under local anaesthesia. This study should lead to a modification of our practice in Lille with a broader use of the paracervical block for our patients.

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    Presenting a recent review

    Nathalie Ambassa, K. Bourzoufi, Francis Collier (France)

    Orthogenics and medicine of the couple department, Hôpital Jeanne de Flandre, CHRU Lille, France

    Objective. Two different local anaesthesia techniques are commonly used for pain relief during first-trimester surgical abortion: paracervical block (PCB) or intracervical injection (ICI). The superiority of one technique versus the other has not been clearly established. In practice, the choice between these two techniques is made empirically, according to specific habits of each centre or each practitioner. This prospective observational study compared the effectiveness and acceptability of these two techniques to reduce pain during first-trimester surgical abortion following cervical priming with misoprostol.

    Patients and methods. Two-hundred and forty-nine women undergoing suction evacuation up to 12 weeks gestation were randomized into two groups: (ICI) 5 mL of 2% lidocaine injected at the 4 and 8 o’clock positions of the cervix; (PCB) 10 mL of 1% lidocaine injected at the 4 and 8 o’clock positions of the vaginal vault. Using a 0-10 scale, women rated pain associated with local anaesthetic administration, cervical dilatation and during and after suction evacuation. Pain scores, post-operative analgesic demand and satisfaction levels were compared among the two groups.

    Results. Pain levels during local anaesthetic administration were significantly lower (p<0.0001) in the paracervical group (2.1±2.1) than in the intracervical group (3.9±2.4). There were no statistically significant differences in the pain scores during cervical dilatation and suction evacuation. Post-operative demand for analgesics was significantly (p=0.0286) higher in the intracervical group. There was no difference between the groups concerning the global satisfaction of the patients (p=0.2489).

    Conclusion. The paracervical block is less painful and at least as effective against the pains related to the cervical dilatation as the intracervical injection. Therefore, the paracervical block seems to be the technique of choice in first-trimester surgical abortion under local anaesthesia. This study should lead to a modification of our practice in Lille with a broader use of the paracervical block for our patients. 


Anissa Ben Amor


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    FC31

    Therapeutic abortion for maternal indications or how to reduce them?

    Ben Amor Anissa1 ,2, Dimassi Kaouther1 ,2, Ben Aissia Nizar1 ,2, Triki Amen1 ,2
    1Mongi Slim Hospital, La Marsa, Tunis, Tunisia, 2University Tunis El Manar, Faculty of Medicine of Tunis, Tunis, Tunisia

    Background: Maternal medical conditions are an important reason for therapeutic abortions. Indeed several medical diseases may deteriorate or even develop during pregnancy.
    Aim : The purpose of the study was to assess the reasons for therapeutic abortion for maternal indications in our department and to determine how to reduce them.
    Methods: We conducted a retrospective study in the Mongi Slim Gynecology and Obstetrics department, La Marsa, Tunisia from 2005 to 2015. All cases of therapeutic abortion were included.
    Results: There have been 127 therapeutic abortions done in 10 years, 32 of them were for maternal indications. The incidence was about 1 per 1000 births. The gestational age varied from 9 to 26 weeks' amenorrhoea. The causes were: obstetric diseases (12%), mainly severe preeclampsia (7%) and premature rupture of membranes (5%); maternal severe heart diseases (5%), mainly valvulopathies; maternal somatic diseases (2 cases : lupus and severe diabetic ketoacidosis); 8 cases (7%) of maternal cancer discovered while pregnant (5 cases of breast cancer, 1 of lung cancer and 2 of digestive cancer); and psychiatric conditions.
    Conclusions: A quarter of therapeutic abortions done in our department were for maternal indications. It seems that chronic diseases not adequately followed up or diagnosed while pregnant are a major cause of therapeutic abortion despite the high frequency of obstetric causes. It is very important to encourage preconception consultations to improve the screening of these diseases and plan the pregnancy care properly. However, pregnancy still constitutes the only opportunity to have a detailed full check-up and to diagnose many diseases.


Jean-Jacques Amy

bea.pion@az.vub.ac.be


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    How do we move forward
    Jean-Jacques Amy, MD, DTM, Prof.
    Co-President, Fédération Laïque de Centres de Planning Familial, Brussels.
    Anne Verougstraete, Lucie Van Crombrugge, Pierre Moonens, Dominique Roynet
    Family planning was given an impetus in the late sixties, following the cultural and sexual
    revolution that took place at that time. People stood up and claimed their right to an
    unrestricted sexuality. Simultaneously, they rejected constraints with regard to the control
    of their fertility. These fights were part of a more ambitious undertaking that aimed at
    restructuring society, making this latter more humane and more equalitarian.
    Contraception, then abortion gained acceptance in many countries, but not without eliciting
    much anger in reactionary circles that correctly perceived that these new freedoms would
    endanger the power they had exerted until then. Various issues are indeed raised by
    abortion: sexuality, the meaning of life and, first and foremost, free will, which is anathema
    to extreme right and religious fundamentalists. We should be on the alert because, since
    the early nineties, the powers of darkness are gaining momentum in the United States, in
    Poland, and elsewhere. We must define strategies, not only to drive back these raging
    opponents, but to further develop the availability of contraception and safe abortion, to
    enforce the right of women to control their bodies, and by doing so, to reduce infant and
    maternal mortalities, which are scourges in many parts of the world. To this end, we might
    1. have the European Parliament legislate on the mandatory implementation by the
    various countries of their existent, liberal abortion law: in many such countries the
    access to abortion centres is limited or non-existent;
    2. write a book on the advantages of liberalizing and de-penalizing abortion;
    3. create a working party that would assess the situation in Portugal, Ireland, Poland,
    and Malta;
    4. create an international centre for training doctors and other health personnel with
    regard to voluntary termination of pregnancy;
    5. propagate the use of mifepristone as a “once-a-month” pill, which would result in a
    much smaller release of steroids in the environment than that associated with the
    widespread use of currently used hormonal contraceptives;
    6. pay much more attention to analgesia during induced abortion;
    7. link European and African countries to increase the safety of abortion in these latter;
    8. elect decent and honest citizens to positions of power, and then control them.


Inga-Maj Andersson

inga-maj.andersson@sodersjukhuset.se


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    Care - special considerations

    Inga-Maj Andersson, Midwife MSc, Södersjukhuset AB, Stockholm, Sweden

    Background: Nursing in late abortion is a challenge that requires sensitivity and professional knowledge. The woman is in a complex situation with many aspects to consider.

    Materials and Methods: Review of the current literature and experience of encounters with women who have had late abortions.

    Results: Attitude and way of communicating security and trust are important for the woman's experience in an abortion situation. To show respect for the woman by being responsive to her story / experience may make  it easier  for the woman  (and her partner)  and for those who care to find a good path through

    the abortion.

    Women’s experience of pain varies with gestational age, maternal age and parity. By estimating the woman's pain perception and evaluate given pain treatment during the abortion gives a greater opportunity to optimal pain relief during the abortion. Systematically given opioids are not optimal treatment in pain from urogenithal region.

    Anxiety is related to pain in a number of procedures and situations. To reduce stress related to the physical and emotional aspects of the abortion information is helpful. It is important for the women to have accurate information before the procedure and high quality care throughout. The information and care should be as effective as possible in meeting the needs for the individual woman.

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    Caring for women undergoing second trimester medical termination of pregnancy

    Inga-Maj Andersson, Kristina Gemzell-Danielsson, Kyllike Christensson Karolinska Institutet, Stockholm, Sweden - inga-maj.andersson@ki.se

    Objective: To explore the experiences and perceptions of nurses/midwives caring for women undergoing second trimester medical termination of pregnancy (MTOP). Method: Semistructured interviews took place at one gynaecological clinic in a general hospital in Stockholm. Twenty-one nurses/midwives with experience in second trimester abortion care were interviewed following a semistructured interview guide. The interviews were recorded, transcribed verbatim and then analyzed using qualitative content analysis to identify common themes. Results: The analysis revealed two themes: "The professional self," with six subthemes describing the experiences and perceptions described in terms of professional behavior: "Being familiar with the process", "Balancing objective information", "Finding ways for pain treatment", "Looking for the woman's needs", "Handling the fetus" and "Needing time for reflection". The theme "The personal self" has four subthemes containing the experiences and perceptions described in terms of personal values: "Conflicting duty and behavior", "Dealing with emotions", "Identifying oneself with the woman" and "Developing inner safety and maturity". Conclusions: Taking care of women undergoing second trimester MTOP is a task that requires professional knowledge, empathy and the ability to reflect on ethical attitudes and considerations. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. Mentorship from experienced colleagues and structured opportunities for reflection on ethical issues enable the nurses/midwives to develop security in their professional roles and also feel confident in their personal life situation. The feeling of supporting women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second trimester MTOP.

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    Comprehensive pain treatment in abortion care
    Inga-May Andersson, Midwife Msc 
    Karolinska University Hospital, Stockholm
    Background: Pain during abortion is a complex condition with many aspects to pay
    attention to in the nursing care of women undergoing abortion. Management of pain during
    abortion has been given insufficient attention.
    Materials and Methods: Review of the current literature.
    Results: The abortion methods have been given a lot of attention in different research
    projects. Several studies focus on the regimen of medical abortion. The methods for
    surgical abortion are also well evaluated.
    Studies show that women’s experience of pain varies with gestational age, maternal age
    and parity. Visceral pain, as abortion pain belongs to, is deep and poorly localised often
    with high intensity score. Systematically given opioids are not optimal treatment in pain
    from urogenithal region; regional blockades are more effective. Early treatment of pain
    reduces the pain intensity.
    Anxiety is related to pain in a number of procedures and situations. Anxiety combined with
    physical (nociceptive) pain makes the total experience of pain more intensive. To reduce
    stress related to the physical and emotional aspects of the abortion information is helpful.
    It is important for the women to have accurate information before the procedure and high
    quality care throughout. The information and care should be as effective as possible in
    meeting the needs for the individual woman.
    Other non-medical pain management strategies should also be given the necessary
    attention. The woman should be offered a choice of abortion methods because women
    report less pain if the choice of early abortion has been their own decision. The importance 

    of positive staff attitudes and a non-judgemental atmosphere in the quality of care is
    emphasised.
    Conclusions: Pain treatment in abortion care is a complex challenge. Correct information,
    positive attitudes together witn non-judgemental atmosphere are important parts to reduce
    stress for the women. Medical pain management during abortion should be mixed with
    drugs acting both central- and periphere. Paracetamol, kodein and NSAID is
    recommended. Local anaesthetic by paracervical blockade is an effective method if
    needed. Prophylactic pain treatment should be considered.

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    Women´s experiences of second trimester medical termination of pregnancy and their feelings and thoughts about viewing the fetus

    Inga-Maj Andersson, Kristina Gemzell-Danielsson, Kyllike Christensson Karolinska Institutet, Stockholm, Sweden - inga-maj.andersson@ki.se

    Objectives: To explore women´s experiences of second trimester medical termination of pregnancy and their feelings and thoughts about viewing the fetus. Method: A cross-sectional and descriptive study using both a questionnaire and semi-structured interviews for data collection. Thirty-one women filled out the questionnaire and among them 23 women were later interviewed. The questionnaires were analyzed by descriptive statistics. The answers from the questionnaires were followed up in the interviews. The interviews were recorded, transcribed verbatim and then analyzed with qualitative content analysis to identify common themes. Results: Indication for the abortion was fetal malformation or unintended pregnancy. Independent of the reason for the abortion similar feelings were expressed by the women. After having divided the feelings into positive or negative, we found that 57 % of the women had chosen both positive and negative feelings, and 40 % of the women had chosen just negative feelings. Concerns for a suffering fetus and a curiosity of what it would look like or what kind of person it could have been were expressed. Thoughts that viewing the fetus would cause increased grief or mental weakness in the future were expressed by some women. The analysis of the interview texts revealed five themes mirroring the women´s experiences, thoughts and feelings related to the abortion: "Not knowing what to expect", "To suffer", "To manage", "To get support" and "To remember", each theme is divided into subthemes to clarify the meaning. Conclusions: Women undergoing second trimester abortion need to have time and the opportunity to reflect on their feelings and thoughts in connection with the abortion. Independent of the indication for the abortion feelings of grief and sadness are seen as well as feelings of having killed their child. It is important to listen to the woman´s individual needs and give the opportunity to view the fetus if the woman wishes regardless of the reason for the abortion.

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    Pain treatment during second trimester abortion
    Inga-Maj Andersson, K. Gemzell-Danielsson, O. Stephansson, K. Christensson,
    Dept of Woman & Child Health, Karolinska University Hospital,/Institutet
    Stockholm, Sweden,

    Objectives To assess pain intensity, methods of pain treatment and predictors for the
    need of analgesia in women undergoing second trimester abortion.
    Design Descriptive study with consecutive inclusion of patients.
    Material and methods A combined treatment with mifepristone and misoprostol was used
    for the termination of pregnancy. From February 2002 to June 2003 data from 122 women,
    undergoing second trimester abortion, was collected into a protocol to describe pain-
    intensity measured by Visual Analoge Scale (VAS) and methods of pain treatment.
    Demographic data such as age, gestational duration and reproductive history were
    collected. The indication for the termination of pregnancy was noted as well as the
    presence or absence of a partner or friend during the abortion.
    Results The age of the women varied from 14 years to 46 years and the length of
    gestation between 86 and 153 days. Indication for the abortion was socio-economic in
    66% of the women. Young women, women with no previous birth and women with higher
    gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
    treatment was higher for these women during second trimester medical abortion. Pain-
    intensity VAS >7 (severe pain) was reported by 63% of the women at some time during
    the abortion. Intavenous morfine was given to 80% of the women. Paracervical blockade
    (PCB) was given to 21% of the women. There was no significant difference in pain-
    intensity, morphine- or PCB-requirements related to the presence of a partner, parent or
    friend during the abortion nor to the indication for the termination of the pregnancy
    (unwanted pregnancy or foetal malformation).Univariat analyses, Chi2-test (p=0.05) and
    Mann-Whitney´s test were used for the data analyses.
    Discussion Management of pain during second trimester abortion must be focused on the
    women’s need. Individual care is crucial for optimal pain treatment. To reduce the high
    frequency of severe pain one step is early active pain treatment to women with known
    predictors for higher pain experience. Different methods of pain treatment should also be

    available (i.ex. NSAID, PCB). Education of the staff in pain management and caring is
    needed to make the abortion care more focused on pain treatment and create a high
    quality and non-judgemental atmosphere. Further research is needed to improve the care
    of women undergoing second trimester abortion.
    Conclusions Young women, women with no previous birth and women with higher
    gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
    treatment was higher for these women during second trimester medical abortion.

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    FC13

    Paracervical block (PCB) as pain treatment during second-trimester medical termination of pregnancy - a randomised controlled trial with bupivacaine versus sodium chloride.

    Inga-Maj Andersson, Lina Benson, Kyllike Christensson, Kristina Gemzell-Danielsson
    Södersjukhuset AB, Stockholm, Sweden

    The most common side effect of misoprostol is pain, however there are sparse studies of pain and pain treatment during MToP, especially in second-trimester abortion. Pain reported in second-trimester medical abortion is often intense, and peaks when the  expulsion occurs.
    Objectives: The aim of the present study was to determine if PCB administered before the onset of pain could decrease women´s pain experience during second-trimester MToP.
    Method: A double-blinded randomised controlled trial, with 113 participants included, was performed during May 2012 until April 2015.  Women who consented to participate were randomly allocated to receive a PCB with either 20 ml local anaesthesia (bupivacaine 2.5 mg/ml) or 20 ml sodium chloride 9mg/ml. The PCB was applied one hour after the first dose of misoprostol as a 2 to 4 millimetre deep paracervical injection into the mucosa at two sites (2 and 8 o´clock). The experience of pain was measured by visual analogue scale (VAS) at the time of administration of the first dose of misoprostol (baseline) and thereafter repeated every half hour during the abortion until the  expulsion. The main outcome was the highest pain intensity recorded on the VAS scale. Secondary outcomes were the induction-to-abortion interval measured from the start of misoprostol to  expulsion, the total morphine consumption, safety and side effects.
    Results: No statistically significant differences were observed between the two groups with regard to the highest and lowest pain intensity and morphine consumption. There was no difference in efficacy between the groups, neither in induction-to-abortion interval and time to placental expulsion nor in the rates of surgical intervention or the need for any additional treatment.
    Conclusion: It can be concluded that prophylactic PCB did not lead to a clinically significant reduction in maximal pain scores and the need for additional opiates during second-trimester MToP.


Andriana Andreeva


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    Medical abortion in Bulgaria is available in unusual circumstances. Abortion in Bulgaria is allowed up to 12 weeks upon wish, up to 20 weeks - for medical conditions or foetal anomalies, and after that - in extreme circumstances.
    The legislation regarding abortion has been made in 1990 and last reviewed in 2000. Medical abortion doesn’t exist in it. It is written envisaging surgical procedures only. It requires blood tests (FBC, MSU, clotting, blood group, Rh) and vaginal swab prior to every abortion. It also requires the abortion to start and end in a medical facility. It otherwise classifies the act as a criminal offence and envisages imprisonment of up to 5 years and if repeated - up to 8 years.
    Medical abortion, however, has been performed in the country over the past 10 years or so. Prior to the official availability of registered drugs, Cytotec was in wide circulation. It still is, regardless of the lack of registration in the country.
    Mifepristone and Misoprostol have been first registered in 2012, reaching the market in the end of 2014. Their registration is for distribution in pharmacies, by prescription. The obs&gynae society, however, is largely against the wide availability of the medications, being afraid women will self medicate, and are reluctant to prescribe them, seeing it as illegal to participate in abortion outside medical facility. Very few hospitals offer MTOP or medical management of miscarriage as an inpatient procedure. Professional knowledge on medical abortion is limited. It is widely believed that every pregnancy must end with delivery or curettage.
    A few hospitals and doctors do provide medical abortion, albeit in variation of regimens, and more and more women request it.
    It is because of women’s increasing interest and the few doctors fighting for the cause, that medical abortion is surviving in Bulgaria.


Gunilla Aneblom

gunilla.aneblom@kbh.uu.se


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    Emergency contraceptive pills over- the-counter; practices and

    attitudes of pharmacy and nurse-midwife providers

     

    Gunilla Aneblom *, Karin Eurenius, Tanja Tydén,  Department of Women’s and Children’s Health, Uppsala University

    Cecilia Stålsby Lundborg, Department of Public Health Sciences, IHCAR, Karolinska Institutet, Stockholm, and Nordic School of Public Health, Göteborg,

    Cecilia Stålsby Lundborg, Anders Carlsten, Research Division of Apoteket AB, Göteborg,

    Tanja Tydén , Department of Public Health and Caring Sciences, Uppsala University,

     

    Introduction: Deregulation of emergency contraceptive pills (ECP) has led to pharmacy staff becoming a new provider group of ECP, together with nurse-midwives, who are already experienced in prescribing contraceptives.

     

    Aim and Method: This postal questionnaire survey aimed to assess practices and attitudes towards ECP and the over-the-counter (OTC)-availability among pharmacy staff (n=237) and nurse-midwives (n=163). Attitudes were measured on a six-point Likert scale.

     

    Results: The overall response rate was 89%. Both study groups were positive to ECP and the OTC-availability and the vast majority agreed that sexually active women should be aware of ECP and that routine information about ECP should be included in contraceptive counseling. Verbal information on all aspects of ECP to clients was reported more often by nurse-midwives than by pharmacy staff. Experience of ECP sale to men was reported by 25% of pharmacy staff, and 38% of pharmacy staff reported on referral of women to local clinics for follow up after treatment. Both groups supported collaboration between providers.

     

    Conclusion: Our findings suggest that further collaboration between pharmacies and family planning clinics should be encouraged to ensure a competent and client-friendly provision of ECP.


Kalpana Apte


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    Gender-biased sex selection

    Lena Luyckfasseel IPPF European Network, Brussels, Belgium - lluyckfasseel@ippfen.org

    Sex selection can take place before a pregnancy is established, during pregnancy through prenatal sex detection and selective abortion or following birth through infanticide or child neglect. Nevertheless, the discussion seems to focus especially on abortion. Sex selection is sometimes used for family balancing purposes but far more typically occurs because of a systematic preference for boys. Practised on a large scale it can result in skewed sex ratios at country-level. The root causes of gender-biased sex selection are situated in persistent gender inequality leading to son preference. Other conditions that need to be present for prenatal sex selection are low fertility (people choosing smaller sized families) and the availability of the technology. In 2011 the Parliamentary Assembly of the Council of Europe in their resolution on "Prenatal Sex Selection" stated that there is "strong evidence that prenatal sex selection is not limited to Asia [...] and has reached worrying proportions in Albania, Armenia and Azerbaijan". This has put gender-biased sex selection firmly on the European agenda. It is important to frame the discussion on gender-biased sex selection in such a way that it does not impede women's access to safe abortion services. Following a short introduction to the topic a diverse panel will explore the following questions: What does gender-biased sex selection mean for us? How do we respond to gender-biased sex selection; towards individuals, practitioners, decision makers and anti-choice?


Annette Aronsson

annette.aronsson@karolinska.se


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    Is preoperative vaginal cleansing necessary for control of infection after first
    trimester vacuum aspiration?
    Annette Aronsson MD, Karolinska University Hospital, Division of Gynecology and
    Obstetrics, Stockholm, Sweden,
    Traditionally, the vagina is cleansed before a vacuum aspiration or a dilatation and
    curettage is performed.
    In the effort to give evidence based recommendations a review of the literature was
    performed to find out if this practice could be supported or safely omitted.
    Available data did not support any increased incidence of infections in women who had not
    undergone any presurgical cleansing compared to the group of women in which cleansing
    was performed.
    Based on the studies reviewed, preoperative cleansing can be safely omitted at first
    trimester surgical abortion without risk for the patient, provided that genital infections are
    excluded.

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    Sublingual compared with oral misoprostol for cervical dilatation prior to vacuum aspiration.

    Annette Aronsson*, MD, Lotti Helström, MD. and Kristina Gemzell Danielsson, MD. PhD

    Dept of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden

     

    BACKGROUND. Vacuum aspiration is still the most common method in late first and early second trimester pregnancy. Prostaglandin analogues have been successfully used for  preparing the cervix before mechanical dilatation and suction curettage since over 20 years to reduce the risk of mechanical injury, incomplete evacuation and haemorrhage. The analogue mainly used today is misoprostol. The most advantageous dose schedule for cervical priming seems to be 0.4 mg misoprostol orally or vaginally given 3 hours prior to vacuum aspiration. However most women prefer the oral route. Recently the possibility to administer misoprostol sublingually has been described. The absorption of misoprostol when given sublingually is equally rapid as following oral treatment but the plasma levels remain elevated for a significant longer time and the effect on uterine contractility is more pronounced.

    The aim of the study was to compare the effect of oral and sublingual administration of misoprostol for cervical priming prior to vacuum aspiration.

    METHODS. Thirty-two first time pregnant women with 8 to 12 weeks amenorrhoea and admitted to the hospital for surgical termination of pregnancy were recruited. The women were randomly assigned to receive 400 mg misoprostol either orally or sublingually 3 hours prior to surgery.

    RESULTS. The degree of baseline dilatation and the cumulative force needed for dilatation of the cervical canal did not differ between the two treatment groups. However, the number of patients in whom a strong force (15 and 20 N with the 8 and 9 mm dilator respectively) was significantly higher following oral than following sublingual treatment. The number of patients with gastrointestinal side effects and need of additional analgesic treatment was higher following sublingual treatment. The opposite was true with regard to the number of patients who had a blood loss at operation of 50 ml or more.

    CONCLUSION. It was shown that sublingual administration is more effective than oral administration of misoprostol for cervical priming and associated with less blood loss but a higher frequency of side effects.


Joyce Arthur

writer@direct.ca


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    Do we need a law on abortion at all?

     

    Joyce Arthur(Canada)

    Director Pro-Choice Action Network

    Editor of the Pro-Choice Press

     

    "Keep Your Laws Off My Body!"

    Canada is the only democratic, industrialized country in the world with NO laws against abortion (since 1988). Abortion is managed like any other necessary health procedure, and as a result, services have flourished and improved significantly, with no ill effects or abuses.  Legal restrictions against abortion are leftover artifacts from the days of criminal abortion and are fundamentally unjust, with many negative consequences:  They reduce access to abortion, pose arbitrary obstacles, marginalize abortion outside the medical mainstream, stigmatize healthcare professionals, turn abortion into a political target for extremists, and breed hypocrisy and disrespect for the law. Most importantly, they discriminate against women and violate women's constitutional right to equality. Laws against abortion amount to a publicly-sanctioned judgment against women's moral reasoning, their sexuality, and their right to control their own lives.

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    Exposing Anti-Abortion "Counselling" Centres
    Joyce Arthur, Abortion Rights Coalition of Canada, Vancouver, BC
    Thousands of "fake clinics" in North America try to prevent women from having abortions.
    These religious centres provide misinformation about abortion and treat women
    unprofessionally, often making them feel confused, afraid, and guilty for seeking an
    abortion. This presentation summarizes a project to research and expose fake clinics in
    British Columbia, Canada.

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    How to Think About the Fetus
    Joyce Arthur, Abortion Rights Coalition of Canada, Vancouver, BC
    Should providers and the pro-choice movement acknowledge the "moral value" of the
    fetus? This philosophical presentation explains that judging what a fetus is, and any value
    it may have, is entirely subjective and personal. Only the individual pregnant woman can
    decide what her fetus means to her, and our role is to respect her opinion.

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    Much attention is given to the alleged right of healthcare professionals to refuse treatment under the guise of “conscientious objection,” especially abortion. But what about those who conscientiously commit to providing this life-saving care despite stigma, obstacles, and legal risks?  The organization Women Help Women believes in the ethical value of conscientious commitment to provide abortion care as a way to break the taboo around provision regardless of legal settings. WHW does this by equipping local activists and health workers to guide women through self-managed abortion in countries where abortion is illegal.

    This presentation will share aspects of WHW’s unique partnership model, which is based on collaborative, participatory, feminist efforts to advance access and knowledge. WHW works horizontally, promotes local ownership of joint initiatives, and strengthens and develops capacities of local and regional movements. One example is WHW’s “Mobilizing Activists for Medical Abortion” network (MAMA), which operates in at least eight African countries.


    MAMA expands community access to information and provides reproductive health training about misoprostol use and self-induction. In 2017, MAMA member organizations reached over 19,000 women with information and services.

    In Latin America, WHW collaborates with activists throughout the region, with a focus on Central America, Brazil, and Chile. The group helps local collectives launch and maintain new safe abortion hotlines, trains activists in counseling skills and medical abortion, and supports access to safe abortion via locally-led campaigns and awareness actions. For example, in Chile, the “Misoprostol for All” campaign used radio spots and street actions to promote information about the local safe abortion hotline and the use of misoprostol.

     


Cécile Artus

Cecile.Artus@mutsoc.be


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    The experience of the settling of a new abortion center in the French speaking part of Belgium

    Cécile Artus (Belgium)

    Center Eve & Adam, Bastogne, Belgium

    The province of Luxemburg shows specificities due to the rural environment : scattered population, great geographical distances, lack of publictransports. This province has also a political story where the catholic party is well present. So, it is only in 2007 that the idea to open the unique abortion center  in this province was born.

    It is obvious that the access to abortion (as well as to contraception and to pregnancy test) is difficult in this rural environment for all the reasons mentionned above.

    The question of the anonymity is raised and reduces this access to abortion. It is the reason why this right must be guaranteed to the women that push the door of the center.

    Since the begining of the abortion center, the staff has established a surprising statement: 25-35 years old women under contraception with a non desired pregnancy of 13-19 weeks old. The hypothesis is that these women have contraceptive accidents and do not have any awareness of the risk taken.

    As a conclusion, the abortion is still a taboo subjet. The professionnal workers of the contraception and abortion have still to focus on prevention and information about reproductive health.


Chilinga Asmani


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    Task sharing in delivering safe abortion services: experience from Africa

    Chilanga Asmani1, Karthik Srinivasan2 1International Planned Parenthood Federation, Africa Regional Office, Nairobi, Kenya, 2International Planned Parenthood Federation, Central Office, London, UK - casmani@ippfaro.org

    Globally, Africa is hardest hit by the current healthcare worker crisis with a shortage of over 800,000 staff primarily among physicians and specialists. As an effort to overcome this shortage and expand access to critical health services, task sharing and task shifting has been promoted in the different health sectors by governments and civil society organizations. This approach has been adopted by IPPF to ensure universal access to sexual and reproductive health services. In many of its Member Associations (MA), IPPF has utilized this approach to expand access to safe and comprehensive abortion care and contraceptive services. A range of health workers comprising non-physicians, clinical officers, nurses and midwives currently provide pre and post abortion counselling, induced medical and surgical abortion and contraceptive services. As a result of these efforts, provision of abortion services by IPPF in the Africa region has increased by 42% between 2012 and 2013. Among the five MAs implementing the Global Abortion Care Initiative in Burkina Faso, Cameroon, Ethiopia, Ghana and Kenya, safe abortion service provision has increased from 6,477 to 14,653; treatment of incomplete abortion services has increased from 1,709 to 2,125 between 2011 and 2013. Although community awareness and acceptance for abortion services has increased and assessments indicate high level of quality of care and satisfied clients, the challenge of abortion stigma and staff attrition still persist. Task shifting and sharing the provision of safe abortion and contraceptive services has proven to be an extremely safe, well-accepted and feasible strategy to expand access to safe abortion care and contraception even in low-resource settings. Looking ahead, IPPF aims to conduct pre-service and in-service trainings and updates for midlevel providers, conduct operational research and develop strategies to increase access to safe abortion and contraceptive services in a stigma-free environment.


Tatiana M. Astakchova


Speeches:

Edna Astbury-Ward

e.astburyward@glyndwr.ac.uk


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    Abortion care - the staff perspective

    Edna Astbury – Ward, PhD, M.Sc, RGN, Dip., H. Ed, United Kingdom

    Methods: A qualitative interpretive study. Face to face in depth interviews with 8 staff.

    Results: Working in abortion care presented a unique set of social, emotional and practical challenges for staff. Because of working in abortion care some staff expressed a sense of isolation from other colleagues. They said that those who didn’t work in abortion care considered it an unpopular job and perceived patients requesting abortion as more ‘challenging ‘and ‘problematic’ than other patients, partly because of the additional time required but also because of the emotional investment which is associated with the role. Staff’s sense of isolation was manifested because they felt they couldn’t talk to others about their job. Irrespective of their perceived sense of isolation the desire to provide a service for women in need was a motivational factor for those staff who had chosen to work in this area.

    Although staff said personal opinions did not have a place in the delivery of care some were unable to disassociate themselves professionally from their own deeply held personal convictions. In addition, some said that they felt unable to voice opposition to an expectation that they would work in this area if it was included as part of a wider women’s health remit. They indicated that sometimes their feelings were compromised by this aspect of the role indicating they felt unable to exercise their right to conscientious objection.

    The subject of repeat abortion provoked particularly negative staff emotions for personal and professional reasons, especially if patients repeatedly accessed abortion services because of non use of contraception. Often staff admitted they wanted to ‘lecture’ patients about the issue and some implied that eventually patients may be less likely to receive good care in these instances. However staff reported that women who requested abortion for foetal abnormality were likely to receive more sympathy, understanding and care.

    The practical challenges mainly concerned whether facilities were appropriate, available and accessible for patient care. Staff recommended that facilities ideally shouldn’t be sited near ante-natal or post-natal areas and there should be provision locally for late gestation abortion and swift access.

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    After abortion: women’s emotions

    Edna Astbury-Ward, United Kingdom

    Methods: A qualitative interpretive study. Face to face in depth interviews were conducted with 17 women aged between 22-57 years, whose abortions took place between 4 weeks and 34 years previously.

    Results: Whilst the study set out to explore women's perceptions of abortion care, it was apparent that care was not experienced in a vacuum and that women’s emotions were inextricably linked with the abortion experience. Women described a range of varied feelings after abortion. They included positive emotions such as the realisation the abortion was over and that it was the end of keeping secrets, women expressed how they were looking forward to life again and that they felt empowered, more in tune with themselves and looking forward to the future. They also experienced a range of negative emotions such as remembering with regret, feeling a sense of emptiness and loss, feeling isolated and concerned about the future. Some felt angry and ashamed at what they described as ‘as a loss of life’ some felt they had disappointed themselves and others. The overwhelming emotion was described as relief and this did not change over time although women re-evaluated their abortion experiences differently as a result of the passage of time and intervening life's experiences, some re-evaluated their abortion negatively and others re-evaluated their abortion positively.

    Conclusion: Women's emotions varied in their response to abortion. The initial feeling of relief was re-evaluated over time; most felt it was the right thing to do at that moment and moved on with their lives. Time may have eroded the details, but not the fact of abortion.


Elisabeth Aubény

Profession: Gynecologist
Affiliation: French Association of Contraception
 

Elisabeth Aubény is a Gynecologist. She is the founder and past director of the Plannification Center of the Broussais Hospital in Paris (France). She conducted many trials on medical abortion. Now she is working on medical abortion outside of hospitals. She is the president of the French Association of Contraception (AFC: Association Française pour la Contraception).

 

EAubeny@compuserve.com


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    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.

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    Emergency contraception

                                                                                                 

    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. 

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    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.

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    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.

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    Austria: only in hospitals
    Germany: not available  under study
    Greece: hospital
    Holland: judged not useful
    Spain: price not yet defined
    Switzerland: RU486 = poison so forbidden

    In France:
    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.

    In Austria:
    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:

    In France:
    The method is perceived as being less aggressive, "natural.
    It represents 14% of the legal abortions in 1990 and 30 to 40% in 1998.

    In Austria:
    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
    being asked.

    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
    November 2000.

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    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.


