Authors
A B C D E FBela Ganatra
Speeches:
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Update on unsafe abortion Despite technological advances, unsafe abortion
continues as a public health problem and
important cause of maternal mortality globally. As
per WHO’s recent estimates, currently, about 22
million unsafe abortions occur every year—98%
of them in the developing world. The global rate
is 14 unsafe abortions per 1,000 women 15-44
years, but there are wide disparities acrossgeographic regions, with Eastern and Middle
Africa having the highest rate of unsafe abortion
at 36 unsafe abortions per 1,000 women aged
15-45. Adolescents and poor women also bear a
disproportionate burden.
Sexuality education, access to affordable,
effective contraception and to lifesaving care to
treat complications can all help to reduce the
unintended pregnancies or the morbidity and
mortality from unsafe abortion, but access to
safe, legal abortion care remains central to
dealing with the problem. Barriers include health
system, finances, regulations, and policies,
stigma and the ways existing laws and regulations
are interpreted and implemented.
Effective interventions do exist and progress
has been made in recent years, as is evidenced
by a decrease in case-fatality rates from unsafe
abortion. The Safe Abortion: Technical and
Policy guidance for health Systems (WHO, 2012)
presents the public health and human rights
based evidence to address the issue. -
Non-physician providers’ roles in access to safe abortion care: an overview of evidence
Bela Ganatra WHO, Geneva, Switzerland - ganatrab@who.int
Unsafe abortion continues to constitute a major mortality and morbidity burden especially in the developing world (21.6 million unsafe abortions; 13% of maternal deaths). Access to safe abortion is limited by numerous barriers but one of the most critical is the lack of trained providers. Many countries limit abortion service provision to specialist doctors. However, most developing country regions suffer from a critical short supply of OBGYNs , generalist doctors and even midwives. Areas with a critical shortage of health service providers also have the highest burden of unsafe abortion-related deaths. Expanding the provider base to include a range of other health workers is a recognized strategy to expand access to health services and scale up implementation of interventions of public health significance including for safe abortion care. Medical abortion as an effective and recommended technology has made it even more relevant to expand health workers' roles in provision of safe abortion care and to look at self-assessment as ways of reducing the need for health worker time and resources. There is a growing body of research evidence on the issue. Additionally, in several countries use of some cadres of non-physician providers is already part of practice (though often not of policy). The Department of Reproductive Health and Research at the WHO is currently reviewing and synthesizing evidence related to task shifting and task sharing in the provision of safe abortion and postabortion care with the aim of developing specific recommendations on the issue. The evidence base includes comparative studies, qualitative data and country case studies to synthesize programmatic experience form countries where non-physician providers have already been providing such care. The presentation will give a broad overview of the evidence on this topic and the process of the guidelines development.
Sophie Gaudu
Speeches:
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Results from a 4-year study on 15447 medical abortions performed by privately-practicing general practitioners and gynecologists in France
Sophie Gaudu, Hôpital Cochin-Saint Vincent de Paul, Centre d’orthogénie et de planification familiale
Co-authors: Drs I. Dagousset, L. Esterle, S. Eyraud, P. Faucher, D. Hassoun, and M. Teboul
The French legislation allows women to get a medical abortion at home under the control of GPs or gynecologists in private surgeries. In 2007, these abortions represented almost 9 % of induced abortions in France and 18% of the medical abortions (DREES, Etudes et résultats, n°712, 2009). The process is strictly defined by law. The termination of pregnancy (max 49 amenorrhea days) should be carried out by doctors who have signed a contract with a referral hospital. This hospital takes the charge of treating any complication that may arise. REVHO, a network of private physicians and hospitals, has been created in Paris and suburban areas in order to train the doctors, to set-up contract-based links with hospital family planning centers and to evaluate the quality of the method as well as the users’ satisfaction.
Five years after the creation of REVHO, 20 200 abortions at home using mifepristone and misoprostol have been performed within the network. This paper presents the results of 15 447 abortions carried out in the network. Data were entered on a PC held database and analyzed using EPI INFOTM Version 6. The women were 41 days of amenorrhea on average (90 % between 35 and 49 days) and their age varied from 14 to 55 (median: 28 years).
From 2005 to 2008, 162 physicians with private practices were involved: respectively 44 % and 56 % of abortions were carried out by GPs and gynecologists. The quantity of supervised abortions varied from 1 to more than 3600 per physician on the 4-year period. Twenty-three physicians (14%) performed more than 200 medical abortions and three, more than 1500.
About 80% of the abortions were followed up two weeks later. The success rate (as defined by the absence of surgical completion) was 97.9%, which is among the highest rates reported for medical abortion. There was a statistically significant difference between GPs (success rate of 98.2 %) and gynecologists (success rate 97.5 %) which can be discussed. The global rate of continuing pregnancy was 0.7%. No serious complication was observed.
These results demonstrate that medical termination of pregnancy at home can be performed under the control of physicians in their private practices without increasing the risks of failures or complications. GPs are efficient as well as gynecologists, which could allow an increase of the number of practitioners involved and contribute to health care proximity. Five years after its creation, REVHO demonstrated its capacity to incorporate the medical abortion into primary practices, with referral hospital services available for complications or surgical completions.
Kristina Gemzell-Danielsson
Kristina Gemzell Danielsson is professor, senior consultant and Chair of Obstetrics and Gynaecology and the Director of the WHO collaboration centre for Research in Human Reproduction at Karolinska Institutet, Sweden. She is a pioneer in research on medical abortion with mifepristone and a prostaglandin analoge which was first developed at the WHOcentre. She is a member of the International Committee for contraceptive research (ICCR), Population Council, and President of FIAPAC. In 2012 she was honoured by the FIGO award in recognition of her research. In 2013 she was invited as the Aw Bon Haw Honorary Professor, Hong Kong University.
Speeches:
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More than 15 years of experience – new developments,
Kristina Gemzell Danielsson. MD. PhD, Associate Professor in Obstetrics and Gynecology at the Karolinska Institute, Stockholm, Sweden
Senior consultant in obstetrics and gynecology at the clinic of Sexual and Reproductive Health, Department of Woman and Child Health, Division for Obstetrics and Gynecology.at the Karolinska Hospital, senior research position at the Karolinska Institute sponsored by the Swedish Research Council
Head of the WHO collaborating centre for research in Human Reproduction, Karolinska Hospital, head of the research group at the WHO-centre. Supervisor of 3 PhDs and 9 PhD students. research nurses and laboratory technicians.
Secretary Swedish association of Obstetrics and Gynecology, task force on Family Planning
Board member of FIAPAC (International federation of abortion and contraceptive associates), and ICMA (International consortium of medical abortion)
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Medical abortion with a combined regimen of mifepristone and a prostaglandin analogue was first approved in France in 1988 followed by approvals in the UK and Sweden, and has been used in China since 1992. In China and France medical abortion is used to 49 days amenorrhea. In the UK and Sweden the method is approved to 63 days amenorrhea. Today medical abortion is available in around 30 countries. During the last 15 years since introduction of the method research has focused mainly on the following issues: To find the optimal dose of mifepristone, the optimal type, dose and route of administration of prostaglandin and to increase acceptability of the method
Pharmacokinetic studies have shown that single doses of mifepristone above 100 mg resulted in similar serum concentrations. Randomised controlled trials have shown that 600 mg of mifepristone is equally effective as 200 mg when followed by a sufficient dose and suitable type of prostaglandin. The prostaglandin most commonly used today is misoprostol (Cytotec, Pfizer), a prostaglandin E1 analogue widely available for the prevention of gastric ulcer in patients taking non-steroidal anti-inflammatory drugs. Although licensed for oral use vaginal administration of misoprostol is becoming a common practice in medical abortion. Several clinical studies have found that vaginal administration is more effective than oral administration. When the absorption kinetics was compared between oral and vaginal treatment it was shown that the systemic bio-availability after vaginal misoprostol was three times higher than after oral misoprostol. This was directly reflected in the effect on uterine contractility. A drawback with the vaginal route is the large individual variation in plasma levels suggesting inconsistent absorption through this route. Furthermore most women prefer to take the tablets by the oral route. Recently the new route of sublingual administration has been described. Preliminary studies suggest that sublingual administration is a promising method for medical abortion. This is supported by pharmacokinetic and uterine contractility data indicating that this is probably the most potent route to administer misoprostol in its present form.
Current research also focuses on the possibility to reduce the time interval between mifepristone and misoprostol. Furthermore home administration of prostaglandin has been shown to be safe and effective, to reduce the number of visits to the clinic and to be preferred by many women in both developed and developing countries
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25 years of mifepristone
Kristina Gemzell Danielsson
Karolinska Institutet/ Karolinska University Hospital, Dept of Woman and Child Health, Division of Obstetrics and Gynecology, Stockholm, Sweden - Kristina.Gemzell@ki.se
Based on the combined regimen of a progesterone receptor modulator, RU 486, developed by Roussel Uclaf and the Nobel prize awarded discovery of prostaglandins, medical abortion with mifepristone and a prostaglandin analogue was developed into a safe and effective method for induced abortion in the 1980ies. A team of researchers led by Pr. Baulieu was critical in the development of mifepristone (RU486) as was the French Ministry of Health. Further researches from Pr. Bygdeman’s team in Sweden described the combined regimen with prostaglandin. Then the WHO and later the company Exelgyn further endorsed this method which provided women with an alternative to surgery. Since the 1980ies research has focused on improving the regimen and care of medical abortion. Today the prostaglandin analogue of choice is misoprostol and medical abortion is a safe option for termination of pregnancy at all gestational lengths. An increasing number of women worldwide benefit from this development. Besides even if there are still differences from country to country not only in access to medical abortions (legal situation, home use, gestational age) but also in the clinical routines of medical abortion care (protocol, reflection delay), Medical methods for termination of pregnancy tend to replace the surgical options in many countries. There is also an increasing recognition that medical abortion can improve access to safe abortion in countries with restrictive abortion laws or lack of abortion providers. However, several barriers remain that limit global access to safe abortion services. Simplifying medical abortion could potentially contribute to increased access and acceptability. Possible approaches include the option to self-administer misoprostol at home, also beyond 9 weeks of gestation. Another possibility is task sharing with midlevel providers to allow these health care professionals to be more involved with the care of healthy women undergoing medical abortion. These possibilities have major impact to increase access to safe induced abortion in countries were medical resources are scarce.
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Increasing access to safe
abortion servicesMedical abortion with mifepristone and a
prostaglandin analogue was developed into a
safe and effective method for induced abortion
in the 1980’s. Today the prostaglandin analogue
of choice is misoprostol and medical abortion
is a safe option for termination of pregnancy
at all gestational lengths. However, several
barriers remain that limit global access to safe
abortion services. Simplifying medical abortion
could potentially contribute to increased access
and acceptability. Possible approaches include
the option to self-administer misoprostol at
home. Another possibility is task sharing with
midlevel providers to allow these health care
professionals to be more involved with the care
of healthy women undergoing medical abortion.
This possibility is likely to have major impact
to increase access to safe induced abortion in
countries were medical resources are scarce. A
simplified treatment regimen may also include
home self-evaluation of complete abortion, an
option which is currently being investigated. -
Mechanism of action of Emergency contraception
Kristina Gemzell MD, PhD, Professor, Kristina.gemzell@ki.se
Dept. of OB/Gyn, Karolinska University Hospital/Institutet, Stockholm, Sweden
Recently post-coital treatment with levonorgestrel (LNG) and the antiprogestin
mifepristone has emerged as the most effective hormonal methods available for
Emergency contraception and LNG in a single dose of 1.5mg has become the
recommended emergency contraceptive pill. However the mechanism(s) of action of these
methods when used for emergency contraception in humans remains largely unknown.