Kader Avonnon


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    In West Africa, the number of deaths due to unsafe abortion is 540 per 100,000 unsafe abortions. In Benin, legal restrictions and prevalent stigma create barriers to access for safe abortion.
    Since 2014, the IPPF Member Association in Benin, Association Béninoise pour la Promotion de la Famille (ABPF) has implemented a project aimed at reducing abortion stigma amongst young people. An adapted “Stigmatizing attitudes, beliefs and actions scale” (SABAS - Shellenberg, 2014) implemented to measure community attitudes to abortion, revealed that 84% of respondents have a negative perception of abortion and they do not favour access to safe abortion services. Young people often use unsafe methods of abortion because of stigma they face in the community. The double stigma of being sexually active and seeking abortion care experienced by young people disempowers and leaves them without accurate information and support, increasing the risk of unsafe abortion.
    Through the project, ABPF has empowered young people to lead initiatives to reduce abortion stigma. ‘Youth Champions’ have been trained on abortion rights and they work with their peers, providing information about sexual health and abortion, and refer young people to clinics for safe abortion services. Some specific strategies that the youth champions have implemented include conducting outreach activities in schools, with students and teachers as well as specific sessions for young people that are out of school. The Youth Champions have conducted advocacy with community leaders to influence policies in support of young people’s access to safe abortion services. The Youth Champions are active on social media, answering questions from other young people and working to destigmatize abortion. Since October 2016, the number of abortion and abortion related services provided to young people is 4561, in addition the Youth Champions have referred 153 young people themselves to ABPF services


Monika Axelsson et al.

monika.axelsson@vgregion.se


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    Abortions at home in Gothenburg

    Monika Axelsson, Liselotte Holmqvist (Sweden)

    Sahlgrenska University Hospital, Gothenburg, Sweden

    Background. This poster describes patient satisfaction in women choosing to perform their abortions at home. Since 1975, the number of abortions in Sweden has varied between 30 000 and 38 000 annually; some 2 500 per year are performed at the Abortion Department at Sahlgrenska University Hospital/Östra. New abortion methods have been introduced since the Swedish Abortion Act was passed in 1975. Medical abortion in early pregnancy is undergoing constant development and more women currently choose it over the surgical method. An increasing number of women, currently 20-25%,  want the possibility to conclude their abortions at home. A quality review was performed in order to develop and improve the method.

    Method. A questionnaire was filled out by 60 women at their follow-up appointment with at midwife four weeks after the ”home abortion”.

    Results. The average age was 34.3. Seventy-one percent had given birth, of whom 64.5% had given birth vaginally. Previous abortions were reported by 34.9%; 90.7 appreciated being scheduled for all abortion-related appointments at the first visit; 69.8 found the interval from the positive pregnancy test to the completed abortion appropriate, while the rest thought that the interval was too long.

    Conclusion. Women choosing to conclude their abortions at home report that the method works well for them and they are satisfied with their choice. Questionnaire results also show that information and access to care are important.

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    Regarding medical abortions at the Gynaecological Clinic in Majorna

    Monika Axelsson Närhälsan Västra Götaland, Gothenburg, Sweden - monika.axelsson@vgregion.se

    We started the office with the idea of facilitating so-called early medical abortions that are terminated at home. After contact with and visits from the The National Board of Health and Welfare, in addition to hard work on routines and quality as well as medical safety, we finally managed to get the permit to open our doors. To summarize the results from the survey, the information given corresponds with the patients´ expectations. The patient receives sufficient analgesics to take home which is crucial. Measuring the level of pain is difficult but I have used a scale without numbers that goes from no pain to severe pain and most fall in the middle of the scale. 37% have chosen the lower end of the scale, meaning less pain, while 42% have chosen the higher end of the scale. 17% chose the middle of the scale. 82% thought they had received enough analgesics. 7% asked for emergency care during 4 weeks following the procedure due to bleeding, dizziness, pain, and so on. An interesting finding was the choice of contraception, where most patients have chosen combined birth control pills (32%) or no protection (22%). The conclusion is that we offer a good service at the gynaecology clinic in Majorna to women that wish to carry out an abortion. What could be explored further, and should be discussed, is the fact that such a high percentage of the women chose to use no contraception after abortion. One solution could be to offer an additional follow-up visit later on. However, important is to be able to offer abortions that are as good and safe as possible.

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    The midwife’s role in care of abortion patients
    Axelsson Monika. RNM, Holmqvist Liselott. RNM, abortion clinic, Göteborg, Sweden

    In Sweden, abortion has been legal since 1975. The law stipulates that termination of
    pregnancy is the woman’s own choice until week 18. After this gestational age, an
    application must be made to the National Board of Health and Welfare. This application is
    made jointly by the gynaecologist, who makes a medical assessment, and a social
    worker/counsellor, who makes a socio-psychological assessment. The Board approves or
    denies the application, based on the special conditions pertinent to the case.
    Counselling with a social worker/counsellor is offered to all women until pregnancy week
    18; after week 18 counselling is compulsory.
    34 800 abortions are performed every year in Sweden. This corresponds to 20.1 abortions
    per 1000 women. The most common age group is 20 – 24.The statistics for 2003 show a
    decrease in abortions among teenagers for the first time since 1995.
    The woman can choose the medical or surgical method surgery until the ninth week of
    pregnancy. At the abortion clinic at Sahlgrenska University Hospital/Östra(SUÖ), the staff
    consists of four midwives and two auxiliary nurses. Two doctors work at the clinic. Social
    workers/counsellors are available when required for consultations. Midwives work in
    abortion clinics in Sweden. In many clinics, midwifes are employed, and together with
    gynaecologists, social workers/counsellors and auxiliary nurses run the organisation.
    The midwife has a unique position, she has a broader view of both the woman’s and man’s
    sexual health. She can thus provide information to the patient/woman and give advice and
    support prior to the abortion decision. The midwife provides contraceptive information and,
    according to Swedish law, prescribes hormonal contraceptives and inserts IUDs and
    implants. Cooperation with the social workers/counsellors with their greater knowledge and
    education about abortion issues, is positive.
    In order to improve our care of and approach to our patients, we performed a study to
    evaluate our work in 2001.With the help of a questionnaire, 50 women were questioned
    during their follow-up visit. They answered 21 questions concerning clinic environment,
    staff availability, information, competence, confidentiality, approach and pain relief.
    Most patients were satisfied with the information, with the exception of that regarding pain.
    Some patients felt that experiencing labour-like pains/contractions was unpleasant.
    Bleeding was also an area, which surprised some of our patients, who had expected to

    bleed less. The majority of women were satisfied with their care, but thought that the
    appointment with the gynaecologist was stressful. We will proceed to improve our
    organisation, based on the results of our study.
    It is our ambition that a midwife is the first person the patient meets when she requires an
    abortion, because the midwife has a unique knowledge of women and their sexual health.
    This knowledge should lead to the midwife being responsible for making appointments and
    providing advice by telephone, including information on abortion and contraception
    methods, so that the woman is well prepared when she comes for her gynaecologist’s
    appointment. In our opinion, it is important that women be offered a follow-up appointment
    with the midwife after the abortion, regardless of whether it is medical or surgical. Offering 

    bleed less. The majority of women were satisfied with their care, but thought that the
    appointment with the gynaecologist was stressful. We will proceed to improve our
    organisation, based on the results of our study.
    It is our ambition that a midwife is the first person the patient meets when she requires an
    abortion, because the midwife has a unique knowledge of women and their sexual health.
    This knowledge should lead to the midwife being responsible for making appointments and
    providing advice by telephone, including information on abortion and contraception
    methods, so that the woman is well prepared when she comes for her gynaecologist’s
    appointment. In our opinion, it is important that women be offered a follow-up appointment
    with the midwife after the abortion, regardless of whether it is medical or surgical. Offering 

    bleed less. The majority of women were satisfied with their care, but thought that the
    appointment with the gynaecologist was stressful. We will proceed to improve our
    organisation, based on the results of our study.
    It is our ambition that a midwife is the first person the patient meets when she requires an
    abortion, because the midwife has a unique knowledge of women and their sexual health.
    This knowledge should lead to the midwife being responsible for making appointments and
    providing advice by telephone, including information on abortion and contraception
    methods, so that the woman is well prepared when she comes for her gynaecologist’s
    appointment. In our opinion, it is important that women be offered a follow-up appointment
    with the midwife after the abortion, regardless of whether it is medical or surgical. Offering 

    bleed less. The majority of women were satisfied with their care, but thought that the
    appointment with the gynaecologist was stressful. We will proceed to improve our
    organisation, based on the results of our study.
    It is our ambition that a midwife is the first person the patient meets when she requires an
    abortion, because the midwife has a unique knowledge of women and their sexual health.
    This knowledge should lead to the midwife being responsible for making appointments and
    providing advice by telephone, including information on abortion and contraception
    methods, so that the woman is well prepared when she comes for her gynaecologist’s
    appointment. In our opinion, it is important that women be offered a follow-up appointment
    with the midwife after the abortion, regardless of whether it is medical or surgical. Offering

    this service is our ambition, albeit a long-term goal, since it currently depends on the
    economical situation in the hospitals. Unfortunately, these women are not a high priority.


R. Baig


Speeches:
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    Situation analysis of family health hospitals of
    Rahnuma-FPAP about the preparedness to provide
    effective post-termination of pregnancy care
    services
    Baig, R
    Rahnuma-Family Planning Association of Pakistan (FPAP), MA of
    IPPF London, UK
    This study is a situation analysis of 10 family health hospitals of
    FPAP regarding their preparedness to provide effective PAC
    services. There were 14 service providers in 10 hospitals in the
    study. The most common procedure used for treating women
    coming with miscarriage or incomplete termination of pregnancy
    (TOP) was manual vacuum aspiration (MVA) (71.4%), followed
    by D&C (64.3%). The most common procedures followed for
    women coming with complications of induced TOP done
    elsewhere were MVA (85.7%) and D&C (57.1%). In 71.4% cases,
    surgical procedures for incomplete TOP were performed on the
    same day. The three most common complications were infection
    (92.9%), haemorrhage (78.6%) and pelvic inflammatory disease
    (78.6%). Length of gestation up to which surgical procedures for
    incomplete TOP was performed, was up to 4 weeks (14.3%), up
    to 12 weeks (42.6%), followed by 13–20 weeks (21.4), more than
    20 weeks (14.3%). A majority of the providers used analgesia,
    anxiolytic/sedation/tranquilizers for conducting surgical
    procedures for incomplete TOP of <8 weeks (64.3%), 9–13 weeks
    (57.1%), 13–20 weeks (21.3%) and >20 weeks (14.2%). The
    aborted fetus/products of conception were incinerated (35.5%),
    burnt (14.2%), thrown in open pit or garbage (14.2%), burnt and
    covered (21.3%) and others (14.2%). Three main reasons of
    choosing the hospital were doctors/staff being well behaved
    (52.8%), good reputation/better care (40%) and less waiting time
    (16.7%). In the present study, 51.4% clients were very satisfied
    and 22.2% were satisfied, while 20.8% classified the services as
    average. Only 4.2% were dissatisfied or highly dissatisfied.


Deborah Bateson


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    Australia is a prosperous country which endeavours to provide equitable access to high-quality healthcare. Yet this is not the case for abortion.


    With the introduction of government-subsidised medical abortion in 2013 it was envisaged that women would be able to access affordable abortions, medical or surgical, across the country. Unfortunately, this promise has not been met, especially for those who are financially disadvantaged or who live in rural and remote areas. 
    Australia has a complex patchwork of abortion laws across its 8 states and territories, ranging from legal abortion available on request up to 24-weeks with potential supply of early medical abortion drugs by nurses in Victoria, to abortion provision still residing in the Crimes Act of 1900 in the most populous state of New South Wales. While decriminalisation has not always led to improved access, the risk of prosecution serves as a barrier to service provision, particularly in the public setting. Publically-funded hospital services, except for fetal abnormality, are difficult to access or non-existent in most states and territories and costs for private medical and surgical abortion services vary widely and can be substantial and unaffordable. While General Practitioners are potentially able to provide low cost medical abortion to their patients only a very small number do so due to perceived stigma, poor remuneration and concerns about managing complications in the absence of clear referral pathways into local hospitals. Australia’s innovative telemedicine service has the potential to overcome barriers to access but reports of obstruction and psychological abuse of women by health care providers providing radiology and other necessary support services highlights that abortion is far from stigma-free in Australia.  Despite these challenges key steps are being taken by professional colleges and other leading health organisations to integrate abortion care within their training pathways and in calling for policy reform focussing on reducing costs and enhancing early access.


Vanda Beja


Speeches:

Cecilia Berger



Isabella Bizjak


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     FC07

    Efficacy of very early medical abortion

    Isabella Bizjak1, Christian Fiala2, Helena Kopp Kallner1, Ingrid Sääv1, Kristina Gemzell-Danielsson1
    1WHO CCR, Department of Women´s and Children´s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Stockholm, Sweden, 2GynMed Clinic, Vienna, Austria

    Background: In countries which have introduced medical abortion an increasing number of women present very early for their abortion. However due to limited data and fear of an adverse effect on a possible ectopic pregnancy many health care providers are reluctant to initiate the abortion treatment before an intrauterine pregnancy can be visualised and therefore tend to delay the treatment. This study was conducted to assess the effectiveness and safety of medical abortion in women with very early pregnancy (VEMA) and no confirmed intrauterine gestation (IUG).
    Methods: Register based multicentree cohort study comparing women undergoing very early medical abortion (gestations ≤49 days) with or without a confirmed intrauterine pregnancy (i.e. yolk sac or foetal structure) at the initiation of the abortion treatment. 435 women without confirmed IUG were identified and compared with 870 controls with confirmed IUG, matched with regard to age, parity and date of initiation of abortion treatment.
    Results: Women with no confirmed IUG were not more likely to experience VEMA failure (i.e. ongoing pregnancy or incomplete abortion) than those with gestations ≤49 days and confirmed IUG.  Ectopic pregnancies (n=3) were diagnosed and treated without any serious adverse events.
    Conclusion: VEMA failure is not more likely in women with very early pregnancy and no confirmed IUG on ultrasound than those with gestations ≤49 days and confirmed IUG. Hence our findings support that VEMA is both effective and safe for terminating pregnancies in women with no confirmed IUG. Women should, therefore, not be subject to unnecessary delay but should be offered medical abortion accordingly.


Kelly Blanchard


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     FC23

    The Zika Virus: highlighting the impact of abortion restrictions on the lives of women in Latin America

    Kelly Blanchard1, Kinga Jelinska2, Susan Yanow2, Cecilia Vieira da Costa2
    1Ibis Reproductive Health, Cambridge MA, USA, 2Women Help Women, Amsterdam, The Netherlands

    The emergence of the Zika virus in Latin America and the Caribbean (LAC) has coincided with increased reports of infants born with microcephaly, and has prompted some governments in the region to issue blanket warnings against pregnancy.  However, the LAC region has some of the most restrictive abortion laws in the world. Government recommendations that women avoid pregnancy without provision of information, education, contraceptives or access to safe abortion care does not address women’s needs or promote their rights and has the potential to increase the incidence of unsafe abortion in the region, particularly among young and low income women who are most at risk of Zika exposure.  This panel will provide an overview of the issues linking Zika and reproductive rights, and will share preliminary results of qualitative research on Zika and pregnancy decision-making among women in Puerto Rico and Brazil.  Additionally, the perspectives of women from LAC seeking information about safe home-abortion from an online service will be shared.  Strategies for potentially avoiding a surge in unsafe abortions will be highlighted.
    Attendees will learn about the current legal framework in LAC for accessing abortion and the impact of the Zika virus in mobilising new strategies for expanding access to safe abortion.  We will also invite participants to engage in a discussion of how to support regional activists in their long-term goals of increasing access to safe and decriminalised abortion and identify lessons learned for efforts to expand access to safe abortion care in other restricted settings.


F. Bloomer


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    Termination of pregnancy rights in Northern
    Ireland – the role of pro-choice activists
    Bloomer, F
    University of Ulster, UK
    This paper considers the protests and activism led by the Alliance
    for Choice movement, an organisation that campaigns for the
    extension of the 1967 Abortion Act to Northern Ireland. The role
    of women in the movement is considered with particular focus on
    its most recent period of activism which began in the months
    preceding a proposed debate in Westminster in 2008 where a
    tabled amendment to the Human Fertilisation and Embryology
    Bill by Diane Abbot MP sought an extension of the 1967
    Abortion Act to NI. In response to this a series of events and
    activities were held to raise awareness amongst MP’s, trade unions
    and the wider public. The Alliance for Choice campaign took a
    strong pro-choice approach, focusing on the issue of equality with
    women in the rest of the UK. Despite the withdrawal of the
    amendment to the Bill in late 2008 the movement has continued
    on with its campaign, including preparation of a submission to
    the United Nations Convention on the Elimination of all forms of
    Discrimination Against Women (CEDAW).
    This paper will review the actions of the Alliance for Choice
    movement, considering the motivations for participation in the
    movement and reflect on the impact of the movement in
    achieving its goal of termination of pregnancy legislation
    extending to Northern Ireland.

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    Objectives: This paper considers recent developments in abortion law and policy in Northern Ireland and analyses their impact on access and future direction. Specifically, the paper considers: the investigation carried out by Committee on the Elimination of All Forms of Discrimination against Women (CEDAW); the implementation of the Centralised Booking System for those travelling to England; the implications of the Irish Referendum; political debates in the UK parliament and the recent Supreme Court Judgement.  

    Methods: the paper reviews research studies, political debates, policy documents, legal cases and considers the views of stakeholders (senior civil servants, health professional bodies, politicians, activists, trade unionists and academics).
    Results: The restrictive legal context in Northern Ireland has resulted in only 16 abortions carried out by the NHS in the last reported year.In contrast 919 abortions were carried out in England to those with Northern Ireland addresses.  Others self-abort at home, risking criminality in doing so.  There is also evidence that abortion is a workplace issue – that women are unable to get sick leave, returning to work too soon and are uncertain who they can access support from.The CEDAW inquiry established that restricted access resulted in grave and systematic violation of human rights, including the chilling effect on clinicians of unclear law and policy, no referral pathway for post abortion care for those that travelled and no pathways for return of foetal remains. 
    Conclusions: the culmination of the CEDAW investigation and court judgements have identified human rights violations as a result of highly restricted access to abortion.  This can only be overcome by decisive legislative action to address inadequacies, until then, for many needing an abortion, travelling to England or self-aborting at home, will remain a harsh reality.

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    Objectives: In societies with oppressive anti-abortion norms, such as Northern Ireland, little is known about how these norms are resisted by the adult population. This paper explores how resistance to religious and patriarchal norms can be fostered through adult community abortion education; and considers how such knowledge can inform engagement with those seeking and providing abortions. 
    Methods: Participants (n=17) of a community-based abortion education programme were interviewed to explore their views on abortion utilising semi-structured interviews.  

    This paper focuses on a thematic analysis of the interview data, with a particular focus on how women resisted oppressive norms and the stigmatised positioning of abortion. 
    Results: The findings indicate that this resistance is multi-faceted and bolstered by a lived experience discourse, which does not necessarily involve eschewing religious notions held within society. 
    Conclusions: Meanings of abortion in society are constructed within socio-historical and gendered spaces and manifested through myriad discourses that impact on the perception and treatment of the issue in that society. The paper concludes that adult abortion education in community settings offers the possibility of creating dialogical spaces for people to reflect on and resist oppressive norms regarding reproduction and abortion, and in so doing can challenge stigma more broadly.  (drawn from article Bloomer, O"Dowd, Macloed, 2014)
     


Paul Blumenthal


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    Wondering how to manage second trimester medical abortion or dilation & evacuation in the setting of an abnormally implanted placenta?

    Looking for advice on advancing the gestational age at which you and your team provide? Have questions about cervical preparation, offering a choice of method, managing prolonged inductions, or anything else related to medical or surgical methods of abortion after the first trimester? Bring your questions along to this panel of five leading experts in second trimester abortion care. Experienced, new and curious providers are all welcome to contribute to what should be a lively and wide-ranging discussion.

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    FC21

    Self-Administered lidocaine gel for pain control with first trimester surgical abortion: a randomised trial (SALSA)

    Jennifer Conti, Klaira Lerma, Kate Shaw, Paul Blumenthal
    Stanford University School of Medicine Department of Obstetrics and Gynecology Division of Family Planning Services and Research, Palo Alto, California, USA

    Objective: To assess pain control during first trimester surgical abortion using a locally applied, patient-administered lidocaine gel compared to traditional lidocaine paracervical block.
    Methods: We conducted a randomised controlled trial of women undergoing surgical abortion at less than 12 weeks gestation in an outpatient clinic setting. Participants were randomised to receive 12ml of a 1% lidocaine paracervical block (PCB) or 20ml of a self-administered, 2% lidocaine gel 20-30 minutes before procedure initiation. In addition, all patients received sedation as per institutional standard. A 100mm visual analogue scale (VAS) was administered to measure anticipated pain, baseline pain, pain with speculum and tenaculum placement, pain with cervical dilatation (primary outcome), pain after suction aspiration and pain 30-45 minutes post-operatively.
    Results: 142 women were enrolled: 68 in the PCB group, 69 in the gel group. Two and three subjects were not analysed due to protocol deviations or drop-out, respectively. Socio-demographic characteristics and VAS scores at all time points, except for tenaculum placement, were similar between groups. Mean and median pain scores for the primary outcome (pain score immediately following cervical dilatation) did not differ between groups. This was also true when nulliparous and parous subjects were analysed separately. The median pain score with cervical dilatation was 65mm in the PCB group and 68mm in the gel group (p=.45). Likewise, there was no statistically significant difference between mean pain scores at any of the other time points measured (speculum placement (p=0.39), tenaculum placement (p=0.07), cervical dilatation (p=0.31), speculum removal (p=0.19) and post-procedure (p=.75).
    Conclusion: There were no statistically significant differences concerning pain control between self-administered lidocaine gel and a traditional paracervical lidocaine block. Lidocaine gel should be considered as an alternative, non-invasive approach to pain control for first trimester surgical abortion.


G. Brady


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    Young women’s experiences of termination of
    pregnancy and miscarriage
    Brady, G
    University of Coventry, UK
    In Britain, the politics and policy of teenage pregnancy places the
    emphasis on ‘prevention’ of teenage pregnancy, positioning
    parenthood for young people as a negative choice; this dominant
    discourse is likely to influence young people’s reproductive
    decisions and experiences. With this in mind, this paper focuses
    on a key finding from a multidisciplinary empirical research
    study, conducted in a city in the West Midlands of England, UK,
    which considered and explored young people’s experience of
    support before and following termination and miscarriage. Data
    were collected via indepth interviews with professionals and
    practitioners, young mothers and one young father. Although
    termination and miscarriage are generally perceived as distinct
    and different issues, the data suggest that the issues become more
    blurred where younger women are concerned. The experiences of
    young, ‘inappropriately pregnant teenagers’ often remain
    unacknowledged and devalued. This paper highlights the social
    and political context in which young women experience
    termination and miscarriage, and suggests that termination and
    miscarriage should be acknowledged as significant medical, social
    and emotional events in the lives of young people.


Wilson Bunde


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    Addressing unintended pregnancies and unsafe abortions among youth in Kenya: family health options of Kenya

    Wilson Bunde Family Health Options Kenya, Nairobi, Kenya - wbunde@fhok.org

    Introduction: The Kenya Demographic Health survey 2008/9 showed that 43% of births in the preceding year were reported by women as unwanted or mistimed. Adolescent women face high risk of unintended pregnancies and therefore unsafe abortions, with devastating consequences for their lives and health. It is estimated that more than half of women with the most severe complications from unsafe abortion are adolescents. Family Health Options of Kenya (FHOK), a Member Association of IPPF, utilized strategies to minimize unsafe abortion among marginalized youth from underserved communities through clinical and community based services. Action: Implemented strategies included recruitment and training of young staff, provision of youth friendly information and services, addressing financial barriers, efforts to mitigate stigma associated with abortion services, and use of innovations such as youth camp and short-messaging system to provide information on adolescent sexual and reproductive health (SRH). Outcome: Following the implementation of these strategies at 4 locations in 2012, FHOK recorded a 61% increase in the number of young clients served for comprehensive abortion care and postabortion care services. Clinic teams have also reported a concomitant increase in the acceptance of contracep-tive services among youth. Qualitative feedback from youth in communities and clinic settings have provided positive feedback on these strategies and increased levels of information among youth. Discussion and Recommendations: Youths are the most sexually active population in Kenya yet are the most neglected group in SRH services initiatives. The lack of adequate information and access to SRH services among youths contributes to the high rates of unintended pregnancies among this group, which in turn forces them to seek unsafe abortion services. Some unique youth-friendly initiatives like the ones described above can increase utilization of services by youths even in situations where such services planning may be sensitive and difficult to address.


Louise Bury


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    Marie Stopes International UK Abortion Study: the association between choice of method of abortion, postabortion contraception and the risk of having another unintended pregnancy

    Louise Bury Options Consultancy Services Ltd, London, UK - loulou.bury@gmail.com

    Objectives: The aim of this study is to explore the behavioural, social and service-related factors that are associated with one or more unintended and unwanted pregnancy amongst young women. Methods: A cross-sectional survey of 430 women aged 16 - 24. Interviews took place four weeks postabortion and participants were asked about pre and post abortion contraceptive use. Women who had had a previous abortion were also asked about their contraceptive use between their two most recent abortions. Results: More than half of the women (57%) reported to have been using contraception (pill and condom) at the time they got pregnant. There were no differences between women who had had a previous abortion and those having one for the first time. Uptake of contraception postabortion was very high with 86% of women reporting using a method at four weeks for both groups of women. Women who had had a previous abortion were more likely to start using effective contraceptive methods (LARCs) (74% and 59% respectively). More women who had a surgical abortion (than those who had an EMA) left the clinic with a method of contraception (84.7% vs. 68.6%) and more women who had a surgical abortion started to use a LARC method (70.3% vs. 49.5%). 82% of women who had had a previous abortion started to use contraception following their last abortion, but 60% discontinued their method within one year due to menstrual irregularities (LARC) or not renewing a supply (pill). Conclusions: Service providers could explore more innovative ways to support women to use their choice of contraceptive method effectively following an abortion, as well as ensure women who choose EMA are provided with appropriate support and information to easily access LARC if this is their chosen method, as well as being provided with a bridging method of contraception.


Catarina Reis Carvalho


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    FC29

    Contraception before and after abortion: what do women seek? – experience of an abortion referral centrecentre in Lisboa, Portugal.

    Catarina Reis Carvalho, Joaquim Neves, Raquel Gonçalves, Carlos Calhaz-Jorge
    Hospital Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal

    Introdution: Abortion by women’s request is one of the most commonly performed procedures in the world. The objective of this study was therefore to assess the choice of contraceptive method after abortion and the factors that may determine this choice.
    Methods: This was a retrospective cohort study based on a medical record review at one hospital in Portugal. We included 613 women who had an abortion in January 2015- March 2016. We conducted associations between age, number of previous abortions, educational status and receipt of contraception at the time of abortion.
    Results: Among the women included, the average age was 28 years (13-47), 47.3% nulliparous and 10.2% unemployed. Concerning obstetric history, 41.4% had a previous, voluntary abortion (1-8) with18.6% within the last five years. Previous to the abortion, 20.1 % had no contraception, 1.8% used natural methods, 22.2% barrier methods and 36.4% oral contraceptives.  When asked, 76% knew why the previous method failed, identifying the main cause as forgetfulness in taking oral contraceptives followed by voluntary suspension of the method. After the abortion, 19.2 % had no review consultation or refused counselling, without getting contraception or adopting their previous method, 14.9% preferred oral contraceptives and the majority (51%) chose long-acting reversible contraceptives (LARC). Women with a previous history of abortions seem to adhere less to later contraception and prefer oral contraceptives while the others prefer LARC (p=0.003). We found no association between age and educational status and contraceptive choice (p=1.12, p=0,67).
    Conclusions: Despite high access to contraceptive services, subsequent voluntary abortions are a reality. Education on contraception is an essential element of high-quality abortion care. Choosing LARC was popular for these women. A major limitation of this study is the short follow-up of the women. More studies are needed.


W. Chatchawet


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    Level of male participation when unwanted
    pregnancy is terminated from the perspective of
    Thai healthcare providers
    Chatchawet, W; Sompron, J; Kritcharoen, S
    Prince of Songkla University, Thailand
    When unwanted pregnancy occurs and ends with termination,
    women usually take responsibility for the consequences due to
    such unsafe termination of pregnancy (TOP) but men typically do
    not have to participate in taking care of women. This qualitative
    study aims to understand the perspective of healthcare providers
    from the viewpoint of male participation when an unwanted
    pregnancy is terminated. The thirteen participants consisted of ten
    professional nurses, two physicians and one social worker with
    exerience in taking care of women who were undergoing
    unwanted pregnancy termination. Individual interviews were
    conducted. Data analysis was carried out through content analysis.
    Member checking was conducted to establish the rigour of the
    study

    The level of male participation when unwanted pregnancy is
    terminated from the perspective of healthcare providers was found
    to be ‘taking care together’ because of mutual sex, men conduct,
    or women hurt and ‘women taking care of themselves’ due to
    male privilege or female surrender. ‘Different aspects on
    termination of unwanted pregnancy’ such as understanding the
    woman’s reason or prejudice from not listening to a woman’s
    voice, affect the level of male participation.
    The findings of the study help to improve the understanding
    about male participation that is influenced by gender bias.
    Encouraging men to participate in taking care of women without
    gender bias will enhance reproductive health care to transform a
    women-only framework to gender equity among women and men.


Alexander Chavchidze


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    Statistical analysis of abortions in Georgia between 2000 and 2013

    Alexander Chavchidze, Gulnara Shelia Tsereteli State University, Kutaisi, Georgia - dodoshelia@yahoo.com

    Objective : To show the number and the structure of women who had decided to interrupt the unwanted pregnancy in Georgia during the period 2000 to 2013. Method : Results are based on statistical analysis of National Centre for Diseases Control and Public Health (NCDC) . Results : Despite decreases in the rate of abortions at the present time, Georgia continues to have one of the highest recorded rates of induced abortion in the region ( 3.7 abortions per woman In 2000 , 3.1- in 2005 and 1.6 - in 2012). Most abortions (86 – 87.1 %) were performed in the legally sanctioned gestation range of up to 10 weeks. The average age of women was 30 years (range 14 – 45 years). Induced abortion was most commonly performed in women ranging from 25 – 34 years old 52.3 % (2000) and 56.4 % (2012). Closely followed by women ranging from age 35 – 39 (25.3 % and 26.5 % accordingly - in 2000 and 2012). Women under 20 were represented with 4.1 % (2000) and 4.2% (2012). 62.7% (2000) and 41.4 % (2012) of the women had undergone their first abortion, for 26.7 % (2000) and 33.5% (2012) it was the second. The abortions were performed : in hospital (55.8%) , in a clinic (42.2 %) and outside of a health care institution (1.9 %). Conclusions: The falling number of abortions in Georgia (in spite of the still large number) reflects the more adequate family planning and usage of contemporary contraceptive methods. In Georgia family planning has not achieved its goal yet and induced abortion is still the most common method of fertility regulation. This underlines the need for fully implementing the organizational measures aimed at improving these indices.


Erica Chong


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    Objectives: In the United States, many women struggle to obtain an abortion due to ever-increasing barriers to access. The TelAbortion Project provides medical abortion directly to women in their homes using telemedicine and mail, enabling them to receive services without going to a clinic. We will report on interim findings from the first two years of the project.
    Methods: TelAbortion is available in Hawaii, New York, Maine, Oregon, and Washington. Interested women contact implementing sites and interact with clinicians by videoconference. After obtaining screening tests at radiology and lab facilities close to them, eligible women are mailed packages containing mifepristone and misoprostol. Women take the medications at home, obtain follow-up tests and have another consultation with the clinician. 
    Results: Through June 2018, 200 women had received medication through the project. Of the 70% who were followed to completion, 5% had a surgical completion. The vast majority of packages were sent within two weeks after the initial study contact, and all women reported taking the mifepristone at gestational ages of 72 days LMP or less. No related serious adverse events were reported. All women reported being very satisfied or satisfied, and the most commonly reported best features of the service were the convenience and privacy.
    Conclusions: Direct-to-patient telemedicine abortion is feasible and can potentially increase access to abortion care in a safe and acceptable manner. Although telemedicine bans and other restrictions are on the rise, TelAbortion could plausibly be legally implemented in about half of the 50 states, where about 56% of the female reproductive-age population reside.

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    CS08.3

    The Telabourtion Study: Evaluation of a Direct-to-Patient Telemedicine Abortion Service

    Erica Chong, Elizabeth Raymond, Philicia Castillo, Beverly Winikoff
    Gynuity Health Projects, New York, NY, USA

    Objectives: Given the difficulties women face in obtaining clinic-based abortion in many parts of the US, provision of medical abortion by telemedicine to women in their homes could be highly beneficial for increasing access. We developed a pilot study to obtain preliminary data on the safety, acceptability and feasibility of direct-to-patient telemedicine abortion.
    Methods: This case-series study of 50 women is being conducted in selected US states with no legal restrictions on telemedicine abortion. Women may learn about the study from staff at the collabourating study sites, from referring providers or from the study website. Each woman who is interested in the study will consult with a study investigator by videoconference and then will obtain screening tests at local facilities. If the results indicate that she is eligible, the investigator will send the abortion medications to her by mail. The participant will obtain tests at local facilities to confirm abortion completion and will have a follow-up consultation with the investigator by phone or videoconference. Data will be collected about interest in, and satisfaction with, the service, abortion complications and difficulties encountered by patients and providers in completing the protocol requirements.
    Results: We will review key legal issues that impact this model and challenges in designing the service to conform to expected standards of care for clinic-based abortion. We will also present data obtained in the project to date.
    Conclusions: In states with no legal restrictions, direct-to-consumer telemedicine abortion has great potential to increase women's access to abortion care in a safe and acceptable manner.


Deborah Constant


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    Using mobile phones to strengthen medical abortion provision: opportunities and dangers identified from the South African experience.