We therefore evaluated the effect of LNG in doses effective for emergency contraception,
on ovulation as well as tubal and endometrial development. Treatment with 1.5 mg LNG in
the late follicular phase inhibited the LH surge in all subjects. No effect on endometrial
development could be found either following preovulatory or postovulatory LNG treatment.
LNG was shown to have no effect on the tubal steroid receptor levels. Furthermore LNG
had no effect on endometrial progesterone receptor concentration and other suggested
markers of endometrial receptivity remained essentially unchanged. Taken together
available data suggest that emergency contraception with a single dose of 1.5 mg of LNG
inhibit or delay ovulation but does not prevent fertilization or implantation.
Increased knowledge on mechanism of action could hopefully increase the acceptability
and thus availability of these methods, to offer women a chance to prevent an unwanted
pregnancy and thus reduce the numbers of induced abortions. -
Medical abortion at 7 - 9 weeks gestation: Considerations and challenges
Kristina Gemzell (Sweden)
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden
kristina.gemzell@ki.se
Medical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined with a prostaglandin has been available in Europe since 1988 for termination of pregnancy up to 49 days of amenorrhea. In the UK (1991), Sweden (1992) and later on Norway the method is approved up to 63 days of amenorrhea. Recently medical abortion up to 63 days has been approved also in the rest of Europe. With the recommended regimen the high efficacy and acceptability of the method can be maintained beyond 49days. Critical aspects to consider when medical abortion is used beyond 49days of pregnancy will be discussed in the workshop. These include the regimen of mifepristone and misoprostol, the interval between the drugs, pain medication and home-use of misoprostol. An increasing number of women in Europe opt for this choice instead of surgical abortion. A shift which is expected to continue in the next years world-wide. It is crucial that providers are familiar with the method and aware of the critical differences compared to medical abortion before 49 days of pregnancy.
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Medical abortion general recommendations
Kristina Gemzell, MD, PhD, Professor
Dept. of OB/Gyn, Karolinska University Hospital/Institutet, Stockholm, SwedenMedical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined
with a prostaglandin has been available in Europe since 1988 for termination of pregnancy
up to 49 days of amenorrhea. In the UK (1991), Sweden (1992) and later on Norway the
method is approved up to 63 days of amenorrhea. Today medical abortion is available in
around 30 countries. Since the introduction of the method research has focused mainly on
the following issues: To find the optimal dose of mifepristone, the optimal type, dose and
route of administration of a prostaglandin analogue, to increase acceptability of the method
and to define the duration of pregnancy for which it can be used.
During this time it has been shown that the dose of mifepristone can be reduced without
affecting its priming effect on the myometrium and cervix. Misoprostol has emerged as the
most optimal prostaglandin analogue with its effect being dependent on the duration of
pregnancy, and on the dose and route of administration. Based on pharmacokinetics and
effect on uterine contractility, it could be hypothesised that a newly developed slow-release
form of misoprostol may offer an alternative to conventional misoprostol. Our studies
further confirm the safety, efficacy and high acceptability of home-use of misoprostol.
Home-use of misoprostol allows women more flexibility, privacy and control in their
abortions.
With the introduction of mifepristone the non-surgical, non-invasive methods for 2nd
trimester abortion could be dramatically improved and has become the recommended
method in many centres. More recently medical abortion has also become increasingly
used in the interval 9 to 13 weeks.
In conclusion the combined treatment with mifepristone and misoprostol is a highly
effective and safe method to terminate pregnancy provided that the dose and route of
misoprostol is adjusted to the pregnancy length. Detailed counseling, adequate pain
management and information and the possibility of getting advice on the telephone are
likely to increase acceptability. -
Beyond the first trimester: Medical methods
Kristina Gemzell Danielsson MD, PhD, Dept of Obstetrics and Gynecology,
Karolinska University Hospital/ Institute, Stockholm, Sweden
Second trimester abortion constitute 10-15% of all induced abortions but are responsible for two thirds of all major complications. The non-surgical methods to terminate 2nd trimester abortion have shown a considerable development during the last 30 years. In the beginning of the 70ies prostaglandins become available on this indication. The non-invasive mode of administration has certainly facilitated the treatment and reduced the risk for complications. With the introduction of mifepristone the method could be further improved.
Mifepristone has been registered in Sweden since 1992 for termination of early pregnancy until 63 days and from 1994 for termination of second trimester pregnancy in combination with gemeprost. With the approved regimen 600 mg mifepristone followed by 1 mg gemeprost vaginally every 6 hours the median prostaglandin to abortion interval was shown to be 9.0 (1.4-40.5) hours for primigravidae and 7.2 (0-152.5) hours for multigravidae. The medium number of gemeprost pessaries to induce abortion was 2. Our data confirms the efficacy and safety of mifepristone combined with gemeprost for termination of second trimester pregnancy when used on a routine basis in the clinic. Today, another prostaglandin analogue, misoprostol, has been shown to be an attractive alternative to gemeprost with higher efficacy and a lower rate of side effects. Various regimens of misoprostol with or without mifepristone have been investigated. Recently it has been shown that sublingual administration of misoprostol is also an effective alternative for second trimester abortion.
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Medical methods: Advantages and disadvantages
Kristina Gemzell (Sweden)
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden
kristina.gemzell@ki.se
Delayed diagnosis of fetal anomalies, logistic and financial difficulties in obtaining abortion services, and failure to recognize an undesired pregnancy in the first trimester all contribute to the continuing need for late abortions. Second trimester abortion constitutes 10–15% of all induced abortions worldwide but is responsible for two-thirds of all major abortion-related complications. During the last decade, medical methods for second trimester induced abortion have shown a considerable development and have become safe and more accessible.