    Deborah Constant1, Katherine de Tolly2, Marijke Alblas3,4 1University of Cape Town, Cape Town, South Africa, 2Cell-Life, Cape Town, South Africa, 3Association des sages femmes, Douala, Cameroon, 4CSU/CNRS, Paris, France - deborah.constant@uct.ac.za

    Objective: To report the South African experience using text systems on mobile phones to provide support and a self-assessment of completion of their procedure to women undergoing medical abortion. Methods: A randomized controlled trial during 2011-2012 recruited 469 women seeking medical abortion at clinics in South Africa. All women received standard abortion care with mifepristone and home administration of misoprostol and were asked to return to the clinic to assess completion 14 - 21 days later. Consenting women were randomized to standard-of-care or intervention groups. The intervention group received timed SMSs over the period between their clinic visits, with reminders on what to expect, alerts to complications and encouragement to complete the self-assessment. They were also prompted to access a contraception mobisite. Interviews were conducted at both clinic visits and one month later by telephone. Results: Most found the SMSs helped them manage the abortion symptoms and would recommend them to a friend; however 20% of recipients had concerns around phone privacy. The intervention group were significantly better prepared (p<0.05) for the pain, bleeding and side effects of the abortion. Of the 5471 messages sent, there was only a 5% failure rate. Seventy-eight percent completed the self-assessment and of these, 93% found it easy to do, however the questions did not predict all cases requiring further surgical management or additional misoprostol. More in the intervention group chose long-acting reversible contraception at their follow-up clinic visit. Conclusions: Support SMSs were effective in assisting women manage their abortion symptoms between clinic visits. Most could conduct a self-assessment of abortion completion on their mobile phones and promotion of contraception can succeed using mobile text systems. The self-assessment showed promise but was not sufficiently accurate; problems with privacy can be of concern for some women and a mechanism for stopping the SMSs is required.

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    PS04.3

    Strengthening autonomy: Mobile technology and self-assessment for medical abortion

    Deborah Constant1, Jane Harries1, Caitlin Gertz2
    1University of Cape Town, Cape Town, South Africa, 2Ibis Reproductive Health, San Francisco, USA

    Shortages of providers of surgical abortion methods are a significant barrier to safe abortion care across diverse settings where abortion is legal. Early medical abortion using mifepristone and misoprostol requires less provider involvement, is highly effective and can largely be managed by women themselves. Medical methods are highly acceptable to women and can increase women’s autonomy.
    Self-determination of gestational age eligibility, self-administration of misoprostol and management of abortion symptoms, self-assessment of abortion outcome and selection of postabortion contraception can be strengthened using mobile phone technology (mhealth). Reliable networks, adequate connectivity, phone ownership and phone privacy are necessary for mhealth to effectively facilitate safe abortion care. These conditions exist in developed but also in many developing countries.
    In South Africa studies have shown most women with gestations within 70 days can recall their last menstrual period with sufficient accuracy and use an online gestational age calculator to determine eligibility for medical abortion. Supportive text messages including reminders and information on complications over 14 days following mifepristone significantly improved preparedness and provided effective emotional support during the abortion. Self-assessment using a text questionnaire was feasible, but not accurate, and a low sensitivity pregnancy test was necessary to better detect ongoing pregnancies. Twenty-three percent of women correctly recalled information from the messages on contraceptive methods 4-6 weeks after they had received them. In Colombia a low sensitivity pregnancy test together with text questions for self-assessment was a safe and feasible alternative to in-facility care.
    Mhealth, using text messages, shows promise for strengthening women's roles and control with respect to medical abortion. Other approaches include telemedicine consultations, automated text checklists on incomplete abortion symptoms, digital images to verify pregnancy test results and online resources with contraceptive advice. The increasing familiarity with digital technology provides a powerful opportunity to strengthen women’s reproductive autonomy.


Fabienne Coquillat


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    Ambivalence about pregnancy: "Toolbox" for professionals

    Fabienne Coquillat, Lauriane Pichonnaz, Saira-Christine Renteria Centre for Sexual Health and Planned Parenthood, Unit for Psychosocial Gynaecology and Obstetrics, Ob Gyn Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland - fabienne.coquillat@chuv.ch

    Introduction: Our annual statistics show that half of the women consulting for elective abortion with an ambivalent attitude end up continuing their pregnancy. This observation led us to question our interview techniques used to guide women and couples with their choice. Objectives: - Identify and describe the necessary or useful elements to the guidance of a woman and/or a couple who has/have to make a decision (continue or not a pregnancy). - Conceptualize those various approaches by making them easily reproducible for other professionals. Material and method: The six sexual health counsellors of the Centre for Sexual Health of the CHUV shared their different interview and communication techniques, as well as their developed reflective methods used on a daily basis. Those methods and techniques have subsequently been conceptualized by the team. Results: These "tools" are based on the following main lines: 1) The attitude of the intervener? Having trust in the ability of the other to make a choice and not feeling responsible for it. 2) How to establish a framework? By providing accurate information about confidentiality, gestational age or the limits of the law. 3) What "key factor" to keep in mind when gathering information? 4) The techniques that encourage the narration, the verbalization of feelings, the identification of strengths and paradoxes, the strengthening of the person's resources. Conclusion: This toolbox for professionals gathers the essential and helpful elements to conduct an interview with a woman or a couple in a situation of ambivalent attitudes towards pregnancy. Gathering, describing and conceptualizing the individual experiences of each counsellor makes them reproducible and thus usable by other professionals. The development of this toolbox has allowed the team to conceptualize personal skills and know-how built up over daily practices and, as a result, to "specialize" and enhance skills.


Antonia Costa


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    FC02

    The impact of a liberalisation law on legally induced abortion hospitalisations

    Manuel Gonçalves-Pinho2 ,3, João V.Santos2 ,3, Antónia Costa1 ,4, Altamiro Costa-Pereira2 ,3, Alberto Freitas2
    1Obstetrics and Gynecology Department, Hospital São João, Porto, Portugal, 2Department of Health Information and Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, 3Centre for Health Technology and Services Research (CINTESIS), Porto, Portugal, 4Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Porto, Portugal

    Objectives: Legally induced abortion (LIA) for maternal option without /maternal pathology (MOLIA) was liberalised in Portugal in 2007. The aim of this paper was to study the impact of the liberalisation of abortion by maternal request on total LIA-related hospitalisation trends.
    Method: We considered hospitalisations of legally induced abortion (ICD-9-CM codes 635.x) with discharges from 2000 to 2014. Data was obtained from a Portuguese administrative database, which contains all registered public hospitalisations in mainland Portugal. Hospitalisations per abortion were calculated by dividing the number of LIA hospitalisation by the number of LIA. Mean ages, number of hospitalisations per age group, complications, admission type and length of stay were also analysed.
    Results: Hospitalisations rose during the study period. Since the liberalisation law was passed there was a significant decrease in the number of hospitalisations per abortion: from 1.07 in 2000 to 0.11 in 2014 (p < 0.001).  Furthermore, the mean age remained stable since liberalisation (30.8 years before 2007 and 40.0 after). Abortion-related hospitalisations are more frequent in women aged 25-39. A significant decrease from the emergency to the scheduled type of admission occurred from 2000 to 2014 (from 83.5% to 56.7% of emergency admissions) (p < 0.001). Complications remained stable and delayed or excessive haemorrhage was the most frequent (4.6%) (p = 0.07).
    Conclusions: Since the liberalisation, hospitalisations per abortion have decreased, reflecting the major impact that the liberalisation of MOLIA had on abortions trends nationwide. LIA-related hospitalisations are more frequent in women aged between 25-39 years old. This study shows the impact that MOLIA liberalisation law can bring to abortion and to hospitalisation trends.


Filipa Mendes Coutinho


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    FC27

    European transnational survey related to medical abortion in the first trimester of pregnancy

    Filipa Mendes Coutinho1, Teresa Bombas1 ,2, Paulo Moura1
    1Serviço de Obstetrícia A, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 2On behalf of Expert Group on abortion, European Society of Contraception and Reproductive Health (ESC), Coimbra, Portugal

    Background: Currently most European countries allow abortion upon women's request in the early weeks of pregnancy. Despite WHO's recommendations, the definitions and methods used in clinical practice are not well established. The knowledge of the different attitudes regarding abortion would be beneficial.
    Methods: We conducted a survey via mail involving 20 centres from 19 countries in which abortion is legal, to understand the differences in clinical practice regarding medical abortion. We performed a statistical analysis assessing a number of variables, including: number of abortions per year; rate of medical abortion; availability of national guidelines; methods of follow-up; among others.
    Results: Nineteen centres responded (95%) and most of these (84%) perform medical abortion. A large number do not use it as a first-line method. Thus, from an estimated 21,925 abortions registered in the past year, only 39% were performed by medical protocol. In spite of the lack of guidelines all the institutions use a combination of mifepristone and misoprostol to terminate pregnancy. The differences lie in the dosage used as well as the route of administration. Concerning follow-up, 52% of the institutions agree on a two week interval and almost 65% perform an hCG blood level as well as an ultrasound scan after this period. Similar percentages (63%) repeat medical treatment in case of ongoing pregnancy after a first cycle of medication and 68% in case of incomplete abortion. When asked if having more precise definitions for success of medical/surgical abortion would be beneficial, nearly 77% responded affirmatively.
    Conclusions: In late years we have witnessed an increase in the number of medical abortions performed in European countries. Despite the WHO recommendations the access to abortion methods are quite different. The majority of the surveyed institutions agree this would be an important step towards improving management of the procedure.


A. Crastes



Dimitar Cvetkoff


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    Medical abortion in Bulgaria: a happy-ending Cinderella story or a Little Match-Seller drama?

    Dimitar Cvetkov1, Svetlozar Stoykov2 1Women's Health Hospital Nadezhda, Sofia, Bulgaria, 2Medical University Pleven, Pleven, Bulgaria - cvetkoff@abv.bg

    Around the world, probably every medicine man possessed an "abortion recipe", and in Bulgaria too, the interruption of an unwanted pregnancy had its common place in traditional medicine. One of famous works of Bulgarian literature, Dimiter Talev's "The Iron Oil Lamp", gives a dramatic description of the terror of a mother who destroyed the life of her daughter by giving her an abortion potion to save her from the shame of unwanted pregnancy. Much has changed in Bulgaria since these times - the country is the sad leader in Europe's statistics on abortion/live birth ratio. When terminating pregnancy up to 12 weeks is in question, the only option regulation allows is surgical abortion. As early as 1994, there were efforts to introduce medical abortion into practice, but no development resulted, due to lack of interest and insecurity on the part of clinicians facing a new method. In 2010, following a symposium on medical abortion, the idea came back to life once more. After an active search for manufacturers and drugs, and even after a period of unregulated import, finally the pharmaceutical companies at last came to see the Bulgarian market as a rightful destination, and shortly after we saw the first registrations. Today, almost 4 years later, the Bulgarian drug market features Exelgyn, Sun Pharma, and Linepharma, in competition for affordable prices and a steady market share. Yet, at the seemingly happy end, we are facing a multitude of questions: regulatory sales regime; minimum age for abortion; reimbursing procedure costs for teenagers; training of clinicians and midwives. If we are not ready to adequately address these challenges and we do not arrive at viable solutions after a discussion among clinicians, the very method may be compromised and rejected, and a happy-ending Cinderella fairy-tale might turn into the Little Match-Seller sad story.


Cecilia Vieira Da Costa


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     FC23

    The Zika Virus: highlighting the impact of abortion restrictions on the lives of women in Latin America

    Kelly Blanchard1, Kinga Jelinska2, Susan Yanow2, Cecilia Vieira da Costa2
    1Ibis Reproductive Health, Cambridge MA, USA, 2Women Help Women, Amsterdam, The Netherlands

    The emergence of the Zika virus in Latin America and the Caribbean (LAC) has coincided with increased reports of infants born with microcephaly, and has prompted some governments in the region to issue blanket warnings against pregnancy.  However, the LAC region has some of the most restrictive abortion laws in the world. Government recommendations that women avoid pregnancy without provision of information, education, contraceptives or access to safe abortion care does not address women’s needs or promote their rights and has the potential to increase the incidence of unsafe abortion in the region, particularly among young and low income women who are most at risk of Zika exposure.  This panel will provide an overview of the issues linking Zika and reproductive rights, and will share preliminary results of qualitative research on Zika and pregnancy decision-making among women in Puerto Rico and Brazil.  Additionally, the perspectives of women from LAC seeking information about safe home-abortion from an online service will be shared.  Strategies for potentially avoiding a surge in unsafe abortions will be highlighted.
    Attendees will learn about the current legal framework in LAC for accessing abortion and the impact of the Zika virus in mobilising new strategies for expanding access to safe abortion.  We will also invite participants to engage in a discussion of how to support regional activists in their long-term goals of increasing access to safe and decriminalised abortion and identify lessons learned for efforts to expand access to safe abortion care in other restricted settings.


Blair G. Darney


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    Objective: The safety of abortion is well established, yet quality abortion care must reflect domains beyond safety. We document quality of care definitions, conceptual frameworks, and measures used in the literature and agency practices to inform ongoing efforts to develop quality metrics for abortion.
    Methods: We reviewed the abortion and contraception literature, the broader health services and quality in healthcare literature, and agency definitions and tools for quality measurement. We identified seminal definitions and frameworks as well as criteria for quality measures. Results: Health care quality is the degree to which services produce desired health outcomes and rely on best available evidence. Key frameworks from the Institute of Medicine (IOM) and World Health Organization (WHO) articulate domains of quality, focused on whether health care is effective, efficient, accessible, acceptable/patient-centered, equitable, and safe. Quality is further classified as technical (appropriate care) and interpersonal (interaction with provider). Evidence exists to guide clinical practice in abortion. However, assessment of the quality of clinical practice remains unstandardized, and very little evidence exists documenting client perceptions of both technical and interpersonal quality. Satisfaction, a common quality measure, is limited: women are nearly universally satisfied when they receive needed care, and global satisfaction does not tell us where or how to intervene to improve quality. A wide variety of measures and indicators have been used in the literature and by implementing agencies, but little evidence exists to link these measures with health or behavioral outcomes.
    Conclusions: Quality abortion care includes, but is not limited to, safety. We lack both common terminology and measures to assess abortion services across diverse health system settings, especially in low- and middle-income countries. Such measures would allow us to build evidence about the effectiveness, efficiency, accessibility, patient-centered-ness, equity, and safety of abortion services, and ultimately to improve abortion care for women across the globe.

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    Objective: There is little consensus about whether commonly used measures of Catholicism lend much to our understanding of abortion support.


    We tested whether degree of Catholicism was associated with support for abortion among Mexican Catholics and if different measures of Catholicism alter the relationship. Methods: We used data from 2,669 Mexican Catholics. Respondents were asked a question about support for legal abortion, as well as support for abortion under 10 exceptions, which we grouped into 2 categories: exceptions with traditionally majority (high) agreement and less than majority (low) agreement based on previous literature. Our independent variable was degree of Catholicism, measured in 4 ways: attendance at mass, degree of Catholicism, perception of a good Catholic, and confession after abortion. We ran multivariable logistic regression for our three outcomes, and separate models for each measure of Catholicism. Results: Perception of being a good Catholic was the only Catholicism measure that was significantly associated with all outcomes (legal abortion, high, and low agreement), controlling for covariates. Attendance at mass and self-identified Catholicism did not lend much beyond inclusion criteria. Respondents who believe a woman who helps someone who aborts can continue being a good Catholic had higher odds of support for abortion under high and low agreement exceptions. Respondents who believe a woman who aborts can confess to God or has no need to confess had higher odds of support for at least one low agreement exception. Conclusion: More nuanced measures of Catholicism that go beyond Catholicism as an identity are valuable in assessing support for abortion, especially exceptions with traditionally low support, which are the reasons most women need abortion.

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    FC05

    Disparities in access to first trimester legal abortion in the public sector in Mexico City: Who presents past the gestational age limit?

    Blair G. Darney1 ,2, Biani Saavedra-Avendano1, Patricio Sanhueza4, Raffaela Schiavon3
    1National Institute of Public Health, Cuernavaca, Morelos, Mexico, 2Oregon Health & Science University, Portland, OR, USA, 3International Pregnancy Advisory Services, Mexico City, Mexico, 4Mexico City Ministry of Health, Mexico City, Mexico

    Objective: First trimester abortion was decriminalised in Mexico City in 2007; laws in Mexico’s other 31 states remain restrictive. Women who present for care past 12 weeks are not able to receive services. The objective of this study was to identify factors associated with presenting for public abortion services past the gestational limit.
    Methods: We conducted a retrospective cohort study using clinical data from the public abortion programme in 2011 and 2012. Our primary outcome was receipt of abortion services. We compared characteristics of women who did not receive abortion services with those who received either medical or aspiration abortion. We used multivariable logistic regression to identify associations between client characteristics and our primary outcome, controlling for socio-demographic and clinical confounders.  
    Results: Our sample included 22,945 women, 73.1% of whom had a medical, and 18.3% an aspiration abortion; 8.6% of the sample (n=1935) did not receive abortion services due to presenting past the gestational age limit. Adolescents (aged <18) made up 14.2% of the total sample and 32.7% of women came from outside Mexico City. In multivariable analyses women who travelled from the nearby State of Mexico (aOR=0.89; 95%CI=0.79–0.98) or from another state (aOR=0.83; 95%CI=0.67-0.99) both had lower odds of receiving services, compared with women living in Mexico City. Adolescents had lower odds of receiving services compared with adults (aOR=0.67; 95%CI=0.58-0.77). Women with basic educational levels (aOR=0.71 and 0.72 for primary and secondary versus high school or higher), or who had not experienced a previous pregnancy (aOR=0.79; 95%CI=0.69-0.90) had lower odds of receiving services.
    Conclusions: Factors associated with delay in seeking abortion services in Mexico City’s public abortion programme include distance travelled, younger age, nulliparity and low education level. Our results can be used to support efforts to promote earlier recognition of pregnancy and timely assistance to access services.


Philip Darney


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    Giving women choices in reproductive health

    Philip Darney University of California San Francisco, San Francisco, CA, USA - darneyp@obgyn.ucsf.edu

    The world's health, prosperity and peace are determined by the choices women have for their own reproductive health. Women nurture children and families and do most of the world's work. Women's unpaid work alone accounts for a third of world GDP and the fate of her family depends on a woman's health: the death of a woman increases the risk of her children's death ten times. Since pregnancy and delivery are by far the most hazardous experiences women have, choice about beginning or completing pregnancies is imperative. The Global Health Policy Summit of 2012 identified two interventions as the most cost effective in preventing women's deaths during their reproductive years: access to contraceptives and to safe abortion. These two reproductive choices have a dramatic effect because half of the pregnancies that lead to maternal mortality and reproductive injury are unintended. These unintended pregnancies also result in high rates of premature birth - the most important cause of neonatal death and injury. In places where women do not have access to the highly effective contraceptives they want or where they are denied the choice of safe abortion when they become pregnant unintentionally, maternal and neonatal mortality rates are high and societies are poor and chaotic. The cost of making these choices available to women is trivial - 0.1% of GDP in countries that succeeded in substantially reducing maternal mortality - but the costs of denying them are huge in health and economic losses and personal happiness.

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    FC20

    Why have abortions decreased in the USA?

    Philip Darney
    University of California, San Francisco, USA

    Background: The rate and number of abortions in the USA increased rapidly after legalisation in 1973 to nearly 1.5 million by 1990.  But by 2009 the total was less than 1 million.  What accounted for a 50% decline in less than 20 years?  Those opposed to abortion rights argue that various restrictive laws in more than half the states have encouraged women to give birth rather than abort.   Advocates of family planning assert that increased use of effective contraceptives has decreased the need for abortion in the USA.
    Methods: State and US National data are reviewed in light of legislative changes to examine the relationships among contraceptive prevalence, method mix, age specific fertility, employment, unintended pregnancy and abortion rates.  Specific states, eg, California and Texas, are compared and contrasted.
    Results: Several factors explain the steep decrease in abortion rates and numbers in the USA, but legislative restrictions and declining numbers of providers account for only a small proportion of state-specific variance.  Changes in age-specific fertility rates, particularly a rapid decline in teen pregnancies, increased use of more effective contraceptives and rising employment rates among women provide, along with other demographic factors, powerful explanations for fewer abortions.
    Implications: Fewer abortions require fewer providers which could further decrease access to family planning for poor women living in medically underserved areas.  Less access in already impoverished regions, where restrictive abortion laws are most likely, increases teen and premature births, poverty rates and local health care costs leading to a cycle of declining reproductive health services and increasing poverty and social disruption.


Philippe David


Speeches:

Angela Dawson


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    FC15

    Access to abortion in Australia: insights from health care professionals

    Angela Dawson1, Deborah Bateson2, Rachel Nicholls1, Anna Doab1, Jane Estoesta2, Elizabeth Sullivan1, Ann Brassil2
    1Faculty of Health, University of Technology Sydney, Sydney NSW, Australia, 2Family Planning New South Wales, Sydney NSW, Australia

    Objectives: Recent changes in Australia's national policy with the approval of mifepristone and misoprostol for medical termination of pregnancy (MTOP) have led to increased choices for Australian women. In New South Wales (NSW), the largest and most populous state, there is no statewide data on abortion and incomplete information on MTOP. Further, there is limited research concerning the practices of trained and credentialled abortion service providers. We undertook a qualitative research study to investigate health professional views, perceptions and practices concerning MTOP.
    Method: Eighty-one general practitioners (GPs), surgeons, gynaecologists, nurses and Aboriginal health workers in urban, rural and remote locations who do and do not provide abortion were interviewed. A deductive content analysis methodology was employed to analyse transcripts based upon a framework we developed to examine access to early abortion.
    Results: Private clinic abortion providers noted that they were busy and were mainly involved in surgical procedures with MTOP accounting for half of their work. Gynaecologists viewed abortion at the fringes of the speciality. GP and gynaecologist non-providers thought of abortion as stigmatised work that ‘others' do in private clinics and referred accordingly. Abortion was not seen as a priority for the public system and only provided at the will of interested doctors. MTOP provision was regarded by GPs as difficult due to the follow up required and most were not interested in provision. GP MTOP providers felt isolated and reported demand was low as was women's awareness. Nurses and Aboriginal health workers play an advocacy and facilitation role for mostly disadvantaged women.
    Conclusions: This study provides insight into access to abortion in the public sector and the low interest in provision from GPs who are at the forefront of primary care provision. Leadership from professional associations as well as the involvement of nurses may increase access for women.


Françoise Dedrie

Profession:
Affiliation:

 

Representative for Belgium

Director of the ‘Centrum voor Verantwoord Ouderschap West-Vlaanderen vzw.’  (Abortion Centre), Oostende, Belgium.

Member of the Board of LUNA vzw., Unie van Nederlandstalige Abortuscentra.

 
Educational Background

1984 – 1987: Bachelor of Social Work, Hoger Instituut Sociale Studiën, De Haan (cum laude)

1997: Training ‘Behavioural Therapy’

1998: Training ‘Systems-theoretical Framework’

2000: Training ‘Parent Training Program’

2004 – 2008: Master of Social Work, Political and Social Sciences, University of Antwerp (magna cum laude)

2008 – 2010: Teacher Education Degree

1988 – 2012: Education, training & formation in Healthcare-related topics, End-of-life care, Quality and Business Practices

Occupational Background

1987: Centrum Gezinsplanning en Seksuele Opvoeding vzw.(Family Planning Centre) Brugge, 5 months apprenticeship

1987 – 1989: Zeepreventorium vzw., Educator for adolescents with multiple chronic diseases

1989 – 2011: Zeepreventorium vzw., Rehabilitation for children, youngsters and adults with Cystic Fibrosis (lethal chronic disease)

February 2011: Centrum voor Verantwoord Ouderschap West-Vlaanderen vzw.

francoise.dedrie@cevo-oostende.be


Speeches:

Mirjam Denteneer



Galina Dikke


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    Access to safe abortion reduces the number of complications and financial costs

    Galina Dikke1, Dmitry Kochev2 1Russian Peoples Friendship University, Moscow, Russia, 2JSC "Pentkroft Pharma", Moscow, Russia - pentcroft@mail.ru

    The main method of terminating unwanted pregnancies in Russia remains a D&C (62%, 2012). Medical abortion (MA) is 8% and vacuum aspiration (VA) 30%. In several regions administrative measures have been taken to implement usage of safe methods into clinical practice. Objective: To evaluate the dynamics of the numbers of early complications and financial costs. Material and methods: We choose two regions in the Ural - Sverdlovsk region (SR) and Tyumen region (TR). SR implemented VA in outpatient and inpatient hospitals up to 12 weeks of gestation (N = 2640). TR introduced the method (the combination of mifepristone/misoprostol (200 mg/400 mcg) up to 42 days of amenorrhoea (N=2758). Results: In 2013, in the SR VA was used in 99.2 % of cases (compared to 45.3% - in 2012). Ambulatory holds 35 % VA procedures, the rest - in the hospital. The number of early complications decreased by 3 times (2.0 % vs. 6.0 % respectively), mainly due to incomplete abortion and postpartum endometritis. MA in the TR was used in 97% in early pregnancy, 34.8% of all medical abortions up to 12 weeks. Numbers of early complications decreased by 3.5 times (4.0 % vs. 13.7% respectively), mainly due to bleeding, haematometra and postpartum endometritis. Costs of treatment of early complications observed were 3 times lower in both regions. Cost savings to perform an abortion is 44 % due to the lack of need for inpatient beds, operating, disinfectants, instruments, medicines, including narcotic drugs, equipment, anaesthesia, etc. Conclusions: The introduction of sound technologies and accessibility of abortion contributes to the preservation of reproductive health (reducing complications 3-3.5 times) and lower financial costs of the procedure to perform an abortion (2 times) and the treatment of early complications (3 times).

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    Whether contraception is effective enough

    Galina Dikke1, Liubov Erofeeva2 1Russian Peoples Friendship University,, Moscow, Russia, 2All-Russian Association for Population and Development, Moscow, Russia - erofeevfamily@mail.ru

    Relevance. Despite the wide choice of contraception in Russia the number of unwanted pregnancies is 41%, most of them are terminated artificially totalling about 1 million per year. Objectives: To study the frequency of the contraception methods used, their effectiveness in the population of the Russian women. Material and methods. In-depth and structured interviews conducted with 1027 women aged 18-45 years in 7 Federal Russian districts in 34 localities. Anonymous survey of 161 patients who applied for abortion on request. Results. Contraception was used by 85%, 15% did not use it. Modern methods (LNG IUSs) used - 46%, condoms - 45%, natural/traditional - 32%. Two methods simultaneously used by 38%. Condoms the most popular - 45%, COC - 30%, coitus interruptus - 23%. LARC: copper IUDs - 11%, releasing systems used by 4.5%. 3 months before this pregnancy 52% used contraception: natural methods - 9%, traditional amounted to 14%, modern - 87% (IUD - 16%, COC - 60%, condoms - 25%). In the structure of hormonal methods, proved ineffective were: COC - 37%, transdermal patch - 27%, vaginal ring - 16%, injection - 6%. 56% of women were looking for, but could not get a doctor's consultation for family planning. Discussion. Half of women who became unwillingly pregnant were using modern contraceptive methods. Nearly 60% of the "failure" is among COCs users, which is 2.5 times higher than among condom users, which does not coincide with the theoretical data on these methods effectiveness (the Pearl Index for condoms is higher than for COCs). Conclusion. The reason for the lack of effectiveness of hormonal methods is its inappropriate use by the consumers because of the limited accessibility to medical care and advice on this matter. Another possible reason is the prevalence of traditional methods and the lack of LARCs among promoted ones.


Jürgen Dinger



Maria do Céu Almeida


Speeches:

C. Dufey-Liengme


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    Termination of pregnancy among teenagers – why
    more surgical terminations?
    Dufey-Liengme, C; Coquillat, F; Demierre, M;
    Renteria, S-C
    Centre for Sexual Health and Planned Parenthood, Unit for Psycho-
    social gynaecology and obstetrics, ObGyn Department, Centre
    Hospitalier Universitaire Vaudois, Lausanne, Switzerland
    Introduction: In 2012, a study by K. Chatziioannidou and S-C.
    Renteria showed that teenagers chose to undergo a surgical
    termination of pregnancy (TOP) more often than a medical TOP
    (mifepristone followed by misoprostol) when they decided to
    terminate a pregnancy. It also showed that the teenagers’ choice
    for a medical versus surgical method is inversely proportional to
    the adults’ choice although the efficiency of the medical method
    showed even better results for teenagers than for adults.

    Accordingtothehypothesismade,thereasonsforthischoice
    mightbeinfluencedbythefollowingfacts:(i)thebelatedcalltomake
    anappointment,themedicalprocedurenotbeingavailableafter
    9 weeksofgestation;(ii)theimperativerequestforconfidentiality;
    (iii)thebeliefsandsubjectiveappreciationofthemedicalstaff.
    Objectives: The aim of this retrospective and qualitative study is
    to analyse the reasons why, in case of a TOP, teenagers chose the
    surgical method more often than their adult counterparts.
    Material: (i) All teenagers who were admitted for an abortive
    procedure during 2011 in the in- or outpatient ward.
    (ii) The professional team (midwives and sexual and
    reproductive counsellors) in charge in the case of a TOP request.
    Methods: The information about the patient’s history and the bio-
    psycho-social data was retrieved from thepatient files filled out by
    midwives and sexual and reproductive healthcounsellors during the
    first appointment for a TOP request orduring its process.
    The professionals’ appreciation was evaluated by means of a
    semi-structured questionnaire.
    Results: Concerning the choice of the method for a pregnancy
    termination, the results of our research show that:
    (i) Out of 47 teenagers, 27 chose the surgical method and 17
    the medical method.
    (ii) Three had a second trimester abortion (which includes use
    of the medical method).
    (iii) Fifteen teenagers out of the 27 who chose a surgical
    method consulted between the 9th and 14th weeks of
    amenorrhoea and therefore did not have any other choice.
    The reasons for their ‘late arrival’ will be explained in detail.
    The 12 teenagers who arrived before the 8th week of
    amenorrhoea and chose to undertake abortion by suction &
    curettage under general anaesthesia did it for the following
    reasons:
    (i) Four were afraid of bleeding and pain.
    (ii) Five thought that the organisation of the surgical procedure
    was easier.
    (iii) Two did not trust the abortion pill.
    (iv) One was taken to her mother’s gynaecologist where she
    had a D&C.
    Confidentiality was requested nine times out of 27 when

    choosing the surgical method, and six times out of 17 when
    choosing the medical method.
    Therefore, although confidentiality concerns a third of the
    teenagers’ pregnancy termination requests, it does not seem to be
    a significant element for the choice of the method.
    As for the subjective appreciation of the professionals, the first
    results of the discussions seem to show that teenagers were
    reluctant or resistant towards the medical method.
    Conclusion: This study shows that the reasons why teenagers still
    prefer the use of the surgical over the medical method compared
    to adults, seem to include the late request for an appointment,
    fear of pain and bleeding and organisational issues.
    Confidentiality does not seem to greatly influence the teenagers’
    choice. Nonetheless, medical professionals seem to favour the
    suction curettage procedure performed under anesthesia because
    they associate young age with vulnerability and psychological
    frailty and consequently diminished ability to cope with pain and
    emotional distress during the medical procedures.


Ilana Dzuba


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    Outpatient medical abortion in the later first trimester: is it possible? desirable?

    Ilana G. Dzuba Gynuity Health Projects, New York, USA - idzuba@gynuity.org

    First trimester medical abortion is typically provided through 63 days gestational age as an outpatient service. Nonetheless, many women with pregnancies more advanced than 63 days wish to avoid a surgical procedure and would opt for medical management if offered. But can women with 64 day gestations or 72 day gestations or 80 day gestations avoid facility-based management with multiple repeat doses of misoprostol and, therefore, heightened side-effects? Recent studies explored the use of an outpatient approach with more advanced first trimester pregnancies to establish efficacy, side-effect profile, acceptability to women and to determine any change in outcomes compared with medical abortions in the previous gestational week. Results support the use of outpatient regimens through 77 days of gestation and suggest new counselling considerations. Successful medical abortion appears to decrease in the 12th gestational week. Expanding provision of medical abortion for additional weeks of pregnancy would increase access, including for those women for whom suction curettage is not feasible.


Alison Edelman


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    Getting to hard to reach places: expanding access to rural Nepal through nurse provision of first trimester medical abortion

    Alison Edelman1, Kusum Thapa2, Deeb Shrestha Dangol2, Indira Basnett2 1Ipas, Chapel Hill, North Carolina, USA, 2Ipas Nepal, Kathmandu, USA - edelmana@ohsu.edu

    In Nepal, abortion was legalized in 2002. It is permitted for any reason to 12 weeks, for rape or incest up to 18 weeks and for maternal or fetal indications at any gestational age. First trimester abortion services became more readily available in 2004. However, Nepal is a country of extremes with mountainous regions that are challenging to access and areas that are impassable at certain times of the year. Health care services are also limited by the number and type of provider. Creating access for women seeking life-saving care such as safe abortion and contraceptive services entails innovative strategies including task sharing. The Nepali Ministry of Health and Ipas have been working to increase abortion access in these hard to reach places. A pilot project was performed in 2010-2012 to train auxiliary nurse midwives (ANMs) from primary health centres/health posts in first trimester medical abortion (MA). As of June 2012, 216 ANMs were trained. Following training, 89% (233) have provided MA with 6056 women served [mean 4.6 women/month (SD=3.3)]. Overall service quality was high; 100% of women received pain management and 88% received postabortion contraception. Perceived enabling factors for MA provision identified by providers and facility managers included community awareness through media and volunteers, well-established referral mechanisms, support by facility administration and clients' beliefs about MA. Similarly, perceived barriers included a stable supply of MA drugs and equipment, insufficient counselling areas, inability to manage severe complications, medication costs and service disruption due to transfer of trained providers. Overall, 98% of women reported being very/mostly satisfied with services. Expanding the abortion provider base to include ANMs has increasing availability of safe services to Nepal's predominantly rural population. With the success of this pilot project, the Nepali government has incorporated the training of ANMs in MA into their national curriculum.