Today, in most cases, safe and efficient medical abortion services can be offered or improved by minor changes in existing health care facilities. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of second trimester pregnancy. In some places medical abortion has become the recommended method for second trimester abortion leading to increased access. In countries where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective, although a higher total dose is needed and efficacy is lower than for the combined regimen. Therefore, whenever possible the combined regimen should be used. Efforts should be done to reduce unnecessary surgical evacuation of the uterus after expulsion of the fetus and future studies should focus on improving pain management. More studies are also needed to explore the safety of medical abortion regimens in women with a previous caesarean section or uterine scar. Advantages and possible disadvantages with medically induced abortion in the second trimester will be discussed.
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Midlevel versus physician provision of medical
termination of pregnancy– a randomised controlled
study
Gemzell-Danielsson, K1; Johansson, M1;
Salomonsson, E2; Gomperts, R1; Kopp Kallner, H1
1 Department of Obstetrics and Gynaecology, Karolinska Institute,
Stockholm, Sweden; 2 Karolinska University Hospital, Stockholm,
Sweden
Objective: To evaluate feasibility, efficacy and acceptability of
midlevel provision of medical termination of pregnancy (TOP) in
clinical practice through a randomised study of midwife or
physician examination and counselling prior to medical TOP.
Background: Midlevel provision of medical TOP is common in
less developed countries and has been shown to be acceptable.
However, access to a gynaecologist is a limiting factor in medical
TOP also in developed countries and causes unnecessary waiting
periods. In developed countries vaginal or abdominal ultrasound
is routinely performed before TOP and has been an obstacle to
midlevel provision of medical TOP.
Methods: Two midwives highly experienced in TOP care with no
previous training in ultrasound were trained in vaginal ultrasound
of early pregnancy. Inclusion criteria for this study were being
healthy with no ongoing medication and willing to participate.
Women signed informed consent and were randomised
accordingly. All patients with pregnancy longer than 63 days
gestational age or without having visible intrauterine pregnancy
were referred to a gynecologist.
Results: So far 1200 patients have been included. A total of 1260
women will be randomised. No serious adverse events have been
recorded. Preliminary results show that acceptability of midlevel
provision of medical TOP is higher than physician provision.
Conclusion: Midlevel provision of medical TOP in a clinical
setting in a developed country is highly feasible. Midwives can be
trained in vaginal ultrasound and thereby provide the complete
spectrum of early TOP services. -
Misoprostol and management of missed and incomplete abortion
Kristina Gemzell-Danielsson, Professor, MD, PhD, Dept. of Woman and Child Health, Div. of Obstetrics
and Gynecology, Karolinska Institutet/ Karolinska University Hospital, Stockholm, Sweden
Misoprostol, a synthetic prostaglandin E1 analogue, is commonly used for medical abortion, cervical priming, the management of miscarriage, induction of labor and the management of postpartum hemorrhage. Thus, misoprostol is a very versatile drug in obstetrics and gynecology. Knowledge of the pharmacokinetic profiles is important for designing regimens for various applications. Misoprostol can be given orally, vaginally, sublingually, buccally or rectally. Studies of misoprostol’s pharmacokinetics and effects on uterine activity have demonstrated the properties of the drug after various routes of administration. These studies can help to design the optimal dose and route of administration of misoprostol for the management of missed and incomplete abortion.
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Mode of action: No evidence for effect post-fertilization
Kristina Gemzell (Sweden)
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden
kristina.gemzell@ki.se
Recently post-coital treatment with levonorgestrel (LNG) and the antiprogestin mifepristone has emerged as the most effective hormonal methods available for emergency contraception. LNG in a single dose of 1.5mg has become the recommended emergency contraceptive pill. However the mechanism(s) of action of these methods when used for emergency contraception in humans remains a matter of concern.
We therefore evaluated the effect of LNG in doses effective for emergency contraception, on ovulation as well as tubal and endometrial development. Treatment with 1.5 mg LNG in the late follicular phase inhibited the LH surge in all subjects. No effect on endometrial development could be found either following preovulatory or postovulatory LNG treatment.
LNG was shown to have no effect on endometrial progesterone receptor concentration and other suggested markers of endometrial receptivity remained essentially unchanged. The effect of mifepristone and levonorgestrel was further studies in an in vitro implantation model. Taken together our data suggest that emergency contraception with a single dose of 1.5 mg of levonorgestrel acts mainly to inhibit or delay ovulation but does not prevent fertilization or implantation. Increased knowledge on mechanism of action could hopefully increase the acceptability and thus availability of these methods, to offer women a chance to prevent an unwanted pregnancy and thus reduce the numbers of induced abortions.
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News in emergency contraception
Kristina Gemzell Danielsson, MD, PhD, Professor Dept. of Obstetrics &.Gyneacology,
Karolinska University Hospital / Karolinska Institutet, Stockholm, Sweden
Unintended pregnancy is a global reproductive health problem. Emergency Contraception (EC) provides women with a safe means of preventing unwanted pregnancies after having unprotected intercourse. While 1.5 mg of levonorgestrel (LNG) as a single dose has been the gold standard EC regimen, a single dose of 30 mg ulipristal acetate (UPA) has recently been approved for EC use up to 120 hours of unprotected intercourse with similar side effect profiles as LNG. The main mechanism of action of both LNG and UPA for EC is delaying or inhibiting ovulation. However, the ‘window of effect’ for LNG EC seems to be rather narrow, beginning after selection of the dominant follicular and ending when luteinizing hormone peak begins to rise, whereas UPA appears to have a direct inhibitory effect on follicular rupture which allows it to be also effective even when administered shortly before ovulation, a time period when use of LNG is no longer effective. These experimental findings are in line with results from a series of clinical trials conducted recently which demonstrate that UPA have higher EC efficacy compared to LNG and thus represents a new evolutionary step in EC treatment.