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    The quest for the optimal regimen for pain control for first trimester surgical abortion is ongoing. The desired characteristics of an optimal regimen include safety, efficacy, relatively inexpensive cost, and easy to administer.  Although paracervical blocks and nonsteroidal anti-inflammatory medication in combination with non-pharmacologic methods (heating pad, support person) fulfil these criteria - many women still experience significant levels of pain during their procedure.  To complicate matters, many clinicians have strong feelings that their pain regimen approach is best but as clinicians have been shown to underestimate the amount of pain women are experiencing, rigorous testing of these regimens are needed.  

    Finally, a woman’s perception of pain is complex with both physical and psychosocial elements that have been associated with higher levels of pain including parity, age, and anxiety levels. The current literature will be discussed as well as a brief review of the pathophysiology of abortion-related pain, patient characteristics associated with increased levels of pain, a practical approach to care and research gaps.

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    CS03.2

    Abortion in women with haematological disease

    Alison Edelman
    Oregon Health & Science University, Portland, Oregon, USA

    Controversy exists regarding the management of haematological diseases in women undergoing abortion. However, the overall risk of either haemorrhage or thrombosis is extremely rare in women undergoing abortion; as such, little change is likely to be necessary in the management of these women other than increased vigilance. Consideration of clinical setting, availability of emergency resources and gestational age may influence clinical management but will vary with the type and severity of the disorder and its risk of "bleeding" or "clotting".  Anecdotally clinicians prefer aspiration or surgical abortion over medical in women at risk for bleeding because of the ability to control and monitor bleeding directly.  As pregnancy exponentially increases the risk of thrombosis, a woman's choice to end the pregnancy returns her risk back to baseline. Measures to prevent bleeding and clotting and the evidence behind them will also be included. Finally, one of the most important aspects of the care for women with haematological diseases is the prevention of and planning for the next pregnancy as well as the non-contraceptive benefits that can be obtained from the use of a contraceptive method for these women.  The current literature will be discussed as well as a brief review of the common haematological disorders likely to be encountered and a practical approach to the clinical management of these patients.


Niklas Envall


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    FC10

    Use of effective contraception six months after emergency contraception with a copper intrauterine device or ulipristal acetate - a prospective observational cohort study

    Niklas Envall1 ,2, Helena Kopp Kallner2 ,3, Nina Groes Kofoed3
    1The RFSU Clinic, Stockholm, Sweden, 2The Karolinska Institutet, Solna, Sweden, 3Danderyds Hospital, Danderyd, Sweden

    Introduction: Emergency contraception must be followed by the use of an effective method for contraception in order to reduce future risk of unintended pregnancy. Provision of long acting reversible contraception (LARC) such as the copper intrauterine device (Cu-IUD) is highly effective in preventing unintended pregnancy.
    Objectives: to compare use of an effective method of contraception 6 months following insertion of a Cu-IUD or intake of ulipristal acetate (UPA) for emergency contraception (EC).
    Method: Women (n=79) presenting with need for EC at an outpatient midwifery clinic chose either Cu-IUD or UPA according to preference. Follow up was three and six months later through telephone interviews. Primary outcome was use of an effective contraceptive method at the six month follow up. Secondary outcomes included use of an effective contraceptive method at three months follow-up and acceptability of Cu-IUD.
    Results: A total of 30/36 (83.3%) of women who opted for Cu-IUD had an effective contraceptive method 6 months after their first visit compared to 18/31 (58.1%) of the woman who used UPA (p=0.03). In the Cu-IUD group 28/36 (77.8%) where still using Cu-IUD at six months and 31/36 (86%) stated that they would recommend the Cu-IUD to others as an EC method.
    Conclusion: Significantly more women who chose Cu-IUD for EC used an effective method for contraception at the six month follow up. The results of this study support increased use of Cu-IUDs for EC.

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    Objective: To evaluate whether intrauterine instillation with Mepivacaine (Carbocain) before insertion of an intrauterine contraceptive device (IUD) decreases pain at insertion compared with placebo (NaCl). Design: Double-blind randomized controlled trial. Setting: Two outpatient clinics providing contraceptive services. Population: Women over 18 years of age opting for IUD for contraception. Methods: Women were randomized to intrauterine instillation of Mepivacaine (intervention) or placebo (placebo, NaCl) with a hydrosonography catheter before insertion of an IUD. During the procedure, women marked their pain on a 10-cm visual analogue scale (VAS). Data were analyzed by intention to treat, using descriptive and inferential statistics. Main outcome measures: Difference in pain score (VAS) at the time IUD insertion between intervention and placebo group. Results: A total of 86 women were randomized. Mean VAS-score was 4.63 in the intervention group (n=41, SD=2,21) compared to 5.67 in the placebo group (n=40, SD=2,62, P = 0.058). The intervention did not have a significant influence on pain but had a significant influence on the overall experience of the procedure (P = 0.003). Conclusions: Intrauterine instillation of Mepivacaine prior to IUD insertion did not significantly affect the pain score but had a significant influence on the overall experience of the procedure. Our findings support further studies with larger sample sizes.


Philippe Faucher

Profession: ObGyn
Affiliation: Trousseau Hospital, Paris
 

Representative for France

Graduated at the Faculty of Medicine of Paris, Philippe Faucher is ObGyn since 1992. He is particularly interested in contraception and abortion since 1994 and also in the gynecological and obstetrical follow up of HIV positive women. He was one of the first in France to evaluate the possibility to provide medical abortion outside the hospital ( 1).
2004 he is a co-founder of REVHO an association for the promotion of medical abortion outside hospitals and clinics, e.g. private providers: gynecologists and general practitioners (2).
Together with Danielle Hassoun, he is the co-author of a book on medical abortion (3).
Postgraduate teacher in Paris: birth control, contraception,colposcopy, adviser in sexual health, HIV and STI.
2013, after working 14 years at the Bichat-Claude Bernard hospital, he joined in the Trousseau hospital and works in collaboration with the hospital team of Les Bluets within a center of Family Planning and Abortion in Paris.
 
 
special publications:
(1): The efficacy and acceptability of mifepristone medical abortion with home administration misoprostol provided by private providers linked with the hospital: a prospective study of 433 patients  
(2): Results of a 4-year study on 15,447 medical abortions provided by privately practicing general practitioners and gynecologists in France.
(3): IVG médicamenteuse
 
 
 

philopera@free.fr


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    PS04.1

    Early and very early medical abortion

    Philippe Faucher
    Hôpital Trousseau, Paris, France

    Early medical abortion will be defined in this presentation by termination of pregnancies with Mifepristone/Misoprostol when no visible gestational sac is visible on ultrasound. Very early medical abortion will be defined by termination of pregnancies before the date of expected menstruation. Providers are reluctant to provide medical abortion so early mainly because of the fear of a missed diagnosis of ectopic pregnancy. Consequences for women are not negligible: repeated consultations, repeated ultrasound, repeated HCG could delay the termination of the pregnancy and induce problems of costs, confidentiality or emotional distress. Arguments will be presented to reassure providers about the possibility to provide early medical abortion safely. A protocol for follow up of early medical abortion will be presented based on correct information given to the women (especially symptoms that must induce a visit to the emergency service) and serum HCG testing seven days after the medical abortion. The second argument is the possibility of a reduced efficacy of medical abortion in the early period of pregnancy which was suggested in one study. Published data on this fact will be presented. Finally very early medical abortion will also be considered in this presentation on the basis of recent studies.

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    FAQ, Frequently Asked Questions in abortion care

    Ellen Wiebe1, Philippe Faucher2 1University of BC, Vancouver, Canada, 2Hôpitaux Universitaires Est Parisien, Paris, France - ellenwiebe@gmail.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.


Iolanda Ferreira


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    FC16

    Safety of medical abortion up to 10 weeks at home

    Iolanda Ferreira, Filipa Coutinho, Manuel Fonseca, Elsa Vasco, Teresa Bombas, Maria Céu Almeida, Paulo Moura
    Obstetrics Service A and B of Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

    Introduction: In Portugal, abortion by women's request is legal until 76 days of pregnancy. The rate of medical abortion is nearly 96% in the National Health System.
    Objectives: Evaluate the safety of medical abortion at home before and after 9 weeks of pregnancy.
    Methods: Retrospective evaluation of 6735 women (Group1-before 9 weeks; Group2-after 9 weeks), who attended our department between January 2007 and December 2015. For abortion the protocol used was mifepristone 200 mg and vaginal misoprostol 800 mcg after 48 hours. Statistical analysis was made using Independent T-test; Chi-Square and Mann-Whitney U test in SPSS 20.0.
    Results: Medical abortion was an option in 98.8% (n= 6650) of cases; 56 (0.8%) at hospital and 6594 (99.2%) at home. Regarding abortion at home, the mean age was higher in group 1 (28.9 vs 28.3; p= 0.05).
    According to national guidelines, an abortion is complete when there is no need for additional medical or surgical intervention. There was no difference in efficacy between groups (Group 1: 97.4% vs Group 2; 96.5%; p= 0.3). The most common side effect was pain, which was moderate (Group1: 34.3% vs Group2: 30.9%) intense (32.3% vs 38.2%) and maximal (11.6% vs 18.2%). Pain scores were significantly higher after 9 weeks of gestation (p= 0.04).
    There were no differences between groups regarding complication rate (Group1: 7.9% vs Group 9.9%; p= 0.2). The most common complication was retained abortion (6.1% vs 6.5%); method failure (1.2% vs 1.6%); endometritis (0.2% vs 0.8%) and severe blood loss (1% vs 1%). The rate of admission to hospital due to complications did not differ between groups (3.7% vs 4.4%; p= 0.5).
    Conclusion: Medical abortion is equally effective and was proven to be safe at home in both groups. The most common side effect was pain and it was significantly more intense after 9 weeks of gestation.


Lisa Ferreira Vicente


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    PS01.3

    Improving women´s journey through abortion in Portugal

    Lisa Vicente
    Directorate of General of Health, Lisbon, Portugal

    Abortion, according to the Portuguese penal code, is considered a crime against intrauterine life. Over the years Portuguese law has incorporated reasons that preclude the illicit use of abortion.
    Serious maternal illness, foetal malformation and rape constitute grounds for termination of pregnancy. These motives are accepted for 32 years in Portuguese health care.
    It was just in 2007, after a national referendum, that the practice of abortion at women´s request up to10 weeks gestation was recognised. Since then it has been performed within the National Health Service (NHS) or in officially recognised, private clinics.
    The implementation of abortion services was made possible within the NHS through a national network, along with the availability of mifepristone and misoprostol, the publication of national guidelines and the creation of a national online registry, mandatory for all health care units.
    Nowadays 67% of all the abortions are performed in the NHS, where 95-97% of interventions are medical abortions.  In private units the majority of the interventions are still performed using the surgical method (98%).
    It is unknown what was the absolute number of illegal abortions before 2007, although 20 000 was the estimated number. We only have data on the complications caused by these abortions because women came to health services looking for treatment. Serious complications included deaths, uterine perforations and sepsis. Many women travelled abroad to seek a safe abortion – a number never known.
    National reports show a significant decrease in the number and seriousness of complications caused by illegal abortions since 2008. With legal abortions complications remain low but in 2010 there was one fatal case of Clostridium Sordellii associated with medical abortion.


Alison Fiander



Diana Foster Green


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    PS03.1

    The Turnaway Study: Women’s experiences five years after receiving versus being denied a wanted abortion

    Diana Foster
    University of California, San Francisco, Oakland, CA, USA

    The Turnaway Study is a longitudinal study of nearly 1,000 women who sought abortions from thirty abortion facilities across the United States between 2008 and 2010. We followed women just above and just below facility gestational limits to examine what happens to women when they have abortions and when they are denied, wanted, abortions. Findings from this study have been used to inform U.S. Supreme Court cases and Senate Committee hearings. It has produced data for 25 scientific papers on multiple aspects of women's experiences with unwanted pregnancy such as reasons for choosing abortion, experiences finding and receiving an abortion and emotional responses to abortion and childbirth. We have completed five years of data collection. In this panel the principal investigator will share results on women's physical health, mental health, emotions, relationships, socioeconomic wellbeing, subsequent pregnancies and the wellbeing of their children. We find no mental health harms from either abortion or birth following abortion denial but significant economic hardships among women denied, wanted, abortions compared to women who receive an abortion. We also find negative consequences for women's existing children and new child if they are forced to carry a pregnancy to term.

    Women are thoughtful, even prescient, in the reasons they give for wanting to terminate a pregnancy. Their concerns around economic security, relationships with the man involved and ability to care for existing children are born out in the experiences of women denied a wanted abortion. Understanding the real consequences to women's lives of abortion and unwanted childbearing is essential to informing policy and providing reproductive health care. These data also help us to identify groups of women who may need additional support after abortion and to support policies to improve abortion access and mitigate the harms of being denied a wanted abortion.


P. Fournet


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Laura Gil


Speeches:

Vislava Globevnik Velikonja


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    Meeting the needs of grieving families after induced abortion for fetal abnormality in Slovenia

    Vislava Globevnik Velikonja University Medical centre, Ljubljana, Slovenia - vislava.velikonja@guest.arnes.si

    The detection of fetal abnormalities in the first and second trimesters is increasingly common due to advances in technology. Parents need counselling to be prepared for the difficult decisions that must be made if their unborn children are diagnosed with a life-limiting condition. Termination after fetal anomaly forces parents to take an active part in the life and death of a nearly-viable fetus. Regardless of the option taken, they often experience intense grief reactions. Both giving birth to a child with a life-limiting condition as well as termination of pregnancy for fetal anomaly can be emotionally traumatic life events. Abortions for fetal abnormality are statistically rare, therefore there is little societal understanding and minimal support for those who experience them. The grieving family should be provided with assistance by professionals at multiple levels, aiming at reaching two main target groups: the grieving family by providing direct counselling and support in the hospital and in the community, and those assisting the bereaved by providing training and support. At our department both parents can be hospitalized together during the period of pregnancy termination. The possibility of seeing the dead baby, to hold it and to say farewell may help the parents afterwards. They are informed about cremation and the day of the funeral in a memorial park named Snowdrop Garden, about the mourning process and the possible psychosocial support during it. If the birth weight of the baby is over 500 grams, we use the protocol for perinatal death. Most parents are able to cope with the decisions they made. Feelings such as doubt, guilt, failure, shame, anger, relief, anxiety and depression are common during the process of abortion, the following weeks and sometimes even months. Only a few couples still need psychotherapeutic help and a support group after one year.


Alisa Goldberg


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    Cervical preparation before second trimester dilatation and evacuation: a multicentre randomized trial comparing osmotic dilators alone to dilators plus adjunctive misoprostol or mifepristone

    Alisa Goldberg2 ,1, Jennifer Fortin2, E. Steve Lichtenberg7 ,8, Eleanor Drey9 ,10, Gillian Dean11 ,12, Paula Bednarek13 ,14, Beatrice Chen15 ,16, Caryn Dutton3 ,1, Sarah McKetta2, Rie Maurer3, Beverly Winikoff6, Garrett Fitzmaurice5 ,4 1Harvard Medical School, Boston, MA, USA, 2Planned Parenthood Leauge of Massachusetts, Boston, MA, USA, 3Brigham and Women's Hospital, Boston, MA, USA, 4Harvard School of Public Health, Boston, MA, USA, 5McLean Hospital, Belmont, MA, USA, 6Gynuity Health Projects, New York, NY, USA, 7Family Planning Associates, Chicago, IL, USA, 8Northwestern University, Chicago, IL, USA, 9San Francisco General Hospital, San Francisco, CA, USA, 10University of California, San Francisco, San Francisco, CA, USA, 11Planned Parenthood of New York City, New York, NY, USA, 12Mount Sinai School of Medicine, New York, NY, USA, 13Lovejoy Surgical Center, Portland, OR, USA,

    14Oregon Health Sciences University, Portland, OR, USA, 15Magee Women's Hospital, Pittsburgh, PA, USA, 16University of Pittsburgh, Pittsburgh, PA, USA - agoldberg@pplm.org

    Objectives: To evaluate adjunctive misoprostol or mifepristone versus osmotic dilators alone for cervical preparation before D&E at 16-23+6/7 weeks. Methods: This double-blind, three arm multicenter randomized controlled trial compared osmotic dilators alone, dilators plus 400 mcg of buccal misoprostol 3 hours preoperatively and dilators plus 200 mg of oral mifepristone during dilator placement for D&E. Our primary outcome was operative time. Secondary outcomes included initial cervical dilatation, D&E completion on first attempt, need for mechanical dilatation and complications. Three hundred women were required for 80% power to detect a 2 minute difference in operative time within two cohorts: 16-18 6/7 weeks (N=150) and 19-23 6/7 weeks gestation (N=150). Results: We found no difference in operative time between treatment arms in either gestational cohort. Initial dilatation was greater with misoprostol than dilators alone in the early cohort (2.4 vs. 2.0 cm, p=.007), but similar in the later cohort. More subjects in the dilators alone arm required additional dilatation in the early cohort (35.3% vs. 9.8% misoprostol vs. 14.3% mifepristone, p=.003); but not the later cohort. We found no difference in procedure completion on the first attempt. Provider satisfaction with cervical preparation was highest after mifepristone (71.8% vs. 78.8% vs. 86.8%, p<.0001). The dilators alone arm had more cervical lacerations requiring repair (4% vs. 0 vs. 0, p=.02) and more uterine re-aspirations (4% vs. 1% vs. 2%, p=.05). Conclusions: Although operative time did not differ, there may be some benefit to use of adjunctive misoprostol or mifepristone for cervical preparation before D&E.

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    Women are seeking abortion at increasingly earlier gestations, with 41% of first trimester patients in the U.S. receiving an abortion at <6 weeks gestation.  The efficacy of medical abortion at <6 weeks gestation is not significantly different than at 6-7 weeks, however, seeking abortion very early in gestation increases the likelihood that providers will have difficulty visualizing the pregnancy on ultrasound, the current standard of care in many clinics. 
    The most serious risk of treating women with an undesired pregnancy with mifepristone and misoprostol without first confirming a diagnosis of intrauterine pregnancy is a missed diagnosis of ectopic pregnancy.  Studies suggest an incidence of ectopic pregnancy of 0.2-0.3% among women presenting for medical abortion. Data support the practice of providing mifepristone and misoprostol medical abortion in the setting of undesired pregnancy of unknown location (PUL) using serial serum hcg testing to simultaneously exclude ectopic pregnancy and determine the efficacy of the medical abortion.  Guidelines that enable provision of medical abortion in the setting of PUL, when the patient is asymptomatic, low-risk for ectopic and when combined with close follow up to exclude ectopic pregnancy exist to support this service development.
    This presentation will review the evidence for providing medical abortion at <6 weeks gestation including in the setting of PUL.


Urška Gruden


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    Comparison of two methods of late termination of pregnancy for fetal anomalies

    Urška Gruden, Barbara Šajina-Stritar, Nataša Vrhkar, Nataša Tul-Mandić Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia - urska.gruden@gmail.com

    Objective: To compare results of intra-amniotic injection of carboprost (IA method) with mifepristone-misoprostol oral/vaginal application (MI-MI method) for termination of pregnancy (TOP) for fetal anomalies after 22 weeks. Methods: We collected data from women requiring TOP after 22w for fetal anomalies from January 2011 to December 2012. After the maternal request and ethical committee approval, feticide was performed followed by IA injection of carboprost 4 ml or by application of mifepristone 200 mg orally and misoprostol vaginally 24-36 hours later. Mifepristone was optional. The first dose of misoprostol was 100 mcg vaginally, continued every 3 hours bucally with rising doses 100-400 mcg until labour started. We collected data about gestational age, parity, average time from beginning of procedure to labour and need for surgical evacuation of the placenta after TOP. We analyzed data using the statistical program SPSS. Results: We included 74 women, 24 in the IA group and 50 in the MI-MI group. Mean gestational age was 26w 2/7 (22w 1/7 -36w 2/7). Mifepristone was administered to 29 of 50 women in the MI-MI group TOP was successful in 24 (100 %) cases after IA and in 49 (98 %) cases after MI-MI. The average time from beginning of TOP procedure until labour was 24.8 hours in IA group and 17.4 hours after misoprostol application in the MI-MI group. Surgical evacuation of the uterus was done in 15 cases (65.2 %) in IA group and 13 cases (26 %) in the MI-MI group. In cases where mifepristone was combined with misoprostol the time interval from administration of vaginal misoprostol to labour was 5.5 hours, shorter than in cases where only misoprostol was used. Conclusions: Both methods are safe and effective, but the MI-MI method has more advantages. These are non-invasiveness, less surgical intervention for retained placenta, shorter interval from beginning of procedure to labour and lower costs.


D. Halleb


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    Medical termination of pregnancy by mifepristone
    and sublingual misoprostol: preliminary results of
    their use in reproductive health centre of Nabeul
    in Tunisia
    Halleb, D1; Temimi, F2; Belcaid, A1; Ben Khedija,
    W1; Wahbi, H1
    1 Centre de la Sante´ de la Reproduction, Nabeul, Tunisia; 2 Office
    National de la Famille et de la Population, Tunis, Tunisia
    Introduction: Medical termination of pregnancy (TOP) is a
    method increasingly used worldwide. It was introduced in Tunisia
    by the National Office of Family and Population, since 1994 as
    part of research. Then it was extended in 22 of the 24
    reproductive health centres. Medical TOP was introduced in the
    Nabeul Centre since November 2002. We used three different
    protocols; the third protocol was introduced since March 2010.
    The aim of the study was to describe the effects of this protocol
    on medical TOP effectiveness; frequency of side effects, and
    frequency of TOP failure.
    Methods: We conducted a retrospective observational study
    performed in the reproductive health centre of Nabeul from April
    2010 to June 2010 about women who chose medical TOP.
    For all women consulting for TOP, the medical staff explained
    the interest of medical TOP and the risks of this method
    compared to the surgical one.
    On the first day, counselling was conducted, clinical and
    ultrasound examinations were made to identify no exclusion
    factors: anaemia, ectopic pregnancy, and pregnancy off the pill,
    kidney failure and liver failure. Then 200 mg of mifepristone was
    administered by the midwife or the physician.
    On the second day, 400 lg of misoprostol was administered by
    the sublingual route. On the fifteenth day, a check was performed
    by a clinical and ultrasound examination.
    We considered as method failure: surgical aspiration for
    ongoing pregnancy, a total retention or significant bleeding.
    Withdrawals were not recorded as such.
    The study analysis was performed by SPSS with statistical
    verification by the v2 and ANOVA at a significance level of 5%
    (P £ 0.05).

    Results: We included 562 women (27.48% single and 72.52%
    married) who have chosen medical TOP during the study period.
    The average age was 32 years, ranging from 18 to 50. Educational
    level was illiterate for 5.1%, elementary or secondary for 78.8%
    and university for 16%. In 77% of cases women had not had a
    medical TOP before, 16.5% of them had one previously, 4.7%
    twice and 1.9% three or more times. The age of pregnancy was in
    60% of cases <6 weeks of gestation, in 34.7% of cases between 6
    and 7 weeks of gestation, and in 6.9% of cases between 8 and
    9 weeks. The expulsion occurred in 54.2% of cases before 4 hours
    and in 44.4% after 4 hours. Pain was reported in 10.5% of cases
    and need appropriate treatment. Surgical abortion was used in
    1.2% (ongoing pregnancy in 1% of cases and bleeding 0.2% of
    cases).

    Statistical analysis showed: (i) a significant relationship between
    gestational age and the period of expulsion (P = 0.047); no
    significant relationship between the gestational age and the failure
    of the TOP; no significant relationship between educational level
    and gestational age at the time of first consultation (P = 0.243).
    Conclusion: The protocol adopted in this study appeared to be
    safe, effective and acceptable to women. However we must be
    aware and explain to women that the use of medical TOP does
    not replace contraception, contrary to popular belief.


Rochelle Hamilton


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    Ability to receive informed choice impacts upon contraception uptake and compliance

    Rochelle Hamilton Barwon Health, Geelong, Australia - rochy321@hotmail.com

    Background: Previous research highlights significant uptake of various contraceptives for women of all ages. More recently, studies support long-acting reversible contraceptives (LARC) specifically for younger women for efficacy, cost and return to fertility. So why do a high number of unplanned pregnancies and subsequent need for termination continue? This outcome is not only about risky sexual behaviour. If women are not supported to make informed choices, poor uptake and poor compliance with contraception continue. Aim: Although previous studies have primarily focused on risky sexual behaviours with adolescents, this research aims to explore the relationship between the education health care professionals (HCP) impart versus the understanding the woman has of the contraceptive. Consequently, this has an impact upon compliance and subsequent efficacy of contraceptives. Method: The clinical information obtained during the period 2001 - 2011 included 3,500 women aged between 12 - 53 years attending a public health setting for first trimester surgical termination. The information collected is part of routine counselling undertaken by all attending. The data collected was originally for a different purpose, however the findings highlighted various themes. Results: Findings revealed that a large percentage of women chose not to use specific contraceptives largely due to a combination of either real or perceived information they receive from their HCP. Additionally, it appears implementation of Quick Start methods is not routinely undertaken. Further barriers to utilisation of LARCs appear to include health literacy, socio-economic status and age. Conclusion: Negative consequences of unplanned pregnancy affect women of all ages. Poor choice or no choice of contraception, together with poor information and preconceived ideas about specific contraceptives by both the HCP and the woman contribute to poor compliance. Education needs to be improved first line to HCP's with unbiased views so all options are available from a biopsychosocial delivery point.


Garik Hayrapetyan


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    Gender-biased sex selection

    Lena Luyckfasseel IPPF European Network, Brussels, Belgium - lluyckfasseel@ippfen.org

    Sex selection can take place before a pregnancy is established, during pregnancy through prenatal sex detection and selective abortion or following birth through infanticide or child neglect. Nevertheless, the discussion seems to focus especially on abortion. Sex selection is sometimes used for family balancing purposes but far more typically occurs because of a systematic preference for boys. Practised on a large scale it can result in skewed sex ratios at country-level. The root causes of gender-biased sex selection are situated in persistent gender inequality leading to son preference. Other conditions that need to be present for prenatal sex selection are low fertility (people choosing smaller sized families) and the availability of the technology. In 2011 the Parliamentary Assembly of the Council of Europe in their resolution on "Prenatal Sex Selection" stated that there is "strong evidence that prenatal sex selection is not limited to Asia [...] and has reached worrying proportions in Albania, Armenia and Azerbaijan". This has put gender-biased sex selection firmly on the European agenda. It is important to frame the discussion on gender-biased sex selection in such a way that it does not impede women's access to safe abortion services. Following a short introduction to the topic a diverse panel will explore the following questions: What does gender-biased sex selection mean for us? How do we respond to gender-biased sex selection; towards individuals, practitioners, decision makers and anti-choice?


National Health Service


Speeches:

Rebecca Heller


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    Postpartum contraception: a missed opportunity for preventing termination of pregnancy and short inter-pregnancy intervals?

    Rebecca Heller1 ,2, Rosie Briggs2, Norma Forson1, Anna Glasier2, Sharon Cameron1 ,2 1NHS Lothian, Edinburgh, UK, 2University of Edinburgh, Edinburgh, UK - rheller@staffmail.ed.ac.uk

    Background: There is a growing realization that women's need for effective contraception in the immediate postpartum period has been underestimated. Unintended pregnancies soon after childbirth may lead to termination of pregnancy (TOP), or short inter-pregnancy intervals that are associated with adverse maternal, perinatal and infant outcomes. Using local TOP and maternity databases in Edinburgh, Scotland, we examined (1) the proportion of women attending for TOP over a 6-month period (Sept 2013 - Feb 2014) who had given birth within the preceding 12 months, (2) the proportion of postpartum mothers over the same time period whose baby followed an earlier birth to pregnancy interval of 12 months or less. (3) We also conducted an anonymous self-administered survey of mothers (n=250) within the first week postpartum about contraceptive intentions. Results: Database analysis showed that (1) 75 women out of 1052 (7.1%) attending for TOP had given birth within the preceding 12 months and that (2) 311 out of 4713 postpartum mothers (6.6%) gave birth following a preceding birth to pregnancy interval of 12 months or less. The majority of postpartum women surveyed - 62/250 (76.6%) - had not decided on an ongoing method of contraception and most (174/247, 70.4%) had not discussed postpartum contraception during the pregnancy with a health care professional. Discussion: Almost 1 in 13 women in our population who present for TOP or who deliver a baby have conceived the pregnancy soon after childbirth. Given the consequences of an unintended pregnancy for women and the risks of short inter-pregnancy intervals, consideration needs to be given to interventions that might improve uptake of effective contraception in the immediate postpartum period.

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    FC19

    An evaluation of postplacental insertion of intrauterine contraception (PPIUC) at elective caesarean section in the UK

    Rebecca Heller2, Anne Johnstone2, Sharon Cameron1 ,2
    1NHS Lothian, Edinburgh, UK, 2University of Edinburgh, Edinburgh, UK

    Objectives: Sexual health policy recognises that increased uptake of the most effective methods of contraception immediately postpartum could prevent unintended pregnancies and short interpregnancy intervals. Our objective was to evaluate uptake, complications and acceptability of postpartum intra-uterine contraception (PPIUC) inserted at elective caesarean section.
    Methods: All women scheduled for elective caesarean section in NHS Lothian, Scotland were given written information on postpartum contraceptive methods antenatally, indicating that intrauterine contraception could be inserted at caesarean section. This included the offer of a thread check at six weeks by a gynaecologist with an ultrasound scan if threads were not visible. At this visit women were asked about their satisfaction with PPIUC.
    Results: To date (July 2015 – March 2016) 787 women were scheduled for elective section and sent information about postpartum contraception. 142 of 787 women (18%) chose PPIUC, which was performed in 136 cases.  6 were unable to be inserted, 2 of these women returned for insertion subsequently. 120 women (88%) still have the device in situ. There have been 10 expulsions, in 6 cases women have had a second device inserted.  6 devices have been removed. There have been no cases of pelvic inflammatory disease. Of 88 women who have thus far attended for a 6 week check, threads were visible in 47% of cases (n=41). Ultrasound confirmed IUC in situ in all cases of missing threads apart from1, this woman awaits an abdominal x-ray to exclude perforation. Of women attending the 6 week check, 78 (89%) stated that they were happy or very happy with IUC insertion at caesarean section.
    Conclusion: PPIUC at elective caesarean section appears to be a popular option, for women, that is safe and highly acceptable.  This could be an important strategy to prevent short interpregnancy intervals and unintended pregnancies in the UK.


W. Hellerstedt


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    Is perceived partner pregnancy intention associated
    withmaternal prenatal and postpartumwell-being?
    Hellerstedt, W
    Division of Epidemiology & Community Health, School of Public
    Health, University of Minnesota, Canada
    Background: While ‘pregnancy intention’ is often crudely assessed
    by a question concerning satisfaction with pregnancy timing, data
    with this measure support that unintended and unwanted
    pregnancies are associated with adverse infant and maternal health
    outcomes. Few studies have examined similar associations with
    perceived paternal intention.
    Methods: We examined data from Minnesota’s (USA) Pregnancy
    Risk Assessment Monitoring System (PRAMS), involving 7266
    women surveyed 2–4 months after delivery of a live-born between
    2004 and 2008. We used weighted multivariate logistic regression

    to examine the associations of perceived partner intention with
    maternal demographics, as well as prenatal and postpartum
    behaviors and experiences.
    Results: Thirty-seven percent of recent mothers reported that
    their pregnancies were unintended by their partners. Compared to
    those who perceived their partners intended the pregnancy, these
    mothers were significantly (P < 0.01) more likely to report that
    they themselves did not intend the pregnancy, smoked prenatally,
    experienced intimate partner violence, experienced postpartum
    depressive symptoms and had prenatal mood problems. They
    were less likely to report that they received adequate prenatal,
    postpartum or well-woman care; father helped with infant care; or
    that they used contraceptives in the postpartum.
    Conclusions: In this population-based sample, more than one-
    third reported their partner did not intend their recent pregnancy.
    We cannot validate whether maternal report of perceived paternal
    intention is accurate, but we also have no reason to doubt it.
    Irrespective of the objectivity of this measure, perceived partner
    pregnancy intention is an independent indicator of a variety of
    maternal and infant risk markers.


Susan Higginbotham



G. Horgan


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    The politics of termination of pregnancy in
    Northern Ireland
    Horgan, G
    University of Ulster, UK
    Policy and politics in relation to termination of pregnancy (TOP)
    remain mired in issues of religiosity, morality and class
    everywhere in the world but perhaps nowhere more so than in the
    one part of the UK where TOP remains illegal – Northern Ireland.
    There, the Health Minister is a creationist and avowed ‘pro-life’
    advocate who has failed to comply with a court ruling to clarify
    for doctors when it is legal to perform a TOP.
    Control over TOP was not devolved to Scotland or Wales,
    despite Scotland having the same control over matters of criminal
    justice as the NI Assembly. Instead, it was admitted in
    Westminster that in relation to TOP, the UK government was
    making ‘….a distinction between Northern Ireland and the rest of
    the United Kingdom for a multiplicity of pressing political and
    other reasons’. As a result, women in NI are not guaranteed even
    life-saving TOPs, still less ‘social’ ones.
    The ‘multiplicity of pressing political and other reasons’ which
    led to TOP being a devolved issue has much to do with British
    politicians needing the votes of the fundamentalist Democratic
    Unionist Party to pass controversial measures, and nothing to do
    with the social or health needs of women in Northern Ireland.

    This paper looks at the politics of TOP in NI and how religious
    fundamentalism has influenced the development of policy in
    relation to TOP in this part of the United Kingdom.


Linda Hunt


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    CS15.2

    Practical management of midtrimester abortion

    Linda Hunt
    Royal Infirmary, Edinburgh, UK

    This presentation will cover the practical aspects of managing mid trimester medical abortion as conducted by a nurse midwife.
    It will draw upon experience from a Scottish hospital setting in Edinburgh where all mid trimester abortions have been performed medically using mifepristone and misoprostol for more than 25 years (approximately 120 per year). The presentation will cover management of complicated cases including the scarred uterus and twin pregnancy. It will also give practical advice for how to manage pain relief and how long to wait before intervention for retained placenta.


Roger Ingham


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    Barriers to presenting sooner

    Roger Ingham University of Southampton, Southampton, UK - ri@soton.ac.uk

    This paper will provide a review of what is known about factors associated with women seeking termination of pregnancy after the first trimester. A few introductory comments will be made about terminology in this area, especially the use of the term ‘late' and its possible stigmatizing effect. Attention will then turn to the extent to which delays in seeking and obtaining terminations are linked to service provider factors and/or women-centred factors. Data from a recently published chapter (in Sam Rowlands' edited collection) which features an international literature review will be presented to illustrate how the relative importance and balance between these factors vary across cultures and contexts. Finally, data from a recent UK-based study will be summarized, and some reflections as to the likely impact of changing the upper limit will be presented.


Karin Emtell Iwarsson


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    FC18

    Contraceptive use among immigrant and non-immigrant women seeking abortion care in Stockholm County

    Karin Emtell Iwarsson1, Elin Larsson1, Kristina Gemzell-Danielsson1, Birgitta Essen2, Marie Klingberg-Allvin1
    1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden

    Background: Globally, immigrant women encounter more challenges in reproductive healthcare than non-immigrants. A previous Swedish study showed being foreign-born was a risk factor for induced abortion and immigrant women had less experience of contraceptive use compared to non-immigrants. In order to ensure equitable care, it is important to investigate if this pattern still exists.
    Aim: To compare the contraceptive use ever in life, at conception and planned use after an induced abortion, including type of methods, between immigrant and non-immigrant women seeking abortion care in Stockholm County.
    Method: A cross-sectional study using an interview-based questionnaire, conducted at six abortion clinics. In total 637 women responded.
    Results: In the study 425 were non-immigrants and 212 immigrants. A significant difference was observed within the immigrant group, therefore it was divided into foreign-born (148) and 2nd generation migrants (64). For all women, 96% reported they had used contraception ever in life. A significant difference was seen where non-immigrants had used pills and withdrawal to a higher extent, and foreign-born women had used copper IUD. At time of conception, 34% had used contraception. There was no significance between the different methods. Planned future use of contraception was 93%. Copper IUD was significantly more common among foreign-born women, implant among 2nd generation migrants and vaginal ring among non-immigrants. 52% of all women planned to use long acting reversible contraception (LARC = IUD’s and implants) after the abortion.
    Conclusion: Immigrant women seem to have less experience of contraceptive use ever in life, at conception and as planned future method compare to non-immigrants. A significance was seen between non-immigrants, foreign-born women and 2nd generation migrants for different types of contraceptive methods ever in life and as planned future method. Efforts are needed to improve access to contraceptives among immigrants and to increase the use of LARC among all groups.


Kirti Iyengar


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    Women’s experiences and perceptions of simplified medical abortion: a qualitative study in Rajasthan, India

    Kirti Iyengar1 ,2, Birgitta Essen3, Marie Klingberg-Alvin1, Kristina Gemzell-Danielsson1, Sharad Iyengar2, Sunita Soni2 1Karolinska Institutet, Stockholm, Sweden, 2Action Research & Training for Health, Udaipur, India, 3Uppsala University, Uppsala, Sweden - kirtiiyengar@gmail.com

    The requirement for repeated clinic visits remains an important barrier to access to medical abortion. Home use of misoprostol and alternatives to routine follow-up have been suggested as interventions to simplify the medical abortion, however there is little evidence on women’s experiences on these from low-resource settings. This qualitative study was conducted in Rajasthan, India, and explored women’s experiences and perceptions of home use of misoprostol and self-assessment of outcome of medical abortion. The reasons for preferring home use included inconvenience of travel, lack of confidentiality and child care commitments. After taking home misoprostol, most women continued with their routine household work, although they didn’t go for work outside the home. Most women experienced no major health problems, while some women made an extra clinic visit because of perceived health problems. A majority said that if they have to undergo another abortion, then they would prefer to use misoprostol at home. On self-assessment of the outcome of abortion, many women were fairly certain that their abortion was complete either because they experienced bleeding or expulsion or because their pregnancy symptoms subsided. Despite this, a majority of women found it reassuring to do the pregnancy test, to confirm that their abortion was complete. According to one woman, “if abortion is not done then we remain in confusion, any problem can arise inside the body, so it’s good to do the test”. Despite low literacy levels, the majority of the women were able to interpret the results of a pregnancy test. They felt that that this saved them a visit to the clinic. The checklist was used by many women, largely as a refresher to see how to do the pregnancy test. Our results indicate that home use of misoprostol and self-assessment using a low sensitivity pregnancy test is feasible in low-resource settings.


Guyo Jaldesa


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    CS13.1

    Barriers to expansion of post abortion contraception within the FIGO Initiative on Prevention of Unsafe Abortion in Africa

    Guyo Jaldesa
    University of Nairobi, Nairobi, Kenya

    An estimated 22 million abortions continue to be performed unsafely each year, resulting in the death of an estimated 47,000 women and disabilities for an additional five million women. Almost every one of these deaths and disabilities could have been prevented through sexuality education, family planning and the provision of safe, legal induced abortion and care for complications of abortion. Further abortions could be reduced through provision of effective postabortion contraception. Though postabortion contraception is an official strategy this is rarely implemented in African countries resulting in very few women leaving hospital with a method, especially long acting reversal contraception (LARC), following treatment for incomplete abortion. The following barriers were identified for poor utilisation of postabortion contraception: lack of awareness of the methods; fear of side effects; ignorance (at times they think they can't conceive immediately after an abortion); lack of partner support/culture; and religious beliefs. Lack of provider knowledge and stock are two of the barriers to postabortion contraception utilisation.


Vid Janša


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    Late termination of pregnancy because of fetal anomaly complicated by placenta praevia: case report

    Vid Janša, Nataša Tul Mandić Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia - vid.jansa@gmail.com

    Introduction: The presence of placenta praevia totalis is an important cause of postpartum bleeding and can be a challenge for obstetricians in cases of late termination of pregnancy (TOP). Case report: A 35-year old woman, G4, P3, was referred to our hospital due to fetal heart anomaly and intrauterine growth restriction (IUGR). The previous pregnancies and deliveries were uncomplicated. The patient’s first antenatal visit in this pregnancy was at 28th week of amenorrhoea and ultrasound at 29 weeks revealed IUGR, complex heart anomaly (ventricular septal defect, double outlet right ventricle, pulmonary atresia) and placenta praevia totalis. A patient request for TOP was approved by the ethical committee. We wanted to avoid caesarean section. The risk of bleeding during TOP because of placenta praevia totalis became an important issue. A decision was made to proceed with selective uterine arteries embolization (UAE), which was performed in the Radiology department. 18 hours after the procedure fetal heart activity was absent. After 5 days of waiting for spontaneous onset of labour, we decided to continue with misoprostol and she received 100mcg vaginally, 3 hours later 100mcg buccally, followed by 200mcg and 400mcg buccally in 3 hourly intervals. The patient was transferred to the delivery room and placenta and stillborn fetus (770 grams) in breech presentation were delivered vaginally 15 hours after first application of misoprostol. After delivery karboprost was applied for prevention of bleeding and overall blood loss was less than 300ml. The patient was discharged in good condition the day after delivery. Fetal autopsy confirmed prenatal diagnostic conclusions. Discussion: The risk of heavy bleeding with vaginal delivery in cases of late TOP complicated by placenta praevia totalis can be reduced by UAE which has low complication rates, shorter hospitalization and avoids surgical risks as published. Embolization can be followed by misoprostol. Care must be taken to prevent postpartum bleeding.


Daniel Ishoso Katuashi


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    FC26

    Analysis of induced abortion-related complications admitted to referral based medical facilities in Kinshasa, Democratic Republic of the Congo.

    Daniel Ishoso Katuashi1, Antoinette Tshefu Kitoto2, Yves Coppierters3
    1Kinshasa School of Public Health, Lemba, Kinshasa, The Democratic Congo, 2Kinshasa School of Public Health, Lemba, Kinshasa, The Democratic Congo, 3Université libre de Bruxelles, Bruxelles, Belgium

    Objectives: This study aims to analyse the extent of induced abortion-related complications at referral health facilities in Kinshasa and their characteristics, the length of hospitalisation, the proportion of deaths and their characteristics, as well as deaths that occurred after two days of hospitalisation.
    Methods: The cross-sectional study focused on 1541 gynaecological patients admitted as emergencies at 7 referral health facilities in Kinshasa, from 1 January to 31 December 2014, facilities that were selected representatively from the 5 types of districts of Kinshasa. Information was collected by reviewing patient files/records and analysed with SPSS20 and Epi-Info3.5.4.
    Results: There were 12.8% (11.2% to 14.6%) cases of induced abortion-related complications with a correlation to adolescence, celibacy, nulliparity, residence in semi-rural districts of Kinshasa and history of one or more abortions; 4.0% of deaths, including more than one third (1.8% to 4.0%) that are related to induced abortion-related complications, with a mortality of 13.6% and a significant increase in risk of death in the presence of a post abortive, pelvic peritonitis type complication. Half of these deaths occurred after two days of hospitalisation. Finally, the median length of hospitalisation was 10 days, higher in post abortive, pelvic peritonitis compared with patients with pelvic peritonitis due to Caesarean section/hysterectomy.
    Conclusion: This study demonstrates that induced abortion-related complications were a significant public health problem, because of their frequency in cases admitted as gynaecological emergencies at referral medical facilities in Kinshasa and their weight on hospital maternal deaths, and, furthermore, that supportive care in hospitals poses a serious problem. Accordingly, there is a need to understand the reason for the problem of hospital care in order to fulfil and provide a set of services that is appropriate for those medical facilities.


Asifa Khanum


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    Addressing abortion stigma in service delivery: the experience of Pakistan and Burkina Faso

    Rebecca Wilkins1, Asifa Khanum2 1International Planned Parenthood Federation, London, UK, 2Rahnuma Family Planning Association of Pakistan, Lahore, Pakistan - rwilkins@ippf.org

    Restrictive legislation and limited service provision remain obstacles to women who seek abortion services. These obstacles are worsened by the impact of abortion stigma and associated secrecy, shame, guilt and fear. Stigma prevents or delays access to safe abortion services as well as making lawmakers reluctant to improve legislation to facilitate access to abortion information and services. As part of its commitment to reducing abortion stigma at all levels, IPPF commissioned research to understand its effect on women accessing services through IPPF Member Association clinics. In-depth qualitative research using semi-structured interviews with abortion clients, service providers and client partners was conducted at Member Association clinics in Pakistan and Burkina Faso. The research aimed to identify the specific causes and manifestations of abortion stigma and to inform interventions designed to reduce abortion stigma. The research found commonalities in abortion stigma in Pakistan and Burkina Faso, as well as some issues that were unique to each country setting. The clinic client pathways, misconceptions and lack of knowledge about abortion, pre-abortion counselling, and the timeliness of seeking medical care were among some of the issues found to have an impact on, or were impacted by clients' experience of stigma. In both countries women who accessed abortion services had a high level of self-stigma which impacted on their expectations of quality of care in the clinics. Abortion stigma is an unspoken reality that significantly impacts both the attitudes and practices of medical professionals and women who access abortion services. However, the nature of abortion and the stigma surrounding it makes this a challenging topic to collect data and information on. The research findings illustrate the need for the pilot testing of interventions at both the community and service delivery levels in order to address abortion stigma through a more comprehensive and systematic approach.

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    FC09

    Stigma associated with abortion is influencing choice to provide or sidestep abortion services

    Asifa Khanum1, Syed Kamal Shah1, Nadeem Mahmood1, syed Mustafa Ali2
    1Rahnuma FPAP, Lahore, Pakistan, 2Individual Consultant, Lahore, Pakistan

    There is little evidence available on the manifestation of abortion stigma in Pakistan. There is marginalisation of abortion services within medical settings through its negligible inclusion in curriculum, knowledge about abortion law in Pakistan, perceptions about abortion and religion, socio-cultural disapproval, etc. These factors all contribute in the decision of healthcare providers to provide or sidestep abortion services. A research study was designed to understand the expression of stigma associated with abortion by service providers providing abortion services and those not providing these services.
    Methods: A mixed method exploratory study was designed to understand perspectives of both types of service providers. Due to restrictive abortion law and taboos that are stigmatising abortion services and its providers, data was collected from 40 providers providing abortion services and 40 non-providers of these services from reference facilities in 4 districts of Pakistan. Basic descriptive analysis was carried out using SPSS.
    Results: It is evident from analytical findings that the knowledge base of service providers on abortion law in Pakistan, perceptions about its religious permissibility, internalisation of negative community perceptions about abortion service providers and stigmatisation of women seeking abortion services are pertinent attributes influencing provider choice of extending abortion services or not.
    Conclusion: In an effort to de-stigmatise abortion, immediate measures are required at various levels such as: integration/institutionalisation of essential contraceptive services including safe abortion services, formal/informal education and knowledge about abortion laws as explained by Shariat Court of Pakistan, Value Clarification and Attitudes Transformation (VCAT) workshops for providers, and behaviour change communications and education strategies for sensitising communities.


Rajat Khosla


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    Guidelines on ensuring human rights in the provision of contraception services

    Rajat Khosla WHO, Reproductive Health and Research, Geneva, Switzerland - khoslar@who.int

    Unmet need for contraception remains high in many settings, and is highest among the most vulnerable in society: adolescents, the poor, those living in rural areas and urban slums, people living with HIV and internally displaced people. The latest estimates are that 222 million women have an unmet need for modern contraception, and the need is greatest where the risks of maternal mortality are highest. International and regional human rights treaties, national constitutions and laws provide guarantees specifically relating to access to contraceptive information and services.

    In addition, over the past few decades, international, regional and national legislative and human rights bodies have increasingly applied human rights to contraceptive information and services. They recommend, among other actions, that states should ensure timely and affordable access to good quality sexual and reproductive health information and services, including contraception, which should be delivered in a way that ensures fully informed decision-making, respects dignity, autonomy, privacy and confidentiality, and is sensitive to individual's needs and perspectives. In order to accelerate progress towards attainment of international development goals and targets in sexual and reproductive health, and in particular to contribute to meeting unmet need for contraceptive information and services, the World Health Organization (WHO) has developed guidelines and recommendations on ensuring human rights in the provision of contraceptive information and services. The presentation will provide an overview of the process used to develop the guidelines and recommendations made by WHO for policy-makers, managers, providers and other stakeholders in the health sector on some of the priority actions needed to ensure that different human rights dimensions are systematically and clearly integrated into the provision of contraceptive information and services.

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    PS02.3

    Regional analyses of abortion laws and policies in the context of international human rights standards

    Rajat Khosla1, Brooke Ronald Johnson1, Bela Ganatra1, Vinod Mishra2
    1WHO, Geneva, Switzerland, 2UN Population Division, New York, USA

    The Global Abortion Policies Project is designed to further strengthen global efforts to eliminate unsafe abortion by producing an open-access, interactive database and repository of current abortion laws, policies, and national standards and guidelines for all countries in the world.  The Project aims to increase the transparency of abortion laws and policies and accountability for implementation and protection of women’s health and human rights.  The database/repository will facilitate comparisons of national laws and policies with WHO guidelines and international human rights standards related to safe abortion.
    Within the context of this project this presentation will provide regional analyses of abortion laws and policies in the context of international human rights standards and highlight the areas of progress and gaps that remain.


Charles Kiggundu


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Helena Kilander


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    Prescription of contraceptive methods in relation to repeated abortions: a longitudinal population study

    Helena Kilander1, Siw Alehagen1, Linnea Widen1, Karin Westlund1, Johan Thor1, Jan Brynhildsen1 1Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 2Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 3Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 4Department of Obstetrics and Gynaecology, Norrköping, Sweden, 5Jönköping Academy for improvement and welfare, Jönköping, Sweden, 6Obstetrics and Gynaecology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden - helena.kilander@lj.se

    Background: Use of long-acting reversible contraception (LARC) has been reported to reduce the risk of repeated abortion compared with use of other contraceptive methods. Swedish women have a long tradition of using intrauterine devices in comparatively large numbers. Despite good access to LARC, Sweden has a high proportion of repeated abortion. Objective: To study the prescription of contraceptive methods in relation to an abortion in a Swedish population and relate them to the likelihood of repeated abortions. We hypothesized that the prescription of LARC after abortion leads to reduced number of repeated abortions compared with other prescribed contraceptive methods. Method: A retrospective cohort study of women seeking abortion at three Swedish hospitals during 2009. The medical records of these women were scrutinized from the date of the index abortion during 2009 to the 31st of December 2012. The study population comprised 1032 women. Results: A total number of 266 (25%) women requested abortion(s) during the follow-up time. Oral contraceptives were prescribed to 43. 6% of the women and LARC were prescribed to 32.4% at the time of the index abortion. Prescription of LARC was associated with a reduced number of repeated abortions compared with prescription of oral contraceptives (OR 0.39 CI 0.26-0.56). Conclusions: The results of this study show that use of LARC is associated with reduced repeated abortion compared to other contraceptives. Implication: Abortion care needs an increased focus in motivating women and professionals to switch from oral contraceptives to LARC.


D. Kirkham


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    Long-acting reversible contraception (LARC)
    take-up following termination of pregnancy.
    A local audit
    Kirkham, D1; Holt, E2; Agass, R3; Holland, C4;
    Dodsworth, B4
    1 Stockport NHS Foundation Trust, UK; 2 Royal Bolton NHS
    Foundation Trust, UK; 3 Pennine Acute Hospital NHS Trust, UK;4 Salford Royal NHS Foundation Trust, UK
    Objectives: Identify the percentage of women undergoing a
    termination discharged with LARC, and factors influencing take-
    up.
    Methods: Age, contraceptive history, parity, previous termination,
    and discharge contraception were recorded for women attending a
    termination clinic over two months. Ninety-nine cases were
    included.
    Discharge contraception was discussed with 100% of cases;
    92.9% made a contraception decision, 79.8% were discharged with
    a chosen method, 13.1% were guided to a family planning centre,
    7.8% declined contraception (condoms supplied), 59.6% were
    discharged with LARC.
    Relevance/Impact: Less than 10% of unintended pregnancies are
    due to true contraception failure, 30–50% because no method was
    used, the remainder due to incorrect/inconsistent use. In
    unintended pregnancies 40.6% lead to termination of pregnancy
    (TOP); 27–48% of all TOP are repeats. Women seeking TOP are
    highly motivated to seek effective contraception. LARC methods

    are not user-dependent, so are very effective. LARC is more cost-
    effective than the combined oral contraceptive pill (COCP) after
    just 1 year. A reduction in unwanted pregnancies and
    terminations benefits the physical/mental health of women and
    the NHS financially.
    Outcomes specific patient groups may benefit from targeted
    counselling to increase uptake of LARC: (i) Patients conceiving
    on the COCP (ii) 14–17 year olds (iii) Nulliparous women
    (iv) Patients with previous terminations.
    Discussion: Sixty-five percent of patients using no contraception
    or condoms, and 75% of women aged 18–22 years old were
    discharged with LARC. Only 32% of patients conceiving on the
    COCP were discharged with LARC, and only 40% of 14–17 year
    olds, with 53% being discharged on the COCP and one with
    condoms. Forty-two percent of nulliparous women were
    discharged with LARC. Patients with previous terminations were
    no more likely to be discharged with LARC.


Marie Klingberg-Allvin


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    FC14

    Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial

    Marie Klingberg-Allvin1 ,5, Amanda Cleeve1 ,2, Susan Atuhairwe3 ,4, Nazarius Mbona Tumwesigye3, Elisabeth Faxelid1, Josaphat Byamugisha3 ,4, Kristina Gemzell-Danielsson1 ,2
    1Karolinska Institutet, Stockholm, Sweden, 2Karolinska University Hopsital, Stockholm, Sweden, 3Makerere University, Kampala, Uganda, 4Mulago Hospital, Kampala, Uganda, 5Dalarna University, Dalarna, Sweden

    Objectives: We investigated the effectiveness and safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians.
    Methods: We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda. Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with first-trimester incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete abortion not needing surgical intervention within 14–28 days after initial treatment. The study was not masked. Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed effects model.  The trial was registered at ClinicalTrials.gov, number NCT01844024.
    Findings: From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife versus physician group was –0·8% (95% CI –2·9 to 1·4), falling within the predefined equivalence range (–4% to 4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse events were recorded.
    Conclusion: Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and effective as when provided by physicians, in a low-resource setting. Scaling up midwives’ involvement in treatment of incomplete abortion with misoprostol would increase access to safe postabortion care.


Judith Kluge


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    CS10.2

    RCOG Leading Safe Choices: Training abortion providers in South Africa

    Alison Fiander3, Judith Kluge1 ,2
    1University of Stellenbosch, Western Cape Province, South Africa, 2Tygerberg Hospital, Western Cape Province, South Africa, 3Royal College of Obstetricians and Gynaecologists, London, UK

    The Choice-on-Termination-of-Pregnancy ACT of 1996 changed laws in South Africa from highly restrictive to more liberal laws for abortion provision. It legalised abortion-on-demand for women in the first trimester and allowed abortion provision for socio-economic reasons, amongst others, up to 20 weeks gestation. The law also allowed trained registered nurses to provide both surgical and medical abortions in the first trimester. In the ensuing years, non-governmental organisations such as Marie Stopes and IPAS assisted the Department of Health with training of nursing staff. Following withdrawal from South Africa by some NGO's a void was left in comprehensive abortion care training. Additionally, other ongoing challenges to ensuring designated TOP facilities had trained staff to provide abortion services continued. In 2011 only 57% of designated abortion facilities were providing abortion services. A persistent high proportion of abortions are performed in the second trimester. Forty present of women who had a second trimester abortion had initially presented to a health facility in the first trimester but had the procedure delayed at the facility or by a requirement to refer to other health facilities. Women still have unsafe abortions, accessing illegal abortion providers. Unsafe abortions also occur in legal facilities due to lack of training and services failing to meet minimum standards.
    The RCOG Leading Safe Choices initiative aims to improve the competence and standing of abortion care providers. It has recently been implemented in Western Cape Province, South Africa with the training of master trainers in December 2015. Subsequent Comprehensive Abortion Care training was initiated in March 2016. The Best Practice paper on Comprehensive Abortion Care was included in the Western Cape Province Department of Health Abortion Policy in 2016. Progress regarding this initiative in South Africa will be presented.


Nadezha Kobzar


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    Adherence of health workers in the Republic of Kazakhstan to the use of hormonal contraceptives

    Nadezhda Kobzar, Nafisa Mirzaraimova, Hadi Leimoyeva Kazakhstan-Russian Medical University, Almaty, Kazakhstan - nafisa.mirzaraimova@mail.ru

    The number of abortions has reduced by 29% in the period 2000-2013 in the Republic of Kazakhstan (RK). However, abortion rate remains very high per 1000 of fertile age women: 2000 - 30.9, in 2013 - 20.8. Study goal: Identification of the incidence of hormonal contraceptive use in the RK. Study materials:Reports of the MoH RK covering female population health for 2000-2013, reports of pharmacies featuring sales volumes of hormonal contraceptives in the RK for 2004-2013. Study outcomes and their discussion: High rate of abortion per 1000 of fertile age women in the RK is due to low use of contraceptives. Thus, only 30.4% of reproductive age women used contraceptives in 2000, while in 2013 their proportion amounted to 38.2%. Within the structure of contraceptives used in 2000-2013 the first place belongs to IUDs. Regardless of their proved high efficiency the rate of use of hormonal contraceptives among women remains low in the RK. The given indicator made up 2.1% in 2004 and in 2013 - 2.2%. Conclusions: 1. Though abortion numbers have gone down in the RK its rate per 1000 of fertile age women remains rather high; 2. Use of contraceptives for unwanted pregnancy prevention is low. 3. Within the structure of contraceptive use in 2000-2013 the first place belonged to IUDs; 4. The use of state-of-the-art hormonal contraceptives remains inadequate, which implies that abortion remains the principal family planning method.


Riina Korjamo


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    FC01

    A randomised controlled trial of immediate initiation of contraception by levonorgestrel-releasing intrauterine system (LNG-IUS) after medical abortion - one year continuation rates

    Riina Korjamo1 ,2, Maarit Mentula1, Oskari Heikinheimo1 ,2
    1Helsinki University Hospital/ Obsterics and Gynecology, Helsinki, Finland, 2University of Helsinki, Helsinki, Finland

    Objectives: Immediate insertion of intrauterine device at the time of the surgical abortion results into higher uptake of effective contraception and prevent unintended pregnancies. We performed a randomised controlled trial comparing immediate (≤3 days) vs. delayed (within 2-4 weeks) insertion of the LNG-IUS after medical abortion.
    Method: Women ≥18 years requesting medical abortion and desiring LNG-IUS contraception were eligible to enter the trial, which was conducted at Helsinki University Hospital between Jan 30nd 2013 and Dec 31st 2014. Trial has registered to www.clinicaltrials.com, NCT01755715. The primary outcome was the LNG-IUS use at 1 year after abortion. Secondary outcomes were expulsions, further pregnancies and abortions.
    Results: Altogether 267 women were randomised to immediate (134) and delayed (133) insertion groups, of which 264 (133 and 131, respectively) were analysed. LNG-IUS was inserted in 127 (95.5%) women in the immediate and 111 (84.7%) women in the delayed insertion groups (OR3.81, 95%CI 1.48-9.83, p=0.004). The verified numbers of women continuing the LNG-IUS use at 1 year were 83 (62.4%) and 52 (39.7%), respectively (OR2.52, 95%CI 1.54-4.14, p=0.001). In the best case scenario (the use of LNG-IUS verified or LNG-IUS inserted) 113 (85.0%) women in the immediate, and 88 (67.2%) women in the delayed insertion group continued LNG-IUS use at 1 year (OR2.76, 95%CI 1.52-5.03, p=0.001). Numbers of total expulsions were 3 (2.3%) vs. 3 (2.3%) (OR0.98, 95%CI 0.20-4.97, p=1.00), partial expulsions 26 (19.5%) vs. 9 (6.9%) (OR3.29 95%CI 1.48-7.34, p=0.003), new pregnancies 6 (4.5%) vs. 16 (12.2%) (OR0.34 95%CI 0.13-0.90,p=0.027) and further abortions 4 (3.0%) vs. 5 (3.8%) (OR0.78 95%CI 0.21-2.98, p=0.75), respectively.
    Conclusions: Immediate insertion of the LNG-IUS after medical abortion resulted in a higher uptake and continuation rates of intrauterine contraception compared to delayed insertion, despite higher partial expulsion rates of LNG-IUS. Immediate insertion of the LNG-IUS decreased the 1-year pregnancy rates but did not affect the rate of further abortions.

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    Objective: To analyze long-term satisfaction to intrauterine contraception after medical induced abortion.


    Minimizing delay from medical abortion procedure to insertion of intrauterine contraception is a new approach to increase intrauterine contraception uptake and reduce subsequent unplanned pregnancies. Effect of this immediate insertion on womens satisfaction and quality of life is unknown. Materials and methods: Subanalysis of a randomized controlled trial. Total of 267 women were randomized to receive levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena, Bayer, Turku, Finland) immediately (?3 days) or later (2-4 weeks) after medical induced abortion during January, 2013 December, 2014 in Helsinki University Hospital, Finland. Selected demographic factors were collected. Women answered questionnaires concerning satisfaction and quality of life at follow-up visits three months and one year after LNG-IUS insertion. Results: Following three post-randomization exclusions, there were 264 participants. Of the immediate-insertion group 98/133 (73.7%) and the delayed-insertion group 78/131 (59.5%) women returned to the 3-month follow-up, and 89 (66.9%) and 63 (48.1%) to the 1-year follow-up. Median age was 27.8 (IQR 23.033.1) vs. 27.3 years (22.532.1), p=0.54. At 3-month visit the immediate-insertion group was more often satisfied or very satisfied with their contraception compared to the delayed-insertion group (89 [89.9%] vs. 61 [79.2], p=0.048). We found no difference at 1-year (71 [79.8%] vs. 47 [74.6%], p=0.45). Womens experienced health, as measured by visual analogical scale (0100 mm), at 3-month visit was 84 mm (median, IQR 77 91) vs. 87 mm (7795), p=0.19, and at 1-year visit 85 mm (7493) vs. 86 mm (7492), p=0.75. Conclusion: Immediate LNG-IUS insertion following medical abortion did not have a long-term effect on womens satisfaction with intrauterine contraception or experienced health. Loss-to-follow-up rate was high and may have produced a selection bias. However, these results endorse the feasibility of immediate initiation of intrauterine contraception following medial abortion.


Jasmina Kostoski


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    Nurse’s role in medical abortion up to nine weeks of pregnancy in a day hospital unit

    Jasmina Kostoski, Sanja Perić, Vlasta Slapničar University Medical Centre Ljubljana, Ljubljana, Slovenia - jasmina.kostoski@gmail.com

    Introduction: The Day Hospital is part of a Reproductive Unit which contains an operating room for aseptic interventions and three hospital rooms with 14 bed units. This is the main unit for all kind of abortions and minor operative procedures in gynaecology. The average annual number of patients is between 2500 and 2700. 1,232 abortions up to 10 weeks are performed, of which 766 medical abortions were recorded last year. Organization and workflow: Patients are coming to the Day Hospital with an already signed application for termination of pregnancy up to 10 weeks of gestation. A nurse will interview the patient in order to determine which kind of abortion will be the most appropriate (depending on the level of pregnancy, her expectations and any additional diagnosis). If medical abortion is appropriate, the patient is going back to the nurse who will give her a prescribed tablet of mifepristone. Together, they will make a plan for the further course of pregnancy termination considering the patient’s career and family responsibilities. The patient will not leave the hospital without having received all the needed spoken and written instructions from the nurse. Approximately 36-48 hours after taking the tablet, the patient is returning. After a brief interview in relation with the course of the first part of the medical abortion, the nurse will give the patient a tablet of NSAID and place the patient into the bed unit. After that the nurse or the resident will insert 4 tablets of misoprostol in her vagina. During that time, nurses are taking good care of the patient, helping to alleviate the possible pain and sickness by giving medications and controlling bleeding and pain. After 3 to 4 hours, the nurse is giving further instructions to the patient who will be able to safely leave the hospital.


Sandra Krause


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    CS14.1

    Tragically lacking: safe abortion care in humanitarian emergencies

    Sandra Krause
    Women's Refugee Commission, New York, New York, USA

    Formed in 1995, and currently comprising a network of over 1700 individual members from 450 agencies, the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) is a broad-based, highly collabourative coalition committed to expanding and strengthening access to quality reproductive health (RH) services for persons affected by conflict and natural disaster. Among populations affected by humanitarian crises, the IAWG documents gaps, accomplishments and lessons learned; evaluates the state of RH in the field; establishes technical standards for the delivery of RH services; builds and disseminates evidence to policy makers, managers and practitioners; and advocates for the inclusion of crisis-affected persons in global development agendas.
    The IAWG undertook a global review of RH in crises from 2012-2014 a decade after its first review from 2002-2004. The 2014 evaluation aimed to identify existing RH services, quantify progress, document gaps and determine directions for future programmes, advocacy and funding.  The evaluation is based on seven complementary studies which explore research, institutional capacity to address RH, changes in funding, implementation of the standard minimum priority RH services in a humanitarian emergency, comprehensive RH services in select settings in three countries, and select RH indicators from the United Nation High Commissioner for Refugee’s Health Information System. The IAWG 2014 global review represents a snapshot of RH in humanitarian emergencies.
    Findings from the IAWG 2014 global review show a major gap in the availability of safe abortion care despite the increased risks for unwanted pregnancy due to increased risks of sexual violence and lack of access to birth control as a result of displacement and disrupted health systems, in humanitarian emergencies. This presentation will focus on the gap in safe abortion care identified in the global review, published reasons for the gap, and IAWG’s initiatives to address safe abortion care in humanitarian settings.


Sandra Kroeze


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    FC32

    Comparing 200 μg and 400 μg sublingual misoprostol before surgical abortion; a Dutch single centre clinical pilot.

    Sandra Kroeze
    Stimezo Zwolle and ASK Mildredhuis Arnhem, Zwolle / Arnhem, The Netherlands

    Study Question. To compare efficacy and side effects of 200 μg and 400 μg sublingual misoprostol for cervical priming prior to first trimester surgical abortion.
    Summary Answer. This study indicates 200 µg misoprostol can be used for cervical priming prior to surgical abortion as the results showed fewer side effects but no difference in cervical dilatation in comparison to 400 µg misoprostol.
    What Is Known Already. Administration of misoprostol prior to vacuum aspiration reduces complications and morbidity in first trimester pregnancies. As a result, the Dutch society of abortion physicians (NGVA) decided to adopt cervical priming with misoprostol in their standard operating procedure (SOP). However, the use of misoprostol is associated with various adverse effects such as abdominal pain, shivering and nausea. A study in the field of Prevention of Postpartum Hemorrhage have suggested that 200 µg misoprostol is just as effective as a 400 µg dose, but with a reduction of adverse effects. This could also be the case for cervical priming prior to surgical abortion.
    Study Design, Size and Duration. This pilot was performed in a Dutch abortion clinic. In regard to the upcoming new SOP for first trimester abortions, all women attending this clinic were assigned to receive either 200 μg or 400 μg sublingual misoprostol prior to surgical abortion. The primary outcome was the complexity of the procedure (an efficacy parameter ), scored as dilatation on a scale of 1 to 5 and the secondary outcome was the presence of side effects before, during and after treatment. Pain registration was performed by the standardised VAS score. The pilot took place between October 2014 and June 2015.
    Participants, Setting and Method. Women requesting a surgical abortion between 5 and 13 weeks of gestation were recruited for this pilot. Exclusion criteria were any contraindication for misoprostol or the administration of breastfeeding. Gestational age was established by ultrasound examination. The allocated dose of misoprostol (200 µg or 400 µg) was self-administered 1 hour prior to treatment. The women either received 1 tablet of 200 µg misoprostol or 2 tablets of 200 µg. Vacuum aspiration was performed under general or local anaesthesia according to clinical routine.
    Main results. In total, 280 women were enrolled in this pilot. These women were divided into two groups; a group receiving 200 µg of misoprostol (n=144) and a group receiving 400 µg of misoprostol (n=136) for cervical priming. Cervical dilatation was measured based on a scale from 1 (manual dilatation was still needed) to 5 (no manual dilatation was needed). There was no difference found between both groups regarding cervical dilatation. This indicates that a difference of misoprostol dosage, when used for cervical priming, does not alter the complexity of the procedure. For the second objective of this study, the prevalence of adverse effects was measured by a questionnaire prior to treatment. A total of 145 side effects were measured in the 200 µg group and a total of 162 in the 400 µg group. 32% of the women who received 200 µg misoprostol experienced no side effects, while this percentage was lower in the 400 µg group (21%). There was a higher prevalence of shivering in the 400 µg group (14%) compared to the 200 µg group (9%) and a greater percentage of women in the 400 µg misoprostol group experienced nausea as a side effect (11,7%) in comparison to the women receiving 200 µg Misoprostol (4.8%). There was no difference in the prevalence of abdominal pain and the dryness of the mouth.