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Recent developments
Kristina Gemzell MD, PhD, Professor
Dept. of OB/Gyn, Karolinska University Hospital/Institutet, Stockholm, Sweden
Medical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined
with a prostaglandin has been available in Europe since 1988 for termination of pregnancy
up to 49 days of amenorrhea. In the UK (1991), Sweden (1992) and later on Norway the
method is approved up to 63 days of amenorrhea. Further development of the method will
be discussed in the workshop and include reduced doses of mifepristone, research on the
optimal type, dose and route of administration of the prostaglandin analogue and reduced
treatment intervals. Furthermore home-use of misoprostol allows women more flexibility,
privacy and control in their abortions. More recently medical abortion has also become
increasingly used in the interval 9 to 13 weeks as well as for midtrimester terminations with
an increased need to optimise pain management.
Anti-D immune globulin is given in most places after early abortion, although evidence is
lacking for the need of this intervention. As a result of the lack of evidence-based data, a
high number of women are receiving foreign immune globulins based on a questionable
indication. Furthermore this practice increases the costs of induced abortion. The need for
studies to clarify the indication of RH-prophylaxis is obvious especially when it comes to
medical abortion.
The generally accepted obligation in medicine to offer every patient the best evidence
based care should also apply to women with an unwanted pregnancy. An increasing
number of women in Europe now opt for medical instead of surgical abortion. A shift which
is expected to continue during the next year’s world-wide.
The need for more research to further improve the procedure, reduce side effects and
facilitate access is obvious. -
LS01.3
A tailored pregnancy test offers new possibilities to women for follow-up after medical abortion
Kristina Gemzell Danielsson
Karolinska Institutet, Stockholm, SwedenOne reason for limited access to medical abortion is that women are required to make multiple visits to the clinic. The purpose of a follow-up visit after medical abortion has been to ensure that pregnancy has successfully terminated, to detect complications and to start contraceptives. However, in case of complications women should not wait until a routine follow-up visit and, importantly, to help women start contraception after the abortion contraceptive counselling and provision should be done at the first visit to the abortion clinic and should not be postponed to the follow-up. Hence the main purpose of a routine follow-up visit after medical abortion is to detect an on-going pregnancy. Most service delivery guidelines recommend that women return at 2-3 weeks for a follow-up visit. However, an increasing number of women choose not to return for follow-up after their medical abortion.
Recently, studies have assessed alternative methods of follow-up after medical abortion, such as using a low-sensitivity urine pregnancy test, semi-quantitative urine pregnancy test or a high sensitivity pregnancy test followed by a telephone follow-up or through text message or online. A few studies have also investigated women’s experiences and perceptions of self-assessment and safety and effectiveness of self-assessment in low resource settings, including women who reside in rural areas, have low literacy levels and limited access to telephone and transport facilities.
Overall there is no increased risk of complications in women who self-assessed their treatment outcome compared with women who attend clinical follow-up. Self-assessment of treatment success after early medical abortion has a resource-saving potential. Women need to be counselled about the risk of continuing pregnancy and any strategy for self-assessment will need to be carefully assessed for test and user performance before introduction.
A simple, reliable test for self assessment allows a one-stop clinic for medical abortion. -
Today many women are reluctant to use any of the existing contraceptive methods due to side effects or fear of experiencing such effects. Unsafe abortion is a major contributor to maternal mortality. Therefore effective methods for contraception and safe and acceptable methods for termination of unwanted pregnancies are prerequisites for reproductive health, for gender equality and for the empowerment of women. New methods for contraception are also needed including improved methods for emergency contraception and new mechanisms of action as well as mode of delivery. Additional health benefits of contraceptive methods such as protection against various cancers, and a wide range of other benefits need to be better recognized. Based on their mechanisms of action Progesterone receptor modulators (PRMs) can be used for emergency contraception as well as regular contraception by various modes of delivery. Progesterone receptor modulators have been shown to be effective when used on demand post coital, as daily pills, once-weekly or once-a-month and is a well establish method for medical first and second trimester abortion. The use of progesterone receptor modulators for contraception and positive health benefits such as the possible protection against breast cancer as well as prevention of uterine leiomyomas and endometriosis deserves to be further explored. Progesterone receptor modulators have also been studied for “late emergency contraception” and for menstrual induction. Very early medical abortion (VEMA) before an intrauterine pregnancy can be visualized by ultrasound has been shown to be acceptable, safe and effective. Medical abortion is also highly effective later in the first trimester and can be self administered by women. Thus PRMs such as mifepristone if offered in a suitable dosage provides a model for a woman centred contraceptive continuum with added health benefits and increased autonomy for women.
Caitlin Gerdts
Speeches:
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Objectives: Existing data suggest that European women from countries with relatively liberal abortion laws travel to other European countries for abortion care, yet, few studies have described this unique experience. Methods: We analysed preliminary data from a five-year mixed method study conducted in the UK and the Netherlands. We examined characteristics of women travelling for abortion services from France, Italy, Germany, and other EU countries. We present results from 127 self-administered surveys collected in the UK (n=41) and in the Netherlands (n=86). From our data we identify main barriers to abortion care, estimate the costs incurred, and describe delays women experienced in the process. We contextualize these findings using data from in-depth interviews. Results will be updated based on the most up-to-date data. Results: Patients incurred large out-of-pocket costs. Only 5% of respondents in the Netherlands and 2.5% in the UK had the costs of the abortion procedure fully or partially covered by insurance and all clients incurred additional travel costs. The majority of participants were in their second trimester of pregnancy. On average, clients had considered an abortion over a month before their scheduled procedure, and almost all wanted to access abortion earlier in their pregnancy, but were delayed because they did not know they were pregnant and/or there were no abortion services near their residence. The main barriers to abortion services included surpassing the gestational age limit in their country of residence or not meeting the legal requirements. On average, clients travelled 3-6 hours to access services in the UK and the Netherlands. Conclusion: Women throughout Europe experience legal, social, and procedural barriers to abortion services in their countries of residence that cause them to have to travel for abortion services abroad. Women incur high costs in travelling for abortion services and in many cases are delayed in accessing wanted abortion services
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Smartphone applications (apps) have been shown to increase health knowledge and agency, and to improve medication adherence and health outcomes. Given increasing restrictions on access to abortion and reproductive health services in the US and around the globe, new technologies that expand access to information about and support for comprehensive sexual and reproductive health issues, including abortion, are needed.
In partnership with safe abortion hotlines, abortion clinics, reproductive justice organizations, and advocate colleagues, Ibis Reproductive Health has conducted formative research examining user needs and preferences for such a smartphone app in Indonesia, Mexico, and the U.S. Formative work has demonstrated that smartphone apps are desirable across a range of contexts, and apps that provides comprehensive SRH information, including information on abortion, delivered through a supportive and secure platform, are needed. Users want an app that can be tailored to their current reproductive health realities and can be modified to meet changing needs throughout their reproductive lives. We will additionally share preliminary findings from a randomized control trial conducted in partnership with Samsara, a safe abortion hotline in Indonesia, to evaluate feasibility and acceptability of a smartphone app that provides information and support for women self-managing medication abortion.
Penney Gillian
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Gillot
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Elona Gjebrea Hoxha
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Anna Glasier
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Bridging Hormonal emergency contraception prevents
between one half and two thirds of pregnancies.
Traditional on-going methods of contraception are
far more effective. A consultation for emergency
contraception (EC) should therefore be regarded
as an opportunity to provide women with an
on-going method of contraception which will
prevent pregnancy more effectively than repeated
use of EC. The on-going method is best started
immediately to prevent pregnancy immediately
including those resulting from further acts of
unprotected sex in the cycle in which EC was
used (so-called bridging).
In most European countries most women now
get EC from pharmacies over (or behind) the
counter. Pharmacists are unable to provide
on-going effective contraception without a
doctor’s prescription and a mystery shopper
study undertaken in Edinburgh demonstrated
that most pharmacists give little or no advice
about bridging. Even when EC is issued by a
health professional who can provide an on-going
method, a disappointingly low number of women
are provided with an effective bridging method.
Strategies to enhance bridging from EC to an
effective on-going method need to be developed
and tested. -
CS10.1
Royal College of Obstetricians and Gynaecologists Leading Safe Choices Project: An overview
Anna Glasier1, Alison Glasier2
1University of Edinburgh, Edinburgh, UK, 2Royal College of Obstericians and Gynaecologists, London, UKObstetricians, gynaecologists and allied healthcare workers are in an ideal position to improve the provision of family planning and abortion services, but sadly these services are often regarded as low priority. The Royal College of Obstetricians and Gynaecologists (RCOG), with 14,000 members worldwide, is in an ideal position to influence both clinical practice and the attitudes of the profession. The RCOG Leading Safe Choices (LSC) initiative aims to put the evidence into practice by strengthening the competence and raising the standing of family planning and abortion care professionals. In collabouration, initially with colleagues in South Africa and Tanzania, the initiative aims to promote best practices in postpartum contraception and comprehensive abortion care (CAC) in South Africa, and comprehensive postabortion care (CPAC) in Tanzania. A three-pronged approach is being taken.
1. Evidence based, practical Best Practice Papers on postpartum family planning and comprehensive, and postabortion care have been developed and disseminated.
2. Short, intensive theoretical and skill training courses have been developed based on the best practice papers, with subsequent ‘on-the-job' training and supportive supervision.
3. The initiative aims to support professionalisation of family planning and CAC/CPAC services through certification and accreditation.The Leading Safe Choices Initiative is now well underway in South Africa and the outcomes of the programme are being monitored and evaluated to determine impact. Development of training materials continues as lessons are learnt along the way. Progress is being made in establishing the initiative in Tanzania. Barriers to successful implementation are being addressed with enthusiasm for the initiative but remain a challenge. Leading Safe Choices has stimulated the RCOG to look closely at both postpartum contraception and the delivery of abortion services in the UK.
Henri Goldstein
Speeches:
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Since 1973, termination has been authorised up to 14 weeks of amenorrhoea.
Beyond 14 weeks a woman must apply to a committee, though these take very
liberal views.
For minors under 18 years of age, the authorisation of the parents or of the
committee is necessary.
Rodolfo Gómez Ponce de León
Speeches:
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Promoting misoprostol for multiple ob-gyn indications: A strategy for increasing access to safe abortion in Latin America
Rodolfo Gómez Ponce de León, Virginia Chambers, Traci Baird, Leila Adesse and Pearl Friedberg (IPAS, United States)
IPAS, United States
bairdtl@ipas.org, adessel@ipas.org, friedbergp@ipas.org
Latin America has some of the world's most restrictive abortion laws and yet abortion is prevalent and the proportion of maternal deaths due to abortion is high. In the past two decades, misoprostol, which is widely accessible as an ulcer treatment drug, has been increasingly well known and used by women to self-induce abortion. In a few countries, health authorities have reacted to women’s own use of misoprostol by restricting access to the drug by making it available only by prescription or limiting its use to hospitals. Given the adverse political environment around abortion and the threat that misoprostol could become severely restricted, Ipas developed a regional strategy in 2004 to promote misoprostol for multiple ob-gyn indications, working closely with the Latin American Federation of Societies of Obstetrics and Gynecology (FLASOG), the Latin-American Consortium against Unsafe Abortion (CLACAI), and other partners.