Anu Kumar


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    CS06.1

    Abortion Stigma: What are we talking about?

    Anu Kumar
    Ipas, Chapel Hill, NC, USA

    This workshop will discuss the concept of stigma and its application to abortion.  The concept of stigma has been used in areas such as mental illness and sexual identity.  Research and action on the topic of abortion stigma is growing with the aim of reducing stigma so that women can access safe abortion care without shame.  Abortion stigma is defined as a negative attribute, ascribed to women who seek to terminate a pregnancy and anyone related to abortion that ‘marks' them as inferior.   Abortion stigma, however, can also affect providers, facilities and those close to women who have had an abortion.  The various levels in which abortion stigma operates will be discussed using an ecological model.  A key aspect of research has been the development of the Stigmatising Attitudes, Beliefs and Actions Scale (SABAS) to measure abortion stigma at the community level.  Research on stigma among abortion providers will also be presented.  Programmematic strategies to reduce abortion stigma developed by Ipas and others will be shared.  Finally, participants will learn more about inroads, The International Network for the Reduction of Abortion Stigma and Discrimination.  The network is an online resource for information, ideas and contacts on the topic.


Dilfuza Kurbanbekova


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    Using research to increase access to medical abortion in Uzbekistan

    Diffuza Kurbanbekova Women's Wellness Center, Tashkent, Uzbekistan - dilfuzabegim@yahoo.com

    The Republic of Uzbekistan, located in Central Asia, is the most populous country in the region with 28 million people. More than a quarter of the population are women of reproductive age. Abortion in Uzbekistan has been legal for over 50 years and abortion services are available without restriction in the first 12 weeks of gestation. Abortion in the second trimester (up to 24 weeks) is available only on broad medical and select socioeconomic grounds. Until recently, the prevailing methods for termination of pregnancy were manual vacuum aspiration (MVA) using outdated equipment and dilatation and curettage (D&C) under local anaesthesia. Although mifepristone has been registered in the country since 2005, there were no national guidelines on medical abortion provision. In addition, the lack of trained providers and absence of an established distribution system for mifepristone inhibited its use on a wide scale. In 2007, Gynuity Health Projects launched a series of collaborative activities in Uzbekistan with the goal of increasing access to medical abortion services in the country. Through its clinical research projects and trainings, Gynuity introduced an evidence-based regimen, trained providers in provision of early medical abortion and expanded access to medical abortion services by conducting a study on an alternative method of follow-up. Additional collaborative activities included dissemination meetings to present study findings and assistance in developing national protocols. This presentation will describe how clinical research has contributed to increased access to medical abortion in Uzbekistan.


Valentyna Kvashenko


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Adriana Lamackova


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    Developments in legal regulation of abortion in Europe

    Adriana Lamackova Center for Reproductive Rights, New York, USA - ALamackova@reprorights.org

    While most European countries continue to provide abortion without restriction as to reason and/or on broad grounds, including socio-economic grounds, the past few years have seen a dramatic rise in legal proposals aiming at restricting abortion laws. One type of proposal seeks to eliminate legal grounds for abortion, while the other type of proposal seeks to impose procedural barriers on access to abortion such as mandatory waiting periods and biased counseling requirements. Refusals of care on the grounds of conscience are another procedural barrier significantly affecting women’s access to legal abortion services that has been on the increase in Europe. This presentation will provide an overview of these restrictions that have been adopted in some countries. It will also address standards developed by United Nations and regional human rights bodies, as well as by the World Health Organization with regard to access to abortion.


Uta Landy


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    PS05.2

    How can a Fellowship in Family Planning be established in Europe?

    Uta Landy
    Fellowship in Family Planning and Ryan Residency Training Programme, San Francisco, CA, USA

    Subspecialisation has expanded with the growth of evidence-based practice and complexity in medical care in the US. There are now 127 accredited subspecialties across all medical disciplines with four in Obstetrics and Gynecology: Reproductive Endocrinology and Infertility, Maternal Foetal Medicine, Oncology and, most recent, Female Pelvic and Reconstructive Surgery. The Family Planning Fellowship is exploring potential accreditation and certification.
    Why did we create a subspecialty in family planning? Historically, US medical schools gave clinical care, training, research and advocacy in abortion and contraception little attention. Since the demand for pregnancy termination was mostly met by freestanding clinics, few teaching hospitals offered or taught abortion or complex contraception.
    In response, we launched two national initiatives. The first, the Fellowship in Family Planning, was started at UCSF in 1990 and now counts 31 sites in leading academic ob-gyn departments. It has produced a new generation of leaders in the field who have advanced abortion and contraceptive research, clinical training, and advocacy. Our 300 graduates have helped launch 90 new academic training programmes through a parallel initiative, the Ryan Residency Training Programme.
    While the results of our model may serve as an inspiration to our European colleagues, our approach may not be replicable in the European context.  There are certain steps required to ensure fellowship success. Leaders in the field must be motivated to serve as champions of the effort, and professional organisations, e.g. ESC, must lend their official support. The service delivery system must allow for clinical training and sources of research funding must be identified. Advocacy for reproductive justice should become part of training.  Finally, the structure and settings, clinical care, teaching and research of the family planning fellowship must be substantial enough for academic centres and the service delivery community to recognise it as an essential component of reproductive health.

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    Integrating abortion and contraception training into medical education: the Family Planning Fellowship and Ryan Residency Training Programs in the US

    Uta Landy The Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences; University of California, San Francisco, San Francisco, CA, USA - landyu@obgyn.ucsf.edu

    Although abortions were legalized in the United States in 1973, the focus was on service access, not training. As a result, the number of teaching hospitals offering abortion services and conducting research declined steadily. A training mandate was finally passed by the US professional standard setting organizations in 1995 when a lack of trained physicians was noted. The mandate has been affirmed regularly despite the increasing political interference with abortion care and teaching. The Fellowship in Family Planning was founded to ensure future generations of leaders for abortion services, research, teaching and advocacy. During the past 23 years, its graduates have ensured the integration of family planning into the curriculum of medical students and postgraduates, conducted seminal research in abortion and contraception, contributed to the family planning work of national and international governmental and non-governmental organizations and become advocates for evidence-based policies. A parallel organization, the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning, was founded in 1999 to support academic programmes in complying with the new training standards. Since its inception, it has initiated formal programmes in 78 departments of obstetrics and gynaecology to ensure the clinical competence in evidence-based approaches in family planning and abortion for future generations of OBGYNs. Systematic training is an essential aspect of ensuring that future physicians are clinically competent, understand and contribute to research, understand the medical, social and psychological aspects of uterine evacuation and contraception and become advocates for evidence-based policies.


Elin C. Larsson


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    Experiences of providing abortion care and contraceptive counselling to immigrant women in Sweden

    Elin C. Larsson1, Kristina Gemzell-Danielsson1, Birgitta Essén2, Marie Klingberg-Allvin1 ,3 1Dept of Womens and Childrens Health, Karolinska Institutet, Stockholm, Sweden, 2Dept of Womens and Childrens Health,Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden - elin.larsson@ki.se

    Universal access to health care services is a public health goal in Sweden and one cornerstone is to promote universal access to safe and secure sexuality and good reproductive health. Immigrants represent 15% of the total Swedish population. Evidence suggests that immigrants might have different sexual and reproductive health (SRH) care needs as compared to non-immigrants. Previous research indicates sub-optimal reproductive health care and adverse SRH outcomes among immigrants living in high-income settings. Family size and contraceptive use is marked by deeply rooted cultural values and norms. A culturally competent approach in service provision has been described to improve reproductive health care utilization among immigrant women. Unintended pregnancies and induced abortions are considered a public health problem and add substantial costs to both the individual women and society at large. Research from Nordic settings has shown higher rates of induced abortion among immigrant women as compared to native-born women. Objective: The aim of this ongoing study is to explore health care providers’ experiences of abortion care and contraceptive counselling to immigrant women in Sweden. Method: Data collection will be completed in September 2014. Individual interviews are carried out to reach a total of approximately 30 health care providers involved in abortion care. A purposive sampling technique is being used to recruit participants with a variety of backgrounds. An inductive approach, using thematic analyses will be applied. Conclusions: Healthcare providers experiences of abortion care and contraceptive counselling has not been described earlier. Healthcare providers are key actors in order to achieve equity in SRH. The results from this study will be used to revise health promotion programmes and healthcare provision to meet immigrant women’s needs and is expected to increase equity within the healthcare system in Sweden.

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    FC22

    Are women with a foreign background more likely to have an induced abortion as compared to nonimmigrant women? A study conducted in Stockholm, Sweden

    Elin Larsson1 ,2, Karin Emtell-Iwarsson1, Kristina Gemzell-Danielsson1, Birgitta Essén2, Marie Klingberg-Allvin1 ,3
    1Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden, 22Department of Women’s and Children’s health/ IMCH, Uppsala University, Uppsala, Sweden, 33School of Education, Health and Social Studies, Dalarna University, Falun, Sweden

    Objectives: To examine if women with a foreign background were more likely to have an induced abortion as compared to nonimmigrant women.
    Methods: A cross sectional study conducted in eight abortion clinics in Stockholm County during January to April 2015. The eight clinics conduct more than 90% of all abortions in Stockholm County. Inclusion criteria were all pregnant women 18 years old or above, seeking for induced abortion. Exclusion criteria were individuals under 18, not decided about having an abortion and women who had travelled to Sweden only to have an abortion. Midwives at the clinics interviewed the women in the end of the first visit, using a standardised questionnaire that they filled in. When needed a professional interpreter was used.
    Results: A total of 787 women were included in the study, 67% of the participants were nonimmigrants, 23% were foreign born and 10% were second-generation immigrants. These proportions were significantly different from the general population. There was a significant higher incidence of abortion among second-generation immigrants. Immigrant women were older as compared to non-immigrant women. However, immigrant status was not a significant predictor for having a subsequent abortion. However, immigrant women from certain countries were over represented among the women seeking abortion care and did not correspond to the proportion in the general population. In addition, contraceptive use ever in life, and at time of conception was lower among immigrant women as compared to non-immigrant women.
    Conclusions: Contrary to previous European research immigrants were less likely to have an induced abortion as compared to non immigrants, but the study suggests that second generation immigrants are presenting for induced abortion in higher numbers. More research is needed to understand the reasons for this and why access to contraceptives is lower among immigrant women.


V. Lavoue


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    Screening for chlamydia trachomatis using
    self-collected vaginal swabs at a public pregnancy
    termination clinic in France: results of a screen-
    and-treat policy
    Lavoue´, V; Vandenbroucke, L; Lorand, S;
    Pincemin, P; Bauville, E; Boyer, L; Martin-
    Meriadec, D; Minet, J; Poulain, P; Morcel, K
    CHU de Rennes, Centre IVG, Service d’obste´trique, Hoˆpital Sud,
    France
    Objective: To assess the prevalence of Chlamydia trachomatis
    (CT) infection and the risk factors for CT infection among
    women presenting for a termination of pregnancy (TOP) at a
    clinic in France.
    Methods: Women seeking surgically induced TOP were
    systematically screened by PCR on self-collected vaginal swabs
    between January 1, 2010, and September 30, 2010. CT-positive
    women were treated with oral azithromycin (1g) prior to the
    surgical procedure.
    Results: Out of the 978 women included in the study, 66 were
    CT-positive. The prevalence was 6.7% (95% CI 5.1–8.3%). The
    risk factors for CT infection were the following: age <30 years
    (Odds ratio [OR] = 2.0 [95% CI 1.2–3.5]), a relationship status of
    single (OR = 2.2 [95% CI 1.2–4.0]), having 0 or 1 child
    (OR = 5.2 [95% CI 2.0–13.0]), not using contraception (OR = 2.4
    [95% CI 1.4–4.1]) and completing 11 weeks or more of gestation
    (OR = 2.1 [95% CI 1.3–3.6]). Multiple logistic regression
    indicated that four factors – having 0 or 1 child, a single
    relationship status, no contraceptive use and a gestation of
    11 weeks or more – were independently associated with CT
    infection. The rate of post-TOP infection among all patients was
    0.4% (4/978).
    Conclusions: These results reveal a high prevalence (6.7%) of CT-
    positive patients among French women seeking induced abortions.
    A cost-effectiveness study is required to evaluate this screen-and-
    treat policy.


Vincent Lavoue


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    Scoring system avoids Chlamydia trachomatis over-screening in women seeking surgical abortion

    Vincent Lavoue1, Marie Catherine Voltzenlogel1, Camille Leonardon1, Jacques Minet1, Patrice Poulain1, Margaret Redpath2, Cyrille Huchon3 1Teaching Hospital of Rennes, Rennes, France, 2McGill University, Montreal (Qc), Canada, 3Université de Montréal, Montreal (Qc), Canada - vincent.lavoue@chu-rennes.fr

    Objective To develop and validate a predictive score to avoid unnecessary screening and prophylactic antibiotic use in abortion clinics by identifying a group of women who are at very low risk of Chlamydia trachomatis (CT) infection. Methods: This population-based retrospective study includes 1000 women who underwent surgical abortion between January and September 2010. The main outcome measure was the rate of CT infection among women seeking an induced abortion according to socio-demographic and clinical data. The score was developed by using 2/3 of the dataset as the derivation sample to identify the strongest predictors of CT. An ROC curve established cutoffs, and applied the score to the remaining 1/3 (validation sample). Results The rate of CT infection was 6.7%. Three criteria were independently associated with CT: gestation >10 weeks [adjusted odds ratio (aOR), 1.96; 95% confidence interval (95% CI), 1.06-3.64], not using contraception (aOR, 2.70; 95% CI, 1.41-5.16) and having 0 or 1 child (aOR, 3.46, 95% CI, 1.34-8.93). The CT score was based on these three criteria. The low risk group was derived from values of the score [probability of CT, 1.3% (95% CI, 0-3.0)]. Application of these criteria to the validation dataset confirmed the diagnostic accuracy of the score (probability of CT, 0%). Sensitivity was 100% and specificity 26.9% for the score in the validation dataset. Applied to the validation dataset, the score avoided 25.4% of CT tests and screened of 100% of CT-infected women before surgical abortion. Conclusions This easy-to-calculate score may prove useful for avoiding CT test in 25% of patients seeking surgical abortion.


Zlata Licer


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    Social counselling in the field of the rights to family planning and to termination of pregnancy

    Zlata Licer, Lili Dreu University Medical Centre Ljubljana, Division of Gynaecology, Ljubljana, Slovenia - zlata.licer@kclj.si

    The right to family planning and to artificial termination of pregnancy is a basic human right. Social counselling on an individual basis should enable people to choose freely to have children and to have access to social rights during periods of distress. Expert assistance in decision-making is necessary in different stages of life, especially among vulnerable groups of women, which consist mainly of a) adolescents, b) women with a pregnancy over 10 weeks and c) women over 35 years of age. Counsellors must treat their sexual and reproductive health as their basic human right and take into account all their needs. For example, adolescents must have a right to comprehensive sex education, education for equal gender relations and youth-friendly and accessible reproductive healthcare. Women with a pregnancy over 10 weeks are usually in a difficult social situation while older women tend to feel more emotionally vulnerable. In the field of artificial termination of pregnancy counsellors need to be especially attentive to provide their clients with all the relevant information which enables the clients to make autonomous decisions in relation to their reproductive health.


Jenni Liikanen


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    Contraception after delivery: mothers should be better counselled about its need and alternatives

    Jenni Liikanen1, Satu Suhonen2 1Department of Social Services and Health Care, City of Helsinki, Helsinki, Finland, 2Centralized Family Planning, Department of Social Services and Health Care, City of Helsinki, Helsinki, Finland - satu.suhonen@hel.fi

    Objectives: Finland has low rates of induced abortions (8.6/1000 women aged 15-49 years, 2012). In Finnish guidelines of maternal care, contraceptive counselling at postpartum visits is emphasized. However, more than 10% of induced abortions are carried out in women who have given birth recently. Therefore the timing and content of this counselling can be questioned. The aim of this study was to examine women´s knowledge about return of fertility, options and use of contraception after delivery. Method: A cross-sectional questionnaire study was conducted 6 months after delivery at two maternity care units in the city of Helsinki, Finland. Results: 45 women returned the questionnaire during a 2 month period (response rate 55 %). Return of fertility after delivery in women not breastfeeding was poorly known. Only 16% (N=7) were aware of all the criteria of LAM (lactational amenorrhoea method) as a family planning method. From all available contraceptive methods most commonly only one was recommended. Condoms was the most popular contraceptive method (44.5%) used. Initiation of efficient contraception was delayed. The knowledge of the possibility of hormonal emergency contraception during breastfeeding was poor. Conclusions: Information about return of fertility, need for contraception, breastfeeding as a family planning method and available effective contraceptive methods is not given sufficiently after delivery. Thus there is an increased risk of unplanned pregnancy. Contraception after delivery and its need must be discussed and initiated early enough if a new pregnancy is not planned. The number of induced abortions during the postpartum period could be reduced if contraceptive counselling were to be improved, correctly timed and supported by the healthcare system. This promotes the psychological, physical, social and economical well-being of the woman and her family and is also cost-effective for the healthcare system.


Eduardo Lopez Arregui



Edjenguele Lotti



Tahir Mahmood



Nausikaä Martens


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Lisa McDaid


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    Abortion remains a contentious and stigmatised medical procedure, despite being a commonly performed gynaecological procedure. 

    It is often framed as a moral, religious or legal issue rather than a medical one and is reinforced at structural, policy, community, and individual levels.  Abortion stigma is a multifaceted phenomenon, impacting on the experiences of women who undergo abortion and the health care professionals involved in abortion care.  Public discourses focussed on particular types of abortion that are viewed as problematic – ‘repeat, ‘late’ – are further stigmatising and potentially discriminating.  Even the language itself is inherently judgemental.  This presentation will review contemporary evidence of the experience of abortion stigma among women and providers, the implications of this for health and wellbeing and inequalities, and how abortion stigma can be countered and challenged.

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    PS03.3

    Challenging stigma and the undesirable: late presentation and multiple abortions

    Lisa McDaid
    University of Glasgow, Glasgow, Scotland, UK

    ‘Repeat' and ‘late' abortion are often framed as problematic, and there is continuing concern from a policy and provision perspective about the proportion of women presenting for ‘repeat' and ‘late' abortions. This presentation draws on findings from two studies of women in Scotland to demonstrate how and why such framings should be challenged.
    In 2013, we completed an audit of 281 women presenting for abortion at ≥ 16 weeks gestation in Scotland and conducted qualitative interviews with 23 of these. Women presenting later were young and a significant proportion were from more deprived areas. Our qualitative analysis suggested that reasons for later presentation were complex, varied and highly context-specific, with the majority having not expected to become pregnant. Factors which necessitated later abortion were often unforeseen and thus not easily amenable to intervention.
    In 2015, we collected questionnaires from 1662 women presenting for abortion and completed qualitative interviews with 23 women identified as having undergone a previous abortion in the preceding two years. 34% reported a previous abortion, while just under half of these reported two or more in the previous two years. Age, education, deprivation and experience of domestic abuse were associated with having had more than one abortion. Our qualitative data suggested more commonalties than divergences between experiences of women who have undergone more than one abortion and those who have not.
    The presentation will address how a disproportionate focus on ‘repeat' and ‘late' abortion' exacerbates stigmatisation and distracts from a more productive focus on improving abortion provision, when in fact it appears women in this position are no different from all women seeking abortion. I will conclude by discussing how efforts could be better spent focusing on how to improve the experiences of women seeking abortion and working to challenge prevailing, negative, social attitudes to abortion.


MRI Mejia


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    Is there possible sexism in termination of
    pergnancy decision-making?
    Mejı´a, MRI
    Centro de Atencio´n Integral a la Pareja, A. C, Mexico
    In April 2007 voluntary termination of pregnancy (TOP) up to
    week 12 of gestation was legalised in Mexico City. Since its
    decriminalisation we have observed at least four hegemonic
    attitudes in male sexual partners with respect to reproductive and
    contraceptive decision-making in the medical services of Centro
    de Atencio´n Integral a la Pareja, A. C: (i) those who go with their
    partner and support the decision; (ii) the ones who decide and
    pressure their partner, (iii) those who do not support the decision
    and do not go with their partner in order to prevent her from
    having an abortion and (iv) those who do not support the
    decision but who go with their partner.
    There is insufficient research on the subject of males’ role in
    reproductive decision-making and its implications on males’
    subjectivities and in their partners’ bonding. This study responds
    to the following questions: In what circumstances do men support
    or deny women’s decision-making? What is the perception of
    women regarding their partners’ participation in the process?
    Within the context of legalisation and in light of new ways of
    sexual and loving bonding practices, is it important to integrate
    males and create friendly services that allow people to express
    their needs and emotions without abuse. Is it fundamental, as
    well, to review their contributions to the process of women’s
    citizenship within this context? This study acknowledges the
    fundamental role of men in the processes undergone by women,
    despite the lack of services to integrate and strengthen the
    democratic advance in equity contexts.

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    Taking care of teenage termination of pregnancy
    during the second trimester of pregnancy with
    solidarity
    Zavala, AMC; Mejı´a, MRI; Zavala, AMC
    Centro de Atencio´n Integral a la Pareja, A. C, Mexico
    If we think that termination of pregnancy (TOP) within the
    second trimester is only an issue of public policy or legality, we
    would minimise a more complex problem of a sexual modern age.
    If we consider that TOP within the second trimester of pregnancy

    presents a higher morbi-mortality risk than the first trimester of
    pregnancy, we could think that it is urgent to create alternative
    spaces to facilitate access to services for a teenage population. It is
    also urgent to train well prepared professionals to prioritise this
    topic within the present conditions of poor countries or emerging
    citizenships with sensibility. However, the tendency of legal
    openness–modern and conservative–has set important limits in
    order to reduce this phenomenon. Most research focuses on
    service providers and moral codes that rule contemporary science
    instead of focusing on the women who take advantage of those
    services. In this paper we will present the results of a qualitative
    and quantitative analysis of 100 teenagers who had a TOP in both
    clinics of the Centro de Atencio´n Integral a la Pareja, A. C. during
    the second trimester within a legal context where a woman’s
    decision is only possible up to week 12. This will lead us to
    discuss and contribute the teenagers’ experiences living in contexts
    of vulnerability which include legal restrictions, stigmatisation,
    and a lack of recognition of women as people in charge of their
    lives and sexuality.


C. Melville


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    Interval insertion of IUDs after induced termination
    of pregnancy: do women come back?
    Melville, C; McInally, J; Struthers, G; Crombie, A
    NHS Ayrshire & Arran, UK
    Background: Long-acting reversible contraceptive methods are
    recognised as the most effective methods of contraception. Our
    termination of pregnancy (TOP) service offers IUD insertion at
    the time of surgical TOPs however IUD insertion is not available
    at the time of medical TOP. In 2010 we launched a post-TOP
    IUD fitting service. Women are offered an appointment 28 days
    after their medical procedure in line with FSRH guidance. We
    reviewed this service in order to inform future provision and to
    determine whether women would return for this appointment.
    Methods: A retrospective review of cases was performed using the
    electronic patient record (Eclipse) and the ward appointment
    diaries. The number of IUD appointments arranged, the number
    of patients who attended, and the type of IUD inserted were
    collected for the first 12 month period of the service (January–
    December 2010).
    Results: In the first year of the service, 76 IUD fitting
    appointments were made for women after induced TOP. Of these
    76, 29 women attended (38%). The DNA (did not attend) rate
    was 62%. Nineteen IUS devices were inserted and 10 copper
    IUDs.
    Conclusion: Although the DNA rate of 62% is high, this is
    reflected in other similar services and for other follow up
    appointments after induced TOP. Ideally, IUD insertion would be 

    available at the time of all induced TOPs, however with our
    current staffing model this is not possible. To increase attendance
    at the IUD service, we recommend using a text reminder service.


Barbara Mihevc Ponikvar


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    Modern contraception use and induced abortion rate in Slovenia

    Barbara Mihevc Ponikvar, Sonja Tomšič National Institute of Public Health, Ljubljana, Slovenia - barbara.mihevc@nijz.si

    Objectives: Knowledge about contraception, access to contraception and quality of family planning services influence induced abortion rate. With this analysis we want to present the current situation and the trends in induced abortions rate and contraception use in Slovenia. Methods: For this analysis we used the data from the national Information System on Fetal Deaths and Database on prescription drugs. These Information Systems contain data on all fetal deaths and all drugs that are prescribed in Slovenia. Results: Hormonal contraception is nowadays the most widespread form of contraception in Slovenia. Throughout the last decade the use remained rather stable but with changes in different age groups. An increase was observed in women aged 15-24 years and a decrease in the age group 30-39 years. In 2012 162 per 1000 women in the childbearing period used this contraception, most prevalently in the age group 20-24 years. 94 % of prescribed hormonal contraception was in the form of a contraceptive pill. Among contraceptive pills 92 % were combined hormonal contraceptives, most commonly with a combination of ethinylestradiol and drospirenone. Intrauterine contraception is gaining in importance in the last decade. The induced abortion rate in Slovenia reached its peak in 1982, since then the rate is steadily declining. In 2012 it was 8.7 per 1000. The highest abortion rate is among women in the age group 25-34 years. There are differences in abortion rates between regions and between women from different educational groups. Conclusions: In the last few decades patterns of use of contraceptive methods have changed significantly in Slovenia. The use of hormonal contraception is still increasing in younger women, but has fallen in women older than 30 years, which can be explained by increasing use of intrauterine contraception. Abortion rates have been declining since 1982 and reflect good availability and use of modern contraception.


Sarah Millar


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    FC11

    Evaluation of two low sensitivity urine pregnancy tests (1000 IU) used for self assessment following early medical abortion

    Sarah Millar, Sharon Cameron
    Chalmers Centre, Edinburgh, UK

    Introduction: The majority of women who have early medical abortion (EMA) at our service choose to confirm the success of the procedure by “self assessment” (a self-performed low sensitivity urinary pregnancy (LSUP) test at home two weeks after EMA). Women contact the abortion service if they have an invalid or positive result or symptoms of ongoing pregnancy. In 2014 we changed from a double cassette LSUP (Babyduo) to a single window LSUP (Check4) (both Quadratech diagnostics, UK). We predicted the Check4 test would be easier for women to use and interpret.
    Aims: To determine if the Check4 test improves the detection of ongoing pregnancies when compared with Babyduo and if there are any differences in reported invalid or positive results between the two tests.
    Methods: A retrospective database review identified women who had EMA “self assessment” in the 10 months before and 10 months after the introduction of the Check4 test. Fishers exact test and descriptive statistics were used for data analysis.
    Results: 1047 women were identified (n=492 Babyduo group and n=555 Check4 group). There were 2 ongoing pregnancies in the Babyduo group and 3 in the Check4 group. Significantly more invalid tests were reported in the Babyduo (n=18, 3.6%) than the Check4 group (n=6, 1.1%) (p=0.0064). Significantly more positive tests tests were reported in the Check4 (n=19, 3.4%) than the Babyduo group (6, 1.2%) (p=0.0244).
    Conclusion: The introduction of the Check4 LSUP has not altered the detection rates, or time to detection, of ongoing pregnancies. It has, however, been associated with fewer attendances for ‘invalid’ results and more for positive results. These findings may reflect that the single window Check4 test gives less margin for error in interpretation than the former double window test. We will continue to use the Check4 LSUP for EMA “self assessment” for this reason.


H Missey-Kolb



Pendo Mlay


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    CS10.3

    Leading safe choices in Tanzania

    Pendo Mlay1, Alison Fiander2, Emma Simpson2, Nia Shepherd2
    1KCMC, Kilimanjaro, Tanzania, 2RCOG, London, UK

    Introduction: Disproportionately, maternal and neonatal morbidity and mortality in sub-Saharan Africa is significantly higher compared to the rest of the world. In Tanzania the estimated number of unsafe abortion is 36 per 1000 women of reproductive age and the National CPR is <34%, while 25% of married women have unmet need for family planning. Provision of effective family planning and postabortal care represents an important strategy to mitigate this maternal health burden. LSC initiative aims at improving access to effective family planning and Comprehensive Postabortion Care. Methods: The programme has three primary goals: first is the promotion of best practice in postpartum family planning (PPFP) and comprehensive postabortion care (CPAC) through development and distribution of Best Practice Papers (BPP); secondly, increasing professional competency in PPFP and CPAC through training and supervision of providers; thirdly, promoting professional respect for providers working in reproductive sexual health through accreditation and certification. A team of local and RCOG experts worked on developing a curriculum using country policy and guidelines, which will be piloted in 4 health facilities in Kilimanjaro and Dar es Salaam regions.
    Expected outcome: LSC intends to influence policy makers and health care providers to set up a regional framework that will meet contraceptive needs for women during the postpartum and postabortal period. Overall expectation of this initiative is to increase awareness and uptake of effective family planning.
    LSC Progress in Tanzania: March 2016, MOHSW and PPFP stakeholders convened in Dar-es-salaam to discuss PPFP issues and agreed to have a harmonisation meeting early May 2016. This was held in Bagamoyo to harmonise LSC and MOHSW curriculums and as a result, one document will be used to train all HCW in Tanzania with Master training set for July 2016.  Further progress will be presented.


Mark Molina



N. Mullin


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    Do women attending a termination of pregnancy
    clinic wish to see the ultrasound scan image of
    their fetus?
    Mullin, N; Prabakar, I
    Countess of Chester Hospital NHS Foundation Trust, UK
    Objective: In our National Health Service termination of
    pregnancy (TOP) clinic we have noticed an increasing number of
    women and their partners asking to look at the ultrasound screen
    during their gestational dating scan and some women have also
    asked for a photograph.
    Method: A prospective pilot study was carried out to discover
    more about our patients’ wishes and their experience of
    ultrasound during their pre-abortion consultation.
    Results: Over 3 months, 53 questionnaires were returned,
    response rate 47% (53/112). All women who completed a
    questionaire had a first trimester TOP, mean age 25 years, range
    15–44 (women with a miscarriage were excluded). The majority of
    respondants, 94% (50/53) were expecting a scan; 32 women
    (60%) did not want to view the ultrasound image or have a

    photograph. The remaining 20 women (one did not respond) said
    they wished to view the image but only seven women actually did
    look at the ultrasound screen, and nine women wanted a
    photograph (median age 19 years, range 16–23). All the women
    were satisfied with the way the scan was carried out and with
    their care.
    Conclusions: Generally women do not want to see an image of
    their fetus when they attend a TOP service. However, a minority
    of younger women would like the opportunity to look at the
    image and this should be allowed as it may be helpful to some
    women. We now inform clients that they may look at the
    ultrasound screen if they wish; a partner may view the screen only
    with the woman’s permission. We do not provide a photograph
    due to cost.

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    What are the contraceptive issues for women conceiving too soon after a live birth, miscarriage or abortion?

    Nicola Mullin, Suzanne Kirkwood, Andrea Brockmeyer Countess of Chester Hospital NHS Foundation Trust, Chester, Cheshire, UK - nicola.mullin@btinternet.com

    Background: Timely access to contraceptive advice and supplies is important for couples following a live birth (LB), miscarriage (M) or abortion (A) to prevent another pregancy too soon. There is national guidance on postnatal care. Method: Women who had an unplanned and unwanted pregnancy within 12 months of their last pregnancy received standard abortion care but were asked 5 questions about the quality/timing of contraceptive advice given previously and any problems accessing or using their chosen method of contraception. Results: Of 40 women identified, 28 previously had a live birth, 6 a miscarriage, 6 had an abortion. Overall, all women who had had an abortion and all but one women who gave birth remembered receiving contraception advice, but only 50% (3/6) women who had had a miscarriage received advice. LB group: 16 women conceived within 6 months and 12 conceived 6-12 months later. Thematic analysis revealed only 50% recalled advice being helpful. Issues: health professionals assuming parous women knew about contraception or were going back to a previously used method or the advice given was too early to be useful. Several women had difficulty obtaining pills or getting an appointment to have an implant or IUD/IUS fitted. Miscarriage group: 3 women conceived within 3 months and one commented ‘that she didn't know it was possible to conceive so quickly'. Two women found the miscarriage particularly traumatic and stated that both they and the staff found it difficult to talk about contraception. Women having a repeat abortion conceived later than the other groups (after 8-12 months). They reported difficulties using contraception and several stopped the long-acting reversible (LARC) method provided at the earlier abortion. Conclusion: The quality of postnatal contraception provision needs to be improved for women who give birth or have a miscarriage. There is a high uptake of LARC in our abortion service but women need more support managing side effects to improve continuation rates.

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    What is the best way to provide women with postnatal contraception?