This multiple-indication approach serves to: open the door to talk with providers or policymakers about “safe” subjects, such as misoprostol for prevention of maternal deaths; increase provider knowledge, acceptance and correct use of misoprostol; reduce the stigma associated with the use of misoprostol; and reach a broad audience with information on misoprostol, even in countries where abortion is restricted. Ipas and our partners are also advocating for inclusion of misoprostol in health system guidelines and formularies for all obstetric uses.
In 2005 FLASOG published and disseminated evidence based guidelines about the use of misoprostol for all ob-gyn indications, which serves as a key tool in educating healthcare providers on misoprostol. In 2007 this publication was updated, and 26,000 copies of the guideline, including the book, CD, and pocket-card, were disseminated to participants at national ob-gyn conferences in each country in the region. Before the formal introduction we distributed a questionnaire to a convenience sample of attendees evaluating their knowledge, use and training needs for misoprostol.
We have had some concrete successes result from the multiple-indications strategy. For example, following the publication of the first edition of the FLASOG manual on misoprostol for ob-gyn uses in 2005, Ipas Brazil and the State Secretary of Health for Rio de Janeiro convened a working group of state hospital administrators and misoprostol experts to develop a consensus statement on ob-gyn uses of misoprostol. The consensus statement was disseminated throughout the state health system.
In this presentation we will outline the major steps taken to promote misoprostol for a full range of ob-gyn indications, present data from surveys of ob-gyns in the region about misoprostol knowledge and use, and discuss the successes that have resulted from this strategy. We will also explore implications and recommendations for other regions.
Rebecca Gomperts
Speeches:
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Demographic characteristics of 400 women from Ireland and the Philippines who completed the online consultation form of the telemedical abortion service Women on Web
Rebecca Gomperts, Marlies Schellekens Women on Web, Amsterdam, The Netherlands - mschellek@zeelandnet.nl
The study analyzes the data of 200 women from the Philippines and 200 from Ireland who completed the online consultation form of Women on Web telemedical service in 2012. The study found that the geographical, cultural and political differences of Ireland and the Phillipines correspond to the demographic characteristics of women who completed the online consultation. For example average rates of contraceptive usage in the Philippines is 41% to 50% . On the other hand in Ireland contraceptives are widely available and accessible and 64.8% of people aged 18-49 use contraceptives. Our analyses found that more women from the Philippines reported that the unwanted pregnancy was caused because they did not use contraceptives compared to women from Ireland (70.5% vs 41.5%). Women in Ireland often already had children and reported failed contraception as a reason for their pregnancy (Table).
Ireland Philippines p-value
Total 200 200
Mean age 28 26
Reason for abortion:
I am too young 20 (10%) 50 (25%) 0.0008
Reason for abortion:
I am too old 10 (5%) 2 (1%) 0.012
Reason for abortion:
family is complete 51 (25.5%) 14 (7%) 0
Nulliparous 88 (44%) 106 (53%) 0.07
No contraceptive use 83 (41.5%) 141 (70.5%) 0
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Regional differences in surgical intervention
following medical termination of pregnancy
provided by telemedicine
Gomperts, R1,2; Jelinska, K1,2; Sabine, S1,2;
Gemzell-Danielsson, K1,2; Kleiverda, G1,2
1 Women on Waves; 2 Department of Obstetrics and Gynaecology,
Karolinska Institutet, Stockholm, Sweden
Objective: Analysis of factors influencing surgical intervention
rate after home medical termination of pregnancy (TOP) by
women in countries without access to safe services using the
telemedical service ‘Women on Web’.
Design: Cohort study.
Setting: Women with an unwanted pregnancy <9 weeks pregnant
who used the telemedicine service of Women on Web between
February 2007 and September 2008 and provided follow-up
information.
Sample: Women who used medical TOP with a known follow up.
Methods: Information from the online consultation, follow-up
form and emails was used to analyse the outcome of the TOP.
Main Outcome Measures: Ongoing pregnancy, reason for surgical
intervention, perceived complications and satisfaction.
Results: Of the 2323 women who did the medical TOP and had
no ongoing pregnancy, 289 (12.4%) received a surgical
intervention. High rates were found in Eastern Europe (14.8%),
Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in
Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%;
P = 0.000). More interventions occurred with longer gestational
age (P = 0.000). Women without a surgical intervention more
frequently reported satisfaction with the treatment (P = 0.000).
Conclusions: The large regional differences in the rates of
reported surgical interventions after medical TOP provided by
telemedicine cannot be explained by demographic factors or
differences in gestational length. It is likely that these differences
reflect different clinical practice and local guidelines on
(incomplete) abortion rather than complications that genuinely
needed surgical intervention. Surgical interventions significantly
influenced womens’ views on the acceptability of the TOP. -
Women on Waves
Rebecca Gomperts, MD, Amsterdam, The Netherlands
Women on Waves, a Dutch non-profit organization, operates a mobile reproductive health
clinic on board a Dutch ship. Outside the territorial waters of countries where abortion is
illegal , the abortion pill can be provided safely and legally to women with unwanted
pregnancies. Women on Waves set sail to Ireland in 2001 and to Poland in June 2003 and
in August 2004 to Portugal. The three campaigns created enormous public interest. The
presentation will address the obstacles, successes and failures of the 3 campaigns. It will
also present Women on Web, a online abortion help service. -
PS01.1 Improving the journey through medical abortion.
Rebecca Gomperts1 ,2
1Women on Web, Toronto, Canada, 2Women on Waves, Amsterdam, The Netherlands, 3Karolinska Institute, Stockholm, Sweden
Women on Web, a telemedical abortion service was founded 10 years ago and today answers 10,000 emails per month. Telemedicine has a great potential to improve the journey though medical abortion especially for women in rural and remote areas, as well as urban areas with a shortage of health care providers or where access to abortion is legally restricted.
So far scientific research has been published about three telemedical abortion services Women on Web (WoW), Willow Women’s Clinic and Planned Parenthood of the Heartland. Lately several new telemedical abortion services were initiated including one in Australia by the Tabbot Foundation and in the USA by Gynuity.