    Nicola Mullin, Rebekah Hughes Countess of Chester Hospital NHS Foundation Trust, Chester, Cheshire, UK - nicola.mullin@btinternet.com

    Background: Many women attending our National Health Service abortion service reported difficulties with using contraception, particularly the women who had had an unplanned pregnancy within 12 months of giving birth. Aims: To discover if women know how soon they should resume contraception postnatally. To understand when and how women prefer to receive information about contraception and contraceptive supplies. Method: A prospective questionnaire was offered to pregnant women accessing an English hospital-based antenatal clinic. The questionnaire was also completed by postnatal women and included a contraceptive ‘pack' of information and condoms. Results: There were 106 completed questionnaires in the antenatal (AN) group (1 refusal). In the postnatal (PN) group 50 women completed questionnaires (no refusals). Most women were aged 21-30 and over 50% in both groups had other children. Very few women could recall having received any kind of information about postnatal contraception: 16% (17/106) AN and 18% (9/50) PN. The majority of women thought contraception should be started as soon as sex was resumed after delivery; however, the knowledge of the effects of breast feeding and when there was a risk of conception if not breast feeding was low. Many women had already decided on their preferred contraception, 38% (40/106) AN and 52% (26/50) PN, including 3 women who wished to be sterilised (2 were currently pregnant). Most women chose contraceptive pills or condoms, few were interested in long-acting reversible contraception. The AN group preferred to receive contraception from their midwives at the one week postnatal home visit or at the routine postnatal check up at 6-8 weeks. In contrast, most postnatal women wanted to leave hospital with their contraception supplies. Conclusions: This work has informed the maternity department of our patients’ wishes regarding receiving information about contraception and how and when they would like to be given supplies of contraception.

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    Who refuses chlamydia screening in a termination
    of pregnancy clinic?
    Mullin, N; Robinson, K; Carter, J
    Countess of Chester Hospital NHS Foundation Trust, UK
    Background: National United Kingdom guidelines recommend all
    women requesting a termination of pregnancy (TOP) are screened
    for Chlamydia Trachomatis (CT) infection beforehand. Two years
    ago in our hospital we had a gravely ill woman with a post-TOP
    pelvic infection, and after a significant event analysis the staff were
    trained to become more effective in offering screening to all
    women.
    Objectives: To audit the documented offer, uptake and refusal of
    CT screening pre-TOP.
    Method: Retrospective case notes review.
    Results: In 12 months, 471 women attended the pre-assessment
    (pre-TOP) clinic, age range 14–48 years, 250 (53%) were under
    24 years. All clients had a documented offer of CT screening,
    including women whose pregnancy was found to be non-viable or
    who decided to continue with their pregnancy. There were 143
    women who declined a test in clinic and in 68 (50%) cases there
    was a documented CT test taken prior to attending the TOP
    service. Of the remaining 75/471 (16%) clients (mean age
    25 years, range 16–43) these women mostly (94%) declined
    screening because they were in a long term relationship or had
    recently been tested in a new relationship.
    Conclusion: Despite staff strongly recommending CT screening to
    all women attending our TOP service, one in six women decline.
    However, this appears to be a self selected low risk group of
    women. No severe post-TOP infections have occured in our
    service recently (universal antibiotic prophlaxis is given as well as
    screening). Further work is needed to encourage referring agencies
    to offer CT screening at the first discussion of pregnancy options
    to ensure maximum uptake.


Aimée Patricia Ndembi Ndembi


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    Effective strategies for improving access to quality care: Central Africa Network for Women's Reproductive Health

    Aimée Patricia Ndembi Ndembi1, Justine Ella2, Marie Irène Bena4 ,3, Marijke Alblas3 ,4 1ONG GCG, Libreville, Gabon, 2Association des sages femmes, Libreville, Gabon, 3Association des sages femmes, Douala, Cameroon, 4CSU/CNRS, Paris, France - ndembipatricia@yahoo.fr

    The Central Africa Network for Women’s Reproductive Health: Gabon, Cameroon, Equatorial Guinea (GCG) aims to enhance reproductive healthcare by facilitating exchange between countries in the region and conducting research, training and education to improve services and provisions pertaining to pregnancy accompaniment, pregnancy prevention and pregnancy termination. The network is committed to implementing feasible strategies for enhancing the capacities of local practitioners and for assuring access to quality primary and emergency care, particularly of rural, adolescent and migrant women. To reach our objective, we created a network of practitioners eager to work together to identify needs by analyzing obstacles to quality care. We then initiated: - Train the trainer programmes in manual vacuum aspiration (MVA) - Rap groups and radio programmes with expert speakers and facilitators in schools, villages and town centres Due to these training and education programmes, hundreds of midwives, obstetric nurses and doctors are now autonomous in bringing improved care to women with pregnancy-related complications. Quantitative evaluation documents a significant decrease in delays for emergency treatment due predominantly to midwife practice of MVA with local anaesthesia. Note that delays in emergency care have been shown to be a prime obstacle to preventing death from postabortion complications. Radio programmes and rap groups with adolescents and women are effective in spreading information about abortion, contraception and a range of sexual issues. In particular, information about IUDs has increased the acceptability of this contraceptive, especially in a rural zone where we have followed about 100 young women whose positive experience is influencing other women. We are currently working to apply this model developed on the border between Gabon, Cameroon and Equatorial Guinea to the border between Gabon and Congo-Brazzaville where people face similar realities.


Joaquim Neves



Victoria Newton


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    ‘I know it's something to do with 28 days': young women's fertility knowledge

    Victoria Newton The Open University, Milton Keynes, UK - victoria.newton@open.ac.uk

    Objectives: This project sought to investigate what young women know about fertility and how this knowledge is interpreted at an individual level. Misunderstandings about fertility can result in some young women engaging in risk-taking behaviour (Williamson et al 2009, Hoggart et al 2010). The Department of Health Framework for Sexual Health (March 2013) identifies fertility perceptions and their influence on contraceptive use as an area for suggested action (Annex C). This project therefore addressed this need by exploring young women's awareness of their fertility in relation to menstruation, contraception and pregnancy risk. Methods: Ten semi-structured qualitative interviews were undertaken with participants aged 16-20. Topics explored include what young women know about their fertility; when they think they are most and least at risk of falling pregnant; to what extent they perceive themselves to be at risk of pregnancy; their contraception use and risk taking; their knowledge of STIs and other factors affecting fertility. Results: It was found that despite a blanket desire to avoid pregnancy, all participants took risks. Almost all had used emergency contraception.

    Although some participants had limited knowledge of when it is easier to get pregnant, there was no evidence that they were more careful during their fertile time. Conclusions: Young women may benefit from a greater knowledge and understanding of their fertility. A better understanding of their fertility may help young women to assess their risk of pregnancy, and when desiring to avoid pregnancy, to take extra precautions during their most fertile time. A greater knowledge may also empower them in the future should they wish to plan for a family.

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    Menstruation and contraception: social and cultural issues on young women's decision-making

    Victoria Newton, Lesley Hoggart The Open University, Milton Keynes, UK - victoria.newton@open.ac.uk

    Objectives: This study examined the attitudes of young women (aged 16-21) towards menstruation and contraception. The study had two main research objectives: to document and investigate what young women think and feel about menstruation and contraception, and to explore young women's preferences regarding the intersection of contraceptives and bleeding patterns. Methods: A qualitative study in which twelve young women were interviewed in-depth, along with six focus group discussions. Results: Although participants held a broad view that menstruation can be an inconvenience, they did ascribe positive values to having a regular bleed. Bleeding was seen as a signifier of non-pregnancy and also an innate part of being a woman. A preference for a ‘natural' menstruating body was a strong theme, and the idea of selecting a hormonal contraceptive that might stop the bleeding was not popular, unless the young woman suffered with painful natural menstruation. Contraceptives that mimicked the menstrual cycle were acceptable to most suggesting that cyclic bleeding may hold a symbolic function for many women. Conclusions: When counselling young women about the effect of hormonal contraception on their bleeding, it would be helpful for practitioners to explore how the young women feel about their bleeding, and ask the young women to recall a ‘worst case scenario' in terms of their bleeding patterns with reference to how they might feel about it. It may also be helpful for practitioners to outline the therapeutic interventions available to alleviate breakthrough bleeding associated with some LARC methods, such as prescribing the COC pill, during their initial contraceptive consultation. Finally, the subjective understanding of the ‘natural body' as held by some women could be acknowledged more fully and in these cases practitioners could be encouraged to support them in their choice and seeking out of non-hormonal methods of contraception.


I. Nisand


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    Medical management of unwanted pregnancy in
    France: modalities and outcomes. The aMaYa study
    Nisand, I; Bettahar, K
    Gynaecolgy Department CHU Strasbourg, France
    Background/Methods: Since WHO recommendations in 2003, the
    use of medical termination of pregnancy (MToP) has become
    wider in Europe, particularly in France where it concerns more
    than 50% of TOPs. However, there are still different practices
    according to various guidelines or drug approvals. Following the
    recent update of French recommendations (December 2010), a
    new observational study was performed to assess in real life
    modalities and outcomes in mToP.
    Results: One thousand five hundred and eighty-seven women
    (mean age: 27.6 ± 6.8; minor: 3.3%) were included by 48 French
    specialised centres from September 2011 to April 2012. At the
    inclusion, when women were given mifepristone, the gestation of
    pregnancy was £49 days of amenorrhoea (DA) for 71.7% of
    patients and >49 DA for 28.3% with >63 DA for 2.1%. Most of
    the time pregnancy dating was done by ultrasound. The most
    frequently used protocol was the one recommended by the French
    authorities (mifepristone 600 mg-misoprostol 400 lg oral) and
    concerned 35.4% of patients. But other protocols were given
    (mifepristone 600 or 200 mg in association with misoprostol
    800 lg) for respectively 23.4% and 13.5%. Gemeprost
    prostaglandin was used by 1.4% of patients only.
    Eighty-one percent of patients attended the follow-up visit
    3 weeks after inclusion. There was no ongoing pregnancy although
    10% of patients were lost to follow-up. Successful abortion rate
    was 94.4%, 5.6% of patients requiring a secondary surgical
    procedure. Seventeen serious adverse events (1.1%) were reported
    (mainly major bleeding).
    Conclusion: Although a relatively wide range of therapeutic
    strategies in MToP, this study emphasises a satisfactory success
    rate of 95% strongly consistent with the literature.


Jacky Nizard


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    CS12.2

    EBCOG and setting standards of care in Europe

    Tahir Mahmood1 ,2, Jacky Nizard1 ,3
    1European Board & College of Obstetrics and Gynaecology, Brussels, Belgium, 2Victoria Hospital, Kirkcaldy, Scotland, UK, 3APHP - Hôpital Universitaire Pitié-Salpêtrière, Paris, France

    There is considerable diversity within EU and EEA countries how women's health services are delivered.  While there are significant economic variants within these countries, outcomes data suggests that within some countries, women are even denied access to basic human rights which have been recognised in the UN Charter.
    There are huge variations in the outcomes in both obstetrics and gynaecology, from maternal morbidity and mortality rates down to access to women's right and access to methods for family spacing.
    EBCOG being a representative body of 37 countries in Europe have developed two documents  to define uniform standards of care in all areas of women's health services to provide support to health care planners. These documents were launched at the EU Parliament in 2014. They have also been translated in Russian language with the help of UNFPA - Eastern Europe and Central Asia Region. They are accessible at our website (www.ebcog.eu)

    This presentation will describe our novel approach to address these issues around health services delivery were developed and will call for an action by all stake holders.


John Nyamu


Speeches:

Jon O´Brien



C. O’Callaghan


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    Te Mahoe Unit-Wellington NZ-an overview
    O’Callaghan, C
    Te Mahoe Unit, Wellington, New Zealand
    The poster will contain an overview of the Te Mahoe Unit which
    is the Early Pregnancy Counselling and Termination Unit in
    Wellington, New Zealand.
    There will be a brief description of the New Zealand law with
    regard to termination of pregnancy (TOP). The referral process
    and certification process will also be explained.
    All procedures that are provided will be described e.g. surgical
    termination with local anaesthetic and conscious sedation up to
    14 + 5 weeks of gestation — early medical termination with
    miferistone and misoprostol up to 9 weeks of gestation.
    A section on products of conception and what happens to
    them. Some explanation around Maori cultural beliefs.
    Also nursing care, after care, on call issues and statistics. The
    latest complication rates and causes of same.
    Finally, law reform issues and looking to the future.


M. Olver


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    What is the outcome of pregnancies that continue
    following administration of mifepristone?
    Olver, M; Scherf, C; Noble, N
    Cardiff and Vale NHS Health Board, UK
    Introduction: The number of medical terminations of pregnancy
    (TOPs) in England and Wales in 2010 compared with the year
    2000 shows an 8% increase. Despite the rapid increase there is
    little published evidence regarding the risks to a continuing
    pregnancy after mifepristone administration.
    Objectives: To investigate the outcome of all cases of continuing
    pregnancy after administration of mifepristone +/- misoprostol in
    the Cardiff and Vale University Health Board over a period of
    4 years.
    Methods: A retrospective case note review of all women with
    unplanned pregnancies who wished to continue their pregnancy
    after administration of mifepristone. Women were identified by
    non-attendance or cancellation for misoprostol, follow-up cases
    and searching antenatal records. The review period was 2007–2011.
    Results: Twenty cases of continuing pregnancies were identified.
    Of these, 10 resulted in live birth, five in miscarriage, two were
    lost to follow-up and three needed a second TOP procedure (one
    of them was given Clause E, fetal abnormality).
    Conclusion: This case series shows the most common
    complication following mifepristone administration is miscarriage
    in the first trimester. Those pregnancies leading to live birth did
    not result in adverse fetal outcomes. However, due to the small
    sample size, damage to the fetus cannot be ruled out and
    therefore close monitoring throughout pregnancy should be
    performed. This detailed case review highlighted the need for
    more work in this area to enable clinicians to provide correct
    advice to women in these difficult situations.


Amália Pacheco



Maureen Paul


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    Abortion providers' resilience to anti-choice tactics in the United States and Canada

    Maureen Paul1, Katharine O'Connell White2, Wendy Norman3, Edith Guilbert4, E. Steve Lichtenberg5, Heidi Jones6 1Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA, 2Baystate Medical Center/Tufts University School of Medicine, Springfield, Massachusetts, USA, 3University of British Columbia, Vancouver, British Columbia, Canada, 4Institut National de Sante Publique du Quebec, Quebec City, Quebec, Canada, 5Family Planning Associates Medical Group, LTD, Chicago, Illinois, USA, 6CUNY School of Public Health, Hunter College, New York, New York, USA - jodotter@aol.com Objectives: To estimate the prevalence of anti-choice tactics on abortion facilities and to evaluate abortion providers' experiences with stigma in the United States (USA) and Canada. Methods: We conducted a cross-sectional survey of abortion facilities identified via publicly available resources in the USA (N=705) and Canada (N=94) from June through December 2013. Clinic administrators responded to facility-level questionnaires; surgical and medical abortion clinicians responded to individual-level surveys which included a 15-item validated stigma scale. Results: 690 clinicians and 456 facilities participated; 54% of USA facilities and 83% in Canada. 83% of USA and 33% of Canadian facilities experienced at least one form of harassment in 2012, most commonly picketing without blocking (66%). These experiences were more common in private offices (88%) or ambulatory centres (83%) than hospital-affiliated facilities (29%). Only 7% of facilities (all in the USA) reported staff resignations due to harassment. 41% of USA-based clinicians and 18% of Canadian clinicians reported personally experiencing harassment in 2012. 99% disclosed being an abortion provider to their partner or close friend, 88% to a parent, and 74% to a child. The stigma scale showed high reliability with a Cronbach's alpha of 0.80. Only 1% had high stigma scores, 26% moderate to high, 65% moderate to low and 8% low, with no differences by facility type. One third reported always/often/sometimes feeling marginalized by other health workers, but 87% reported always/often feeling they are making a positive contribution to society. Conclusion: Abortion providers and facilities experience several forms of harassment, which is more commonly reported in the USA than Canada. However, providers demonstrate resilience to stigma in both settings.


Lucija Pavse


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    Psychological adjustment following induced abortion for fetal abnormality

    Lucija Pavse1, Vislava Globevnik Velikonja1, Robert Masten2, Nataša Tul-Mandić1 1University Medical Centre Ljubljana, Gynaecological clinic, Ljubljana, Slovenia, 2University of Ljubljana, Faculty of Arts, Psychology Department, Ljubljana, Slovenia - lucija.vidmar@gmail.com

    The purpose of this study was to explore the ways in which bereaved women perceive and cope with induced abortion for fetal abnormality. We examined the relative impact of major variables for predicting adjustment (in terms of depression, anxiety and grief) among bereaved women. 108 bereaved women who had had an induced abortion for fetal abnormality completed standardized self-report questionnaires measuring depression (Beck Depression Inventory–Short Form; BDI-SF), anxiety (State- Trait Anxiety Inventory; STAI-X1) and grief (Munich Grief Scale; MGS). More educated women had lower levels of depression and anxiety and felt less guilty. Women with more remaining children were more anxious. Women who had induced abortion at a higher gestation of pregnancy had higher levels of sadness and anger. Women with two or more induced or spontaneous abortions had higher levels of anger. These findings increase the understanding of the impact of factors associated with bereavement outcome following induced abortion for fetal abnormality. On that basis adequate intervention strategies should be established to identify and help mothers at high risk of poor psychological adjustment following perinatal loss.


Anabela Araujo Pedrosa



Dhammika Perera



Alissa Perrucci


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    Decision assessment and counseling in abortion care

    Alissa Perrucci University of California, San Francisco, San Francisco CA, USA - perruccia@obgyn.ucsf.edu

    In this session participants will learn an approach and framework for conducting pre-abortion decision assessment and counseling that is applicable across all types of decision conflict and ambivalence as well as decision certainty. I will outline the components of this model of counseling and how it corresponds to the process of informed consent in the practice of medicine. I will also describe my philosophy of education and training for counselors in this field. Decision assessment and counseling is an approach and framework that is grounded in patient autonomy and agency and follows the fundamental principle that the patient has the answer to her dilemma. The approach emphasizes techniques for active listening, bracketing of assumptions, and self-reflection. The framework provides a conversational map as well as specific skills for working with challenging patient statements. Participants will be able to describe the components of the framework, analyze their own style of counseling in the context of this model, and plan for implementation of new skills for working with emotional, spiritual and moral conflict with pregnancy decisions.


Lauriane Pichonnaz Pichonnaz


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    Unwanted pregnancy: who are the ambivalent women?

    Lauriane Pichonnaz, Fabienne Coquillat, Saira-Christine Renteria Centre for Sexual Health and Planned Parenthood, Unit for Psychosocial Gynaecology and Obstetrics, ObGyn Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland - lauriane.pichonnaz@chuv.ch

    Introduction: Certain studies show that the women who are the most at risk for postabortion problems are those who were ambivalent at the beginning of the pregnancy (Adler, N.E., and al., 1990). Other studies show that influences/pressures from other people (Romans-Clarkson, S.E., 1989), a lack of a support from the partner, a psychiatric history or belonging to a cultural group that is anti-abortion (RCOG, 2000) also increase the risk of postabortion distress. These studies clearly demonstrate the importance of studying ambivalence towards pregnancy. Aim: The purpose of the study is to have a better understanding of women ambivalent towards their pregnancy. The study will do so by exploring the reasons for becoming pregnant, the possible existence of conflict between couples, external pressure and violence, as well as the link to their final decision to go on with the pregnancy or not. Material and methods: From May 2012 to May 2013, the six sexual health counsellors of the Centre for Sexual Health of the CHUV gathered data about every ambivalent woman consulting for counselling. The data of a total of 88 subjects was collected. Statistical analyses were made, completed by qualitative data. Results: 64.8% of the women had been using a contraceptive method. We can thus suppose that they intended not to get pregnant. Nevertheless more than a quarter of them used a contraceptive method in an inconsistent way. Conflicts between couples were high (47.7%). Concerning external pressure, half of the women were under pressure (53.4%), predominantly from the spouse (44.3%). Actual violence was present in 10.2% of the situations and mostly exercised by the male partner (6.8%). Conclusions: Half of the women decided to give birth and half to have an abortion. This demonstrates the importance of the health professionals' support during the decision-making process.


Ingrida Platais


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    Making medical abortion woman-centered and accessible in Kazakhstan: a study of 600 mcg sublingual misoprostol following 200 mg mifepristone for abortion up to 70 days’ gestation

    Ingrida Platais1, Tamar Tsereteli1, Galina Grebennikova2, Beverly Winikoff1 1Gynuity Health Projects, New York, NY, USA, 2Kazakhstan Association on Sexual and Reproductive Health, Almaty, Kazakhstan - iplatais@gynuity.org

    Objective: To assess whether the option to take mifepristone at home is feasible and acceptable to women with pregnancies up to 70 days' LMP seeking medical abortion in Kazakhstan. Method: Typically, medical abortion in Kazakhstan consists of four visits. This study consisted of two visits. During their initial visit, women were given the option to swallow mifepristone at the clinic or take it home, and all women were instructed to take misoprostol at home. The follow-up visit was scheduled two weeks after mifepristone. This open-label study enrolled women with pregnancies ≤70 days' LMP. The study regimen consisted of 200 mg mifepristone, followed by 600 mcg misoprostol 24-48 hours later. Results: As of April 2014, 106 women were enrolled. Ninety-eight percent of women had successful abortions. All women took mifepristone and misoprostol at the scheduled time, and no woman took mifepristone after 70 days' LMP. No serious adverse events were reported. Most women (99.0%) reported that the ability to plan when the abortion would occur was important for them. More than half of the women (61.3%) chose to take mifepristone at home, citing compatibility with home and family duties as the top reason for their choice in location of mifepristone administration. For clinic users, the presence of a provider was the most common reason for their choice. Almost all women (99%) were satisfied with the abortion procedure and most (98.1%) would choose medical abortion in the future. Most home users (90.8%) said they would choose to take mifepristone at home again if they needed another abortion, whereas only 12.2% of the clinic users would choose to take mifepristone in the clinic again. Conclusion: An outpatient medical abortion procedure up to 70 days’ gestation using mifepristone and misoprostol, taken at a place of women's choosing, is safe, effective and acceptable.


Volodymyr Podolskyi


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    Postabortion contraception in Ukraine: a pilot study

    Volodymyr Podolskyi1, Kristina Gemzell-Danielsson2, Lena Marions1 1Institute of Paediatrics, Obstetrics and Gynaecology, Kiev, Ukraine, 2Karolinska Institutet, Stockholm, Sweden, 3Karolinska Institutet, Stockholm, Sweden - podolskyivv@gmail.com

    Background: The abortion rate in Ukraine is high and the use of effective contraceptive methods is low. Aiming to explore women’s knowledge and attitudes towards modern contraceptive methods, we performed a survey among women undergoing surgical pregnancy termination in the first trimester. Material and Methods: A survey was provided in the Maternity House №6, Kiev Ukraine. The aim is to include 300 eligible women and the present data represent a pilot analysis of 30 women. The study was approved by the Ukrainian Ethical Committee, Kiev Results: Mean age was 27 years, 63% were married, 47% had graduated from college. A majority of the women (27/30) had given birth at least once. Only 2 women were pregnant for the first time. Seventeen women had performed at least one abortion earlier and almost half of the women (14/30) had experienced at least 2 abortions. Fourteen women wanted to have more children whilst the remaining 16 women stated they never wanted to have more children. Most women (26/30) had heard about contraceptive pills but only 13/30 were aware of intrauterine devices. Weight gain, future infertility were reported by the women as reasons for not using hormonal contraceptive methods. Previous experience of contraceptive methods included condoms (25/30), contraceptive pills (10/30) and IUD (5/30). Thirteen women had never heard about emergency contraceptive pills. Conclusion: Our pilot study indicates that Ukrainian women presenting with an unwanted pregnancy have an unmet need for long-lasting effective contraceptive methods. Repeat abortions were common among women included in our study. They showed insufficient knowledge regarding effective methods and expressed misconceptions regarding side effects of hormonal contraception methods. There is a need for education among fertile women and future studies need to explore whether insufficient knowledge also is prevalent among healthcare providers.


Anna Pompili


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    The Italian case: can MTOP minimize the problem of conscientious objection?

    Anna Pompili1, Mirella Parachini2, Giovanna Scassellati Sforzolini3, Gelsomina Orlando4, Daniela Valeriani5, Cristina Francesca Damiani6, Patrizia Facco7, Marina Marceca8 1Sapienza University, Rome, Italy, 2San Filippo Neri Hospital, Rome, Italy, 3San Camillo Hospital, Rome, Italy, 4San Giovanni Hospital, Rome, Italy, 5San Camillo Hospital, Rome, Italy, 6San Giovanni Hospital, Rome, Italy, 7Sandro Pertini Hospital, Rome, Italy, 8San Giovanni Evangelista, Tivoli, Italy - pompili.anna@tiscali.it

    In Italy abortion has been legal since 1978. During these 36 years, we have seen an increasing percentage of gynaecologists who declare themselves "conscientious objectors", in contrast with women's right to stop an unwanted pregnancy. The anti-choice front, which looks to catholic fundamentalism, forced an abuse of this right, in an attempt to obstruct women's access to safe abortion. The official data about conscientious objection from the Italian Health Ministry, reports a percentage of about 70% among gynaecologists, but this phenomenon concerns also anaesthetists (about 50%) and other health personnel (about 46%). In 2012, in a survey "in the field", we showed that data about conscientious objection are critical, with rates in some regions near to 100%. This abuse of conscientious objection has the intent to make the law a dead letter, negating "de facto" the right to reproductive health for many Italian women. In March 2014 the European Committee of Social Rights, on the basis of a complaint by IPPF-EN condemned Italy because the law is not applied; so, a lot of Italian women are forced to migrate from one region to another, even to other countries, because of the inability to exercise their reproductive rights. In this paper we want to give a real picture of the Italian situation, and try to analyse how easier access to MTOP would minimize the effect of the abuse of conscientious objection on women's rights.


G. Preti


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    Who consults for an emergency pill? Survey about
    users profile. Comparison between 2008 versus
    2011 at the sexual and reproductive health and
    family planning centre, Geneva’s University
    Hospital, Switzerland
    Preti, G1,2; Bettoli, L1,2
    1 Unite´ de sante´ sexuelle et de planning familial de Gene`ve;2 Association Romande et Tessinoise des Conseille`res en Sante´ Sexuelle
    et reproductive (ARTCOSS), Suisse
    Context: In Switzerland, the sexual health and family planning
    centres ensure the provision of the emergency pill (EP) at reduced
    cost with relevant counselling on sexual and reproductive health
    (SRH) matters.

    Which kind of profile do women visiting for the emergency pill
    at the SRH centre in Geneva have? Can we observe an evolution?
    Methods: The first survey took place in 2008 and was repeated in
    2011. Both occurred in the months of December and January
    (2008: 139 women, 2011: 90 women).
    Conclusions: The age of women requiring EP at the SRH centre
    was between 14 and 30 years with a majority of women aged
    between 16 and 17. Younger women often visit Geneva’s centre
    with a friend or a partner. Seventeen percent of all women visit
    with their partners.
    Lack of contraception is the main reason for EP requests with
    40% prevalence, second in line of all requests is condom failure at
    39%.
    Women from other countries have a higher percentage request
    for non-use of contraception than Swiss women.
    Approximately a third of the situations have complex psycho-
    social elements.
    Between 2008 and 2011, we observed an improvement in time
    lapses between sexual risk and the EP requests (within 12 hours:
    22% in 2011, against 9% in 2008). Also, there are fewer repeated
    EP requests when comparing the second survey with the first.
    In 2011, we observed that at least 11% of surveyed women had
    had repeated unprotected sex, before and after their EP request.


Cristina Puig



M. Rajic


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    Termination of second trimester pregnancies with
    mifepristone and misoprostol
    Rajic, M; Vrhkar, N; Stritar, BS; Tul Mandic, N
    Division of Gynaecology and Obstetrics, Department of Perinatology,
    University Medical Centre Ljubljana, Ljubljana, Slovenia
    Objective: To evaluate the safety and efficacy of termination of
    pregnancy (TOP) for medical reasons (structural fetal congenital
    anomalies, fetal chromosomal abnormalities, intrauterine fetal
    death, early preterm prelabour rupture of membranes) using
    mifepristone and misoprostol (MI-MI) between 11 and 22 weeks
    of gestation.
    Methods: We collected data from all women requiring TOP with
    MI-MI for medical reasons. The protocol consisted of 200 mg of
    mifepristone orally, 36–48 hours later 800 lg of misoprostol
    vaginally, followed by 400 lg buccally every 3 hours until TOP
    (maximum of four doses in 24 hours). If the placenta was
    retained, uterotonics were adminsitered, and a decision was made
    whether to evacuate the uterus surgically. The data were analysed
    using the statistical software program SPSS, version 18.
    Results: A total of 435 women were enrolled in the study (we
    analysed 157 cases, the remainder will be analysed by the
    beginning of FIAPAC Conference 2012). The mean gestational age
    was 16.5 weeks. For 58 (36.9%) women this was their first
    pregnancy. The method was successful in 156 (99.4%) cases. The
    average time interval from the beginning of the procedure till
    TOP was 47.3 hours (13.8–168 hours). The average duration of
    hospital stay was 39.3 hours (25.0–167 hours). In 40 (25.5%)
    cases surgical evacuation of the uterus after TOP was performed.
    Conclusions: The use of MI-MI is safe, effective and non-invasive
    regimen for TOP for medical reasons between 11 and 22 weeks of
    gestation.


Elizabeth Raymond


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    Can we eliminate the mifepristone visit in medical abortion?

    Elizabeth Raymond Gynuity Health Projects, New York, USA - eraymond@gynuity.org

    The requirement to present to a clinician in person to receive abortifacient drugs is problematic for some women. Eliminating this requirement would enable intriguing new service delivery options, including provision of medical abortion in non-traditional, non-clinical venues and provision by prescription or mail. This presentation will review data regarding the utility of examination and ultrasound prior to medical abortion and will discuss potential alternative approaches to assess eligibility that could be used over the telephone or internet.


Marija Rebolj Stare Rebolj Stare


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    Medical abortion performed at home

    Marija Rebolj Stare University Clinical Centre Maribor, Maribor, Slovenia - mitzirs@gmail.com

    Introduction: At the University Clinical Centre, Maribor, the start of medical abortions was in the year 2006, with a full service from July 2007. With the recognition of its course and a lack of major complications, we decided to perform medical abortions up to 63 days of gestation in the outpatient clinic. A complete working plan was done, with exact briefings for all enrolled. Methods: On 24 February 2014 we started with outpatient medical abortions. At visit all reports (ultrasound report, blood haemoglobin level, blood type, Rh factor, ICT) and possible contraindications were evaluated. In case of uncertainty we repeated tests. Written explanation and patient consent, ambulance report, strict instructions were featured, for term and preterm control if needed. Analgesic therapy was prescribed. Oral intake of mifepristone 200 mg was followed, after 36-48 hours, with vaginal insertion of 4 pills of misoprostol 200 mcg. We advised attendance of adult and one week of sick leave. Two weeks later we performed follow-up. Results: Between 24 February and 3 April.2014, 47 patients aged 16.4-41.3 years, were enrolled. Average gestation was 52 (37-62) days. Seven didn't come to check-up; they probably had no problems. In 4 patients medical abortion failed and pregnancies were ongoing. Two had surgical abortion and 2 medical by extended protocol - one complete, one with curettage due to residua. For 36 patients medical abortion was successful. At 30 patients was complete, 6 had residua (15-31 mm) with high βHCG level (460-21164). Two were directed to hysteroscopy and 4 had curettage. Prophylactic antibiotic therapy was given once, prior to curettage. No transfusion was needed. Conclusions: Medical abortion at home proved to be safe for gestations up to 63 days of duration. Complications such as bleeding, residua or infection did not occur more often than at hospitalization. Failed medical abortions tended to occur; that confirms a need for a check-up some patients are avoiding.


Regina-Maria Renner


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    Providers’ perspective on pain in abortion care, including cultural aspects

    Regina-Maria Renner University of British Columbia, Vancouver, BC, Canada - rerenner@bluewin.ch

    The majority of women report pain associated with abortion; either during or after the procedure. A variety of pain management options are available but no option is perfect. A paracervical block with or without oral analgesics has been shown to decrease pain but typically not enough to be pain-free whereas general anaesthesia provides a pain-free experience for the procedure, but women still report pain postoperatively. Conscious sedation provides an option in between the two. Access to these pain management options varies internationally, and is influenced by the interplay of safety concerns, woman's choice and available resources. Providers' perspectives of women's pain experience and pain management also vary internationally and are shaped by their respective clinical and in some cases, personal experience. In many European countries the majority of abortions are provided under general anaesthesia, while in North America the majority of procedures are done under local anaesthesia. In Canada, for example, IV sedation is more common. Cultural norms affect patient's reaction to pain and coping mechanisms coping with pain, not only in the context of abortion provision. All these aspects influence providers' perspective on women's pain and the acceptance of women's pain. Providers accustomed to an asleep patient may not be used to seeing patients in pain and "talking a woman through the procedure". Providers used to an awake patient oftentimes are more comfortable with a patient experiencing some pain and have practice in supporting her. Additionally, studies have shown that providers' perception of women's pain does not always correlate with the women's self-reported pain.


Carolina Ribas Barrera


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    Reasons that motivate requesting induced abortion and the options that women choose facing a restrictive abortion law in Spain

    ACAI Clinics1, Carolina Ribas Barrera2 1ACAI associated Clinics, from all regions, Spain, 2Clínica El Sur, Sevilla/Andalucía, Spain - alberto.ginecenter@gmail.com

    Objectives: After the 2010 law on abortion came into force, the objective of the study was to find out what are the motivations to have an abortion and what changes should take place in the women’s situation to make them continue their pregnancies. After presentation of the abortion Bill December 2013, it was important to know, what women think they will do in the future, if the law is restrictive. Method: In 2 different periods (2012 and 2014) 5100 and 6045 women had abortions in 15 ACAI clinics . Besides sociological and medical data, they were asked about the pregnancy (originally not wanted/wanted) and the conditions that should change (socioeconomic, partnership etc.) to make them reject their decision to terminate the pregnancy. In the second period another question was added, what they would do in the future, if the new law does not allow them to perform the abortion. Results: Data for both periods were statistically analyzed. Results for both periods are similar. The variables are: age, nationality (34% and 29 % foreigners), educational level, job (35% and 36.5% jobless), contraceptive method (nothing 36.8% and 47.9%), abortion method (medical 5% and 4.7%), pregnancy condition (wanted/not wanted from the beginning) and circumstances that should change to reject abortion (none 48% and 41%, economic situation 21% and 23%). In case of a restrictive law, 29% would continue the pregnancy, 31% would go abroad and 30% would try an illegal abortion. Conclusions: 95 % of pregnancies that actually end as a legal abortion are unwanted from the beginning. Modern contraception is not widely used by the women. In 60% no changes in the women’s situation could make them take another decision. If the announced law comes into force, more than 99% of 120,000 women asking for abortion in 2012 couldn’t perform it under legal conditions.