In this talk I will present
- Examples of women who contacted Women on Web because they could not obtain regular abortion services even if they are living in countries where abortion is “legal” and “available” due to economic and social circumstances and domestic violence.
- Criminal prosecution of women using Women on Web in a high resource setting.
- Criminal prosecution of women using Women on Web in a low resource setting.
While these cases are caused by the local, legal context it shows clearly that, even if telemedical services can give access to medical abortion in places where this is not available, we have to continue to work on changing abortion laws and making sure local, safe abortion services will become more easily accessible even in countries where it seems abortion services are available as they are still not available for those women who are in the most vulnerable social economic situations. To improve the journey through medical abortion for women we have to improve it for all women.
-
All restrictions to access abortion services, legal logistic financial, creates social inequality. Women with access to financial means and information will always be able to access safe abortion services and women without the financial resources are most affected by these obstacles. abortion laws. Women on Waves and Women on Web use new technology (drones, robots, internet, apps) and research, to break the taboo around abortions and change policies and laws and in the same time make sure women have access to contraceptives and safe medical abortions. This presentation will highlight some of the work, achievements and challenges in the past years.
-
Women on Web
Rebecca Gomperts Women on Waves, Amsterdam, The Netherlands - gomperts@womenonwaves.org
Women on Web is a telemedical abortion service for women with an unwanted pregnancy up to 9 weeks living in countries without safe abortion care. Three studies looked at the outcome and factors influencing the surgical intervention rate after the medical abortion provided to women through telemedicine. One retrospective study analyzed information from 484 women who received a medical abortion at their home addresses in 2006 and 2007. Sixteen of the 265 (6.0%) women who provided follow-up information reported that they did not use the medication. Of the remaining 249 women who did the medical abortion at home, 13.6% reported having a surgical intervention afterwards and 1.6% reported a continuing pregnancy. After the follow-up rate increased from 54.8% to 77.6% of the cases, 12.6% of the women reported they did not take the medication and only 6.8% of the women having the medical abortion at home underwent a surgical intervention afterwards. Another study analyzed the influence of geographical location on the outcome of the 2323 women. High rates were found in Eastern Europe (14.8%), Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%; p=0.000). The third study evaluated the data from women living in Brazil.. Of the 370 women who used the medicines, 307 women provided follow-up information about the outcome of the medical abortion. Of this group, 207 (67.4%) of the women were up to 9 weeks pregnant, 71 (23.1%) were 10, 11 or 12 weeks pregnant, and 29 (9.5%) of the women were at least 13 weeks pregnant. There was a significant difference in surgical intervention rates after the medical abortion at the different gestations (19.3% at <9 weeks, 15.5% at 10-12 weeks and 44.8% at >13 weeks, p=0.06). However, 42.2% of the women who had received a surgical intervention afterwards did not have any symptoms of a complication. This research shows that medical abortion can be safely and effectively provided to women themselves through telemedicine. Surgical intervention rates after the medical abortion provided via telemedicine reflect local medical practices. The risk of surgical intervention and ongoing pregnancy after home medical abortion only tends to increase after 12 weeks of pregnancy.
Deyanira Gonzales de Leon
Speeches:
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Medical abortion: analysis of three marketing websites selling misoprostol
Deyanira González de León, A., Universidad Autónoma Metropolitana Xochimilco, Mexico City, Mexico
Co-authors: Erika Troncoso, María Elena Collado, Raffaela Schiavon (Ipas Mexico)
The use of Internet has increased considerably and has become a common tool to search for information on issues like abortion, especially among young people. Internet is an important source of information about the use of misoprostol as abortifacient and currently there are websites selling the drug (commercially distributed as Cytotec). In this paper we present the results of a study aimed to explore the information about medical abortion (MA) offered through websites selling Cytotec, as well as the most common questions from its users. The final purpose of this study was to obtain evidence that could be used to improve information strategies on the use of misoprostol as abortifacient.
MA is, alongside with manual vacuum aspiration, one of the standard methods recommended by the World Health Organization (WHO) to terminate pregnancies. The practice of MA has increased in many countries over the recent years and has substantially contributed to improving the quality of legal abortion services. The combined use of mifepristone and misoprostol is currently the most effective regimen for early MA and has been included in the complementary List of Essential Medicines of the WHO since 2005. Millions of women worldwide have used this combination of drugs and have found it to be safe and
effective.
Mifepristone is not legally available in most countries of the developing world and the use of misoprostol alone has become a safe alternative to provide early MA in places where the drug is available. An optimal regimen for the use of misoprostol alone is still under research, but clinical studies report high efficacy rates –around 85% and more- when applied vaginally or sublingually for pregnancies of 63 days’ gestation or less.Because of legal restrictions on abortion the use of misoprostol alone has gained interest and acceptability among physicians in Latin America. Besides, the drug is increasingly being self-administered by women as an alternative to other dangerous methods. In many countries, misoprostol is available at pharmacies without medical prescription, and in some, such as Brazil and Peru, its use has been associated with less complications and deaths.
In Mexico, abortion laws remain highly restrictive except for Mexico City where abortion was decriminalized in 2007 and is permitted on demand during the first 12 weeks of gestation. Since then, public health services governed by the local Department of Health provide abortions using the WHO recommended methods. In 2008, 39% of all legal pregnancy terminations were done using misoprostol alone.11 On the other hand, the use of misoprostol as abortifacient is common and increasing in Mexico, but as in other Latin American countries both women and pharmacists, and even many physicians, lack of enough information on the safest and most effective doses of the drug, or about what to expect during the process or what to do if it fails.
A search performed in 2008 found seven websites offering misoprostol, out of which three were selected for further analysis: Ayuda Cytotec, Cytotec México, and Soluciones Cytotec. Criteria