Michael Rimmer


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    ellaOne in practice

    Michael Rimmer, Victoria Sephton Brook Advisory Centre, Liverpool, UK - michael.rimmer@doctors.org.uk

    Objectives: To audit the day-to-day use of emergency contraception and compare the failure rates of levonorgestrel (previously the first line choice for emergency contraception) and ulipristal acetate (the new first line choice of emergency contraception) since implementation of new guidelines. Background: Unplanned pregnancy is a multifactorial problem affecting up to 7% of women each year. Despite emergency contraception (EC), many women still become pregnant and require termination of pregnancy (TOP). Increased effectiveness of EC and less reliance on TOP has positive benefits on a women’s social, mental and physical wellbeing. Studies looking at follicles close to ovulation have shown that levonorgestrel inhibits 14.6 % of follicles whereas ulipristal acetate inhibits 58.8% (Brache V et al, 2010). This suggests that ulipristal acetate works closer to ovulation, when risk of pregnancy is highest. This resulted in a change in guidance from the Faculty of Sexual and Reproductive Healthcare to offer ulipristal acetate (trade name - ellaOne) as first line of EC over levonorgestrel. Methods: An audit of women, receiving ulipristal acetate as 1st line (EC) was compared to a retrospective audit of women who received levonorgestrel as 1st line. Results & Conclusions: 662 women received ulipristal acetate of which 1 required a TOP; 1397 received levonorgestrel of which 5 required a TOP. This is shown below in the table with the failure rate.

    No. of women No. requiring TOP Failure rate Ulipristal acetate 662 1 0.0015106 Levonorgestrel 1397 5 0.0030157

    The odds ratio (of the failure rates) between ulipristal acetate compared to levonorgestrel is 0.50. (Calculation: Odds Ratio = 0.0015106 / 0.0030157 = 0.50091189). This demonstrates that the change in Faculty guidance is justified and that data from studies suggesting that ulipristal acetate is more effective than levonorgestrel is reflected in clinical practice.


Carolina Rivas


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    CS11.1

    The situation of minors under the new abortion law in Spain

    Carolina Rivas
    ACAI, Sevilla, Spain

    In 2010 the socialist Government passed a new law, which allows abortion on request up to 14 weeks and by maternal or foetal causes up to 22 weeks. In very special situations, the minors between 16 and 18 years could decide without the consent of the legal representatives.
    Sociological data (which were not included in the mandatory notification form) of 36718 women were collected from July 2010 to October 2011 to analyse the situation of the minors.
    In 2015 the conservative Government partially amended the Abortion Act, requiring in all cases the consent of the legal representatives of the young women of age 16 and 17.
    From May to August 2016 data of women who had a TOP have been collected to determine the changes in the situation of the minors following the reform of 2015.
    In the first study it was found that:

    • Out of 36718 women (100%), 1186 were age 16 and 17 (3.23%).
    • Out of 1186 minors (100%) only 151 (13%) failed to inform their parents.
    • These 151 minors represent 0.41% of all women (36718).
    • 87% of the minors age 16 and 17 reported their representatives and were mostly accompanied by them.

    The reasons given by the 151 minors for failing to inform their parents correspond to those cited in the law itself: serious family conflicts, domestic violence, ill-treatment, anti-abortion attitudes in the family, disabling or psychiatric diseases etc.
    Although details of the second phase are still picking up, the experience accumulated since September 2015 allows us to verify that the minors without the consent of their parents face restrictive interpretations of the law (e.g. in the Madrid Region, where the presence of both is required) or delays in the processing of the necessary judicial authorisation, potentially exposing them to unsafe abortion.


Anjum Rizvi



Eneli Salomonsson



Catrin Schulte-Hillen


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    CS14.3

    MSF: Addressing challenges to providing safe abortion in humanitarian emergencies

    Catrin Schulte-Hillen
    Medecins Sans Frontieres, Geneva, Switzerland

    MSF responds to needs for the termination of pregnancy, including on request (TPR); it is part of the organisation's work aimed at reducing maternal mortality and preventing unsafe abortions in the countries where we work. The presentation shares insights into MSF's experience over the past few years. A policy decision on safe abortion care was taken in 2004 - the fact that care did not expand rapidly came as a surprise. It also took time to recognise that specific efforts are required to understand and address key challenges that present barriers to the provision of safe abortion care.
    With policy, guidance, tools and training in place, humble progress has been made and some key lessons have emerged: the importance of making patient needs a priority over other considerations; acting accordingly requires organisation of services and other measures to mitigate potential risk for the patients and staff. There are undeniably strong social norms regarding abortion and they must be considered. An important knowledge gap remains, even among MSF staff. An open dialogue with staff, relevant medical actors and at community level is essential to address this and result in a change in attitude.


John Sciarra



Gilda Sedgh


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    Characteristics of women who obtain legal abortions across countries

    Gilda Sedgh, Akinrinola Bankole, Susheela Singh, Anna Popinchalk Guttmacher Institute, New York, NY, USA - gsedgh@guttmacher.org

    Context: Abortion levels may differ between subgroups of women because of variations in the level of unintended pregnancy and in the likelihood that women will choose to terminate their pregnancies if they become pregnant unintentionally. Understanding differentials in levels of abortion according to women's characteristics can shed light on the circumstances surrounding the reasons leading to abortion. Methods: Data from government statistics on characteristics of women who obtain legal abortions were obtained from countries where legal abortion is generally available and reliable abortion statistics are compiled. We compute the percentage distributions of abortions and abortion rates by selected characteristics of women, particularly age, marital status and parity. For a few countries, we present the proportion of abortions that are obtained by immigrants from other countries. Since the adolescent years are a particularly vulnerable period for many females, we highlight adolescent abortion rates and the proportion of pregnancies among adolescents that end in abortion across countries. Results: In general, abortion rates are higher among 20-24 year olds than any other age group. In most countries with reliable evidence, married women obtain a larger proportion of abortions than unmarried women. More than half of abortions are obtained by women with at least one child. Although adolescents account for a high proportion of abortions in some countries, they do not obtain a disproportionate share of procedures. The proportion of teen pregnancies that end in abortion varies widely across countries, even among countries with liberal abortion laws. Conclusions: Abortion rates vary across socio-demographic subgroups of women. However, within all subgroups examined here, some women will obtain an abortion when faced with an unintended pregnancy.

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    Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends

    Gilda Sedgh

    Guttmacher Institute, New York, USA

    Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We estimated subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014 and abortion rates in subgroups of women. Estimates were made using abortion data compiled from government agencies, nationally representative studies and a Bayesian hierarchical time series model. We estimated that, on average, 56 million (90% UI 52·4 to 70·0) abortions took place each year in 2010- 2014, for an annual abortion rate of 35 (90% UI 33 to 44) per 1000 women aged 15-44 years. Estimates of abortion trends globally and across subregions will be presented. We also used the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion.


Katarina Sedlecky


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    Barriers in access to contraception for minors

    Katarina Sedlecky Institute for Mother and Child Health Care of Serbia, Belgrade, Serbia - ksedlecki@gmail.com

    Use of effective contraception is one of the crucial issues in the sexual and reproductive health care for minors. However, far too many adolescents are at a risk of unplanned pregnancy, due to the many and varied factors that hinder them from recognizing and fulfilling their needs in the field of safe sexual behavior. The barriers can be grouped into macro and micro determinants. Among macro determinants the most significant are the sexual and reproductive health (SRH) legislative framework, socio-cultural environment, economic conditions, public awareness of the rights and needs of minors in relation to SRH, sexuality education, availability of appropriate healthcare services and access to modern contraceptive choice. The general and individual biological and psychosocial characteristics of adolescents, the influence of the family and peers, as well as school performance and aspirations comprise the major micro determinants of the access of contraception for minors. Due to different historical, sociocultural, political, and economical conditions, a diversity exists across Europe in means and motives of teenagers to use reliable contraception, societal acceptance of sexual activity among teenagers, commitment of different European countries to prevent teenage pregnancy, prevalence of health risk behaviours among teenagers, as well as in sexual and reproductive health care for migrant population and vulnerable groups. Recognition of SRH needs of minors, easy access of contraception, reimbursement of contraceptive methods and higher prevalence rates for medical contraceptive methods usually result in low teenage pregnancy rates.


Wendy Sheldon


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    FC25

    Buccal versus sublingual misoprostol alone for early pregnancy termination in legally restricted Latin American settings: A randomised trial

    Wendy Sheldon1, Ilana Dzuba1, Heather Sayette2, Jill Durocher1, Beverly Winikoff1
    1Gynuity Health Projects, New York, NY, USA, 2PP Global, New York, NY, USA

    Objectives:  To examine the efficacy and acceptability of two misoprostol only regimens that are commonly used for medical abortion in legally restrictive settings; as well as the feasibility of a multi-level pregnancy test (MLPT) for at-home follow-up.
    Methods: This randomised open-label trial is ongoing at six clinics in two Latin American countries where abortion is highly restricted.* A total of 382 eligible, consenting women with gestations of ≤ 70 days who request medical abortion is required to show an expected difference of 8% in efficacy between the two study arms. Participants are randomised to three doses of buccal or sublingual administration of 800 mcg misoprostol every three hours. Study providers are blinded to group allocation. All women receive two MLPTs to administer and interpret abortion status: the first is taken in-clinic on the day of enrolment and the second at-home on the day of follow-up.
    Results: Data collection should be completed before October 2016. To date, the overall rate of successful, non-surgical abortion is 93.4% (183/196) and rate of ongoing pregnancy is 1.0% (2/196). Among those with no ongoing pregnancy, the MLPT successfully identified this outcome in 83.5% (162/194) of cases; it also identified need for follow-up among all those with ongoing pregnancy (2/2). More than 80% (160/195) of participants stated they would select medical abortion in the future and 87.6% (170/194) felt they could use an MLPT on their own.
    Conclusion: The efficacy of misoprostol alone is higher than expected based on published literature. Study findings will provide important evidence on the efficacy of a three-dose buccal misoprostol alone regimen. In addition, multi-level pregnancy tests appear to be a feasible and potentially useful tool for abortion service delivery in legally restrictive settings.
    *Note: To protect study providers and their clinics, we are not disclosing country locations at this time.

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    CS08.2

    Multi-level pregnancy test for medical abortion follow-up: what do we know so far?

    Elizabeth Raymond, Tara Shochet, Jennifer Blum, Wendy Sheldon, Beverly Winikoff
    Gynuity Health Projects, New York, NY, USA

    Objectives: To summarise data on the effectiveness and feasibility of a strategy involving serial use of an urine multi-level pregnancy test (MLPT) for at-home follow-up after early medical abortion.
    Methods: We included data from five published studies involving a total of 1,848 women who received treatment at ≤63 days of gestation. In all five studies, an MLPT with five hCG ranges was used for assessing medical abortion outcomes. A baseline test was administered just prior to mifepristone and a follow-up test was administered 1-2 weeks later. Declining hCG concentrations in successive tests were interpreted as indication of abortion success, while stable or increasing hCG concentrations were interpreted as indication of possible continuing pregnancy. The MLPT results were then compared with results from standard clinical assessment.
    Result: A total of 93.8% (1487/1585) of those with successful abortion outcomes (no ongoing pregnancy) observed declining hCG concentrations in successive tests. All those with continuing pregnancies (21/21) observed stable or increasing hCG concentrations. The predictive value of the MLPT strategy for identifying continuing pregnancy was thus 100%. In addition, 94.0% (1496/1591) of women reported that the MLPT was either very easy or easy to use.
    Conclusions: The MLPT strategy is highly successful at identifying continuing pregnancies as well as absence of continuing pregnancy. Use of this strategy is both feasible and effective and would reduce the need for clinic follow-up after medical abortion for the majority of women.

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    Alternative schemes for follow-up, including use of a semi-quantitative pregnancy test

    Wendy Sheldon Gynuity Health Projects, New York, USA - wsheldon@gynuity.org

    Semi-quantitative urine pregnancy tests are a recent innovation with the potential to revolutionize abortion care worldwide. Sequential use of such tests enables women to monitor the success of their abortion procedures in the privacy of their own homes and can be an effective replacement for serum hCG and/or transvaginal ultrasound, thus reducing overall abortion-related costs and, for many women, the need to return for clinic-based follow-up. This presentation will summarize data from multiple studies conducted in the United States, Mexico, Tunisia and Vietnam using a semi-quantitative test with five bracketed hCG ranges (25-99, 100-499, 500-1,999, 2000-9,999, and 10,000 mIU/ml). The studies explore the effectiveness, feasibility and acceptability of using a semi-quantitative pregnancy test for at-home medical abortion follow-up at various points in time up until 14 days after initiation of the abortion procedure.


Gulnara Shelia


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    Sociological aspects of violating the natural gender balance of newborns in Georgia

    Gulnara Shelia1, Nino Tsuleiskiri2 1NGO"Association HERA-XXI", Tbilisi, Georgia, 2Tsereteli State University, Kutaisi, Georgia - dodoshelia@yandex.ru

    Objective: Explore the sociological aspects of disturbing the natural gender balance and reasons behind “skewed sex ratios”at birth (111 boys for 100 girls) in Georgia. Method: 1600 women have been interviewed. The target groups of investigation were women of childbearing age and their families, also medical staff of 4 cities . Quantitative and qualitative data analysis was conducted using the computer program SPSS. Results: Analysis of the data shows, that sex selection in Georgia really exists. As a consequence there is significant evidence of prenatal sex identification practice. Additionally to the existing stereotype, technological innovations and disseminated information about modern family planning methods resulted in determination of the number of children and identification of the sex of the fetus by women.This behaviour is not inhibited by service providers.The existing economic and social conditions and level of education are contributing factors to having an abortion. Religion is the only deterrent to abortion.To the question “how important to you is the sex of the future child ?“, 52-72% answered that ”has no relevance“, but correlative analysis shows inconsistency of this response with other answers. 63% of the investigated women had undergone their first abortion; for 24% it was the second. Conclusion: Abortion is still the main method of birth control in Georgia. Termination of pregnancy, by interviewed women , is socially conditioned.There is the practice of prenatal sex selection with the termination of unwanted pregnancy in Georgia. Directly and spontaneously or under pressure Georgian women decide not to give birth to daughters, who are considered a burden to their family and unable to perpetuate the family lineage. This situation (the prenatal sex selection and related selective abortion) requires more adequate attention from authorities and development of specific measures for prevention.


Gabrijela Simetinger


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    Cultural beliefs on the so-called natural methods and their impact on abortion in Slovenia

    Gabrijela Simetinger1, Vesna Leskosek2 1General Hospital, Novo Mesto, Slovenia, 2Faculty of Social Work, University of Ljubljana, Ljubljana, Slovenia - gabrijela.simetinger@siol.net

    Objectives: The use of contraceptives in a particular social environment depends on a cultural conviction about the body, sexuality and conception. One of the ideological issues is also the so-called natural methods of contraception, i.e. coitus interruptus (CI) that are used independently of health care professionals. According to the data, CI is the major cause of abortions in Slovenia among those that use it as a contraceptive method. The aim of the study was to explore women contraceptive users’ views and opinions on contraception and sexuality, focused on CI. Method: Qualitative study included in-depth interviews with women contraceptive users regarding contraception and sexuality in general and CI and sexuality in particular. A total of 52 semi-structured in-depth interviews with women contraceptive users from various geographical parts of Slovenia were carried out between December 2010 and May 2011. Results: Results show that 38 out of 52 interviewees used CI as contraception at a particular time of their life. Of those, 23 interviewees use it on a regular basis and the same number believe that they have no other choice. Eight out of 38 got pregnant using CI. They use CI despite the fear of getting pregnant and awareness that sexual pleasure is therefore limited. More than half of the interviewed users of CI experience difficulties in having orgasm. Most of them think that they cannot influence their sexuality and accordingly they feel powerless. Conclusions: Even though gynaecologists in Slovenia generally do not promote CI as a method of contraception the use among women is quite widespread. They still follow traditional cultural beliefs about ‘reliable natural methods’ even though they are familiar with the consequences. In addition, new channels of communication and ways of exchange of information contributed to a new belief that ‘natural’ prolongs human life and ensures health and well-being.


Susanne Sjöström


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    Medical abortion provided by nurse-midwives or physicians: a cost-effectiveness analysis

    Susanne Sjöström1, Helena Kopp Kallner1, Emilia Simeonova2, Andreas Madestam3, Kristina Gemzell-Danielsson1 1Karolinska Institutet, Stockholm, Sweden, 2John Hopkins University, Baltimore, USA, 3Stockholm University, Stockholm, Sweden - susanne.sjostrom@ki.se

    Objective: To make a cost-benefit analysis of medical abortion provided by nurse-midwives and physicians. Study Design: A cost-effectiveness analysis is conducted based on a previously performed randomized controlled equivalence trial comparing efficacy, safety and acceptability of medical abortion performed by nurse-midwives or physicians in a high-resource setting. Materials and methods: Direct and indirect costs associated with the standard and intervention treatment have been calculated and an incremental cost-effectiveness analysis is performed. Equivalence in effectiveness was established for the primary and secondary outcomes in the original study, the outcome measures were complete abortion, and safety in terms of hospitalization, blood transfusion and acceptability. Direct costs include salaries including general payroll tax, rent, training of providers and costs for consultation (second opinions). Since the patients received the same treatment there was no difference in costs of disposables, ultrasound or medication. Indirect costs include women’s loss of salary and alternative cost for consultants (second opinions). Benefits emerging from increased prescription of long-acting contraceptives (LARCs) and also possible utility such as decreased waiting time for abortion seeking women from first contact to consultation/ treatment will be considered. All costs were taken from Karolinska University hospital where the parent study was conducted. Results: Preliminary results are that medical abortion provided by nurse-midwifes alone is more cost-effective than the standard treatment involving both nurse-midwives and physicians. The savings are mainly derived from lower salary costs for nurse-midwives but also from less total time for the visit.

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    Medical students' attitudes and perceptions on abortion: a cross-sectional survey among medical interns in Maharastra, India

    Susanne Sjöström1 ,2, Birgitta Essén2, Filip Sydén2, Kristina Gemzell-Danielsson1, Marie Klingberg-Allvin3 ,1 1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden - susanne.sjostrom@ki.se

    Introduction: Although abortion care as a procedure to prevent maternal death has been an established routine for decades in India, eight per cent of maternal mortality is attributed to unsafe abortion. Increased knowledge and improved attitudes among healthcare providers have a potential to reduce barriers to safe abortion care by reducing stigma and reluctance to provide abortion. Previous research has shown that medical students’ attitudes can predict whether they will perform abortions. The objective of our study was to explore attitudes toward abortion among medical interns in Maharastra, India. Study Design: A cross-sectional survey was carried out among 1,996 medical interns in Maharastra, India. Descriptive and analytical statistics interpreted the study instrument and significant results were presented with a 95% confidence interval. Results: A majority of the respondents rated their knowledge of sexual and reproductive health as good, but only 13% had any clinical practice in abortion care services. Most participants agreed that unsafe abortion is a serious health problem in India. However, many considered abortion to be morally wrong, one fifth did not find abortions for unmarried women acceptable, and one quarter falsely believed that a woman needs her partner or spouse’s approval to have an abortion. Conclusion: Despite good self-assessed knowledge of reproductive health, disallowing attitudes toward abortion and misconceptions about the legal regulations were common. Knowledge and attitudes toward abortion among future physicians could be improved by amendments to medical education, potentially increasing the number of future providers delivering safe and legal abortion services.


Ingrid H. Solheim


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    FC06

    Seeking clandestine abortion safely: Unwanted pregnancy and medical abortion among young women in Dar es Salaam

    Ingrid H. Solheim1 ,2, Catherine Kalabuka3, Karen-Marie Moland1 ,2, Andrea B. Pembe4, Astrid Blystad1 ,2
    1Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway, 2Centre for International Health, University of Bergen, Bergen, Norway, 3CSK Research Solutions, Dar es Salaam, Tanzania, 4Muhimbili University of Health and Associated Sciences, Dar es Salaam, Tanzania

    Objective: The aim of this project was to enhance knowledge about the challenges faced by young women with unwanted pregnancies living in an urban, low-income settings where abortion is criminalised but assumed to be performed clandestinely with increasing off-label use of the recently registered drug misoprostol.
    Methods: The study was explorative, involving the use of in-depth interviews with women ≤ 25 years having performed medical abortion (n = 15), postabortion care providers (n = 16) and pharmacy workers (n = 10) and informative interviews with different stakeholders (n = 15). Focus group discussions (FGDs) were performed with women from low-income areas and students ≤ 25 years (n of FGDs = 10).
    Results: To induce abortion is viewed as a common practice by young women in Dar es Salaam. While hospitals are often considered the safest providers of abortion, misoprostol is viewed by many as the best method. Misoprostol is perceived to be more accessible, simple to use, private, cheap and less dangerous compared to surgical hospital procedures. Many health workers experience fewer and more manageable complications among their postabortion care patients related to misoprostol use for abortion. However, girls often view the procedure as a ‘matter of chancing'.  Low drug doses are typically used, and there is little follow-up and lack of information from vendors concerning potential complications. Finally, even though ‘miso' is commonly known among young women, traditional methods are still the cheapest and therefore the only option for some.
    Conclusion: In Dar es Salaam misoprostol can be accessed clandestinely for pregnancy termination through drug stores or health facilities offering different levels of safety and costs. For many young women this is the preferred abortion method but use, and especially safe use, is limited to those who can afford it.


Karthik Srinivasan



Amina Starvidis


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Jody Steinauer


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Vesna Stepanic


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    CS04.4

    Avoiding unwanted pregnancies in Zagreb

    Vesna Stepanic, Vlastimir Kukura
    Clinical Hospital Merkur, Zagreb, Croatia

    An unwanted pregnancy is associated with an increased risk of serious problems for the mother and baby.
    According to the Croatian National Institute of Public Health, in 2014, there were 3,020 legal terminations of unwanted pregnancies in Croatia - less than in previous years. It is unclear whether the reason for the decrease is that the abortion rate is actually decreasing or because of inappropriate data collection.
    Contraception and termination of unwanted pregnancies are closely related. Reproductive health education should emphasise the necessity of contraception use if there is no chance to cope with an unwanted pregnancy, no matter what reasons a woman might have for such a decision.
    Improved education and counselling about responsible sexual behaviour is considered to be the optimal method of decreasing the number of unwanted pregnancy terminations.
    To this end, the first symposium on “Avoiding Unwanted Pregnancies” with assistance and a grant from the European Society of Contraception and Reproductive Health, was held in Zagreb in May 2015.
    The Symposium was dedicated to addressing the global public health problem of unwanted pregnancies by convening experts involved with this issue to engage in lively discussion, develop conclusions and propose guidelines for further action in terms of counselling and education about responsible sexual behaviour.
    In conclusion, the necessity of counselling and education about responsible sexual behaviour was emphasised, as well as the necessity of having further discussion about the institution of conscientious objection and about changes in laws regarding pregnancy termination.
    The organiser warmly hopes that the importance of the Symposium will be recognised by national authorities. However, this issue is also a political problem and no matter how much the professionals want to do there are limits that are established by the government and social constraints.


Jaydeep Tank


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Kusum Thapa



George Thomas



Natasa Tul Mandic



David Turok


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    CS05.3

    IUD for EC

    David Turok
    University of Utah, Salt Lake City, Utah, USA

    Widespread availability of oral emergency contraception (EC) has failed to have a public health effect on reducing unintended pregnancies. The EC visit presents an opportunity to initiate a highly effective method of contraception in a population at high risk of unintended pregnancy at a time when they actively seeking to avoid pregnancy. The copper IUD is the most effective method of EC and continues to provide contraception as effective as sterilisation for up to 12 years; it should be offered as the first line method of EC wherever possible. Clinic-based EC visits should include access to the copper IUD as optimal care and should ideally include access to all highly effective methods of contraception. At the conclusion of this programme, participants will be able to:

    • Provide women with user specific recommendations for the most effective methods of EC
    • Optimise strategies for the use of the copper IUD as EC and initiating highly effective methods of contraception
    • Identify opportunities to initiate highly effective contraception with EC

André Ulmann



Paul Van Look



Melinda Vanya


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    Postpartum contraceptive preference in South-Eastern Hungary

    Melinda Vanya1, Ivan Devosa2, Zoltan Kozinszky3, Katalin Barabás2, György Bartfai1 1Department of Obstetrics and Gynaecology, Faculty of General Medicine, Albert Szent-Gyorgyi Health Centre, University of Szeged, Szeged, Hungary, 2Institute of Behavioural Science, Faculty of General Medicine, Albert Szent-Gyorgyi Health Centre, University of Szeged, Szeged, Hungary, 3Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, University of Tromsø, Tromsø, Norway - vmelinda74@gmail.com

    Objective: The objective of our study was to determine the contraceptive practices among mothers in the postpartum period. Patients and methods: All women who delivered between 1st September 2013 and 31st March 2014 in the Department of Obstetrics and Gynaecology, University of Szeged were invited to participate in the cross-sectional survey. We prepared a 63-item questionnaire form which was asking socioeconomic and demographic background, contraceptives methods before/after delivery, sexual activity after delivery, length and effectiveness of lactational amenorrhoea as a natural contraceptive. Structured questionnaires have been sent by code to a secured webpage by email. Results: Data from 200 questionnaires were analysed. The average age of women in the study group is 26 (±4.96) years. 18.4 % of women didn’t use any contraceptive methods at 6 weeks after delivery because of the lactational amenorrhea. 53.2 % of the 200 couples didn’t used reliable contraceptive methods such as (40.7%) condom, (10.7%) withdrawal, (0.9 %) vaginal douche and (0.9%) spermicide. 12.6 % of women used progestogen-only pill (POP), 3.7 % of women reported that they used an intrauterine device, 4 % of participants were using an intrauterine system and 2.7 % of the study group underwent sterilisation. The influence of planned pregnancy and the father’s income were significantly higher among the reliable contraceptive user than in the less reliable contraceptive user (p=0.002 and p=0.036) Conclusion: In our setting 81.6% of women have used a contraceptive method in the postpartum period. The POP was the most preferred method. Acknowledgement: The project was supported by the European Society of Contraception and Reproductive Health.


L. Vicente


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    Termination of pregnancy at women’s request in
    Portugal – data from the national registry
    2008–2011
    Vicente, L; Henriques, A; Almeida, T; Freire, A;
    Nogueira, P; Ramos, M
    Directorate General of Health, Portugal
    Termination of pregnancy (TOP) at women’s request was legalised
    in Portugal up to 10 weeks of gestation, in June, 2007. All public
    and private services that deliver TOP care are recorded in a
    national web-based database. It is a record of episodes of TOP
    and not a register of users, in which anonymity and
    confidentiality is guaranteed, to be used for statistical purposes of
    public health. Induced TOP at a woman’s request represent 97%
    of all legal induced TOPs. Sociodemographic charactristics of the
    users, distribuition by time of the procedure and contraception
    after TOP, will be presented and analysed. In Portugal more than
    65% of terminations are performed within the National Health
    Service (NHS), where medical TOP is mainly used (96%). Annual
    variation of the induced TOP at women’s request: the largest
    annual growth occurred between the years 2008 and 2009 – with
    an increase of 6.7%. Between 2009 and 2010, the variation was
    1.8% and 1.2% between 2010 and 2011.


Johanna Westenssen



Carolyn Westhoff



Rebecca Wilkins


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    Addressing abortion stigma in service delivery: the experience of Pakistan and Burkina Faso

    Rebecca Wilkins1, Asifa Khanum2 1International Planned Parenthood Federation, London, UK, 2Rahnuma Family Planning Association of Pakistan, Lahore, Pakistan - rwilkins@ippf.org

    Restrictive legislation and limited service provision remain obstacles to women who seek abortion services. These obstacles are worsened by the impact of abortion stigma and associated secrecy, shame, guilt and fear. Stigma prevents or delays access to safe abortion services as well as making lawmakers reluctant to improve legislation to facilitate access to abortion information and services. As part of its commitment to reducing abortion stigma at all levels, IPPF commissioned research to understand its effect on women accessing services through IPPF Member Association clinics. In-depth qualitative research using semi-structured interviews with abortion clients, service providers and client partners was conducted at Member Association clinics in Pakistan and Burkina Faso. The research aimed to identify the specific causes and manifestations of abortion stigma and to inform interventions designed to reduce abortion stigma. The research found commonalities in abortion stigma in Pakistan and Burkina Faso, as well as some issues that were unique to each country setting. The clinic client pathways, misconceptions and lack of knowledge about abortion, pre-abortion counselling, and the timeliness of seeking medical care were among some of the issues found to have an impact on, or were impacted by clients' experience of stigma. In both countries women who accessed abortion services had a high level of self-stigma which impacted on their expectations of quality of care in the clinics. Abortion stigma is an unspoken reality that significantly impacts both the attitudes and practices of medical professionals and women who access abortion services. However, the nature of abortion and the stigma surrounding it makes this a challenging topic to collect data and information on. The research findings illustrate the need for the pilot testing of interventions at both the community and service delivery levels in order to address abortion stigma through a more comprehensive and systematic approach.


Wei-Hong Zhang


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    FC08

    Contraception needs and induced abortion in China: two cross-sectional studies

    Wei-Hong Zhang1 ,2, Shangchun Wu3, Marleen Temmerman1 ,4
    1International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium, 2Research Labouratory for Human Reproduction, Faculty of Medicine, Université Libre de Bruxelles (ULB), Brussels, Belgium, 3The national Research Institute for Family Planning (NRIFP), China, Beijing, China, 4The department of Obstetrics and Gynecology, Women’s health Centre of Excellent East-Africa, the Faculty of Health Science, Aga Khan University, Nairobi, Kenya

    Objective: In China, the official estimated annual number of induced abortions ranges from 7 million to 13 million in recent years. Chinese family planning (FP) services, with a major concern on birth control among married couples, have been a political priority for more than thirty years prior to the two child policy implemented recently.  Abortion is commonly used to end unintended pregnancy. This study aimed to describe the characteristics of abortion seekers in two, time periods of studies in China.
    Methods: Two cross-sectional surveys were conducted in 2005 and 2013 respectively and similar methods were used for collecting data.  A questionnaire was completed by abortion service providers for all women seeking abortion within 12 weeks of pregnancy during a period of two months. The information included self-reported demographic & economic characteristics, history of induced abortion and practices regarding contraception. Twenty-four hospitals from 3 cities in 2005 and 295 hospitals from 30 provinces in 2013 participated in the studies, respectively.
    Results: Total numbers of participants consisting of 7291 in 2005 and 79,174 in 2013 were included in the analysis.  A higher proportion of subsequent induced abortions were reported in 2013 (65%) than in 2005 (35%).  The main reason of current unintended pregnancy was non-use of any contraception (65.1%) in 2005 and failure of contraception (50.3%) in 2013. Condoms were the most used contraceptive method among married and unmarried women in both periods of studies, but the proportions of consistent and correct utilisation of condoms were low in both time periods. 
    Conclusion: The large numbers of induced abortions are primarily due to contraceptive failure or no use of contraception. Postabortion FP services are often lacking in hospital settings where the majority of induced abortions were performed. Integrating postabortion family planning into the existing health system is urgently needed and is an opportunity and a challenge in China.


Flavia Zimmermann


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    Current medical and multi-sectoral challenges in sexual assault responses in Malta

    Flavia Zimmermann Three Cities Foundation, Vittoriosa, Malta - chairwoman@threecities.org

    The current legal and social framework in Malta poses a set of specific and compelling challenges for evidence-based medicine and service provision in the context of sexual violence and contraceptive care. This presentation aims to give an objective overview of facilities available to female victims of sexual violence in Malta. It will review services and interventions for underage and adult survivors of sexual assault, the circumstances (including withholding of emergency contraception) which affect standards of Care-and-Evidence in the medical, forensic and psycho-social sectors - along with the range of consequences on patients' health. A summary of critical or urgent issues to redress the effects of this significant public health crisis will be presented. It will also include victimology approaches for survivors' recovery. The main objective of this presentation is to initiate an ongoing discussion about viable reforms to develop an ethical, humane and effective multi-sectoral service. The evidence to be presented has been gathered and updated since 2010, as part of a previous Daphne-Cosai III-funded international project to assess and improve sexual assault services in Europe.


Aleksandar Zivanovic


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    FC12

    Analysis of cervical resistance during continuous controllable balloon dilatation

    Petar Arsenijevic, Slobodan Arsenijevic, Aleksandar Zivanovic, Slavica Djukic Dejanovic
    Faculty of medical sciences, Kragujevac, Serbia

    Background: Hydraulic dilatation is a novel method of cervical dilatation that is based on continuous and controllable dilatation by the pumping of fluid into the balloon extension of the system for continuous and controllable balloon dilatation (CCBD). The main advantage of this procedure is that it allows control and insight into the process of cervical dilatation.
    Methods: For the purposes of our research, we created a new and upgraded system for continuous and controllable balloon dilatation (CCBD), which consists of a programmed hydrostatic pump connected to a balloon extension. With regards to our aim to precisely measure and determine the location of the cervical resistance, we placed two pressure-measuring films on the top and on the bottom of the balloon extension. This study included 42 women in whom cervical resistance was measured prior to the suction curettage.
    Results: Cervical dilatation and measurement of cervical resistance were successful in all women. The analysis of the pressure-measuring films showed that the points of highest resistance are located in the zone of the internal cervical os and that these values are much higher than those in the zone of the external cervical os (0.402 versus 0.264 MPa at the upper pressure-sensitive film; 0.387 versus 0.243 MPa at the lower pressure-sensitive film). This study also showed that an increase in cervical resistance in the zone of the internal cervical os was followed by an increase in cervical resistance in the zone of the external cervical os.
    Conclusion:
    During continuous controllable balloon dilatation, the internal cervical os is the centre of cervical resistance, and the values do not decline with the number of miscarriages or the number of previous births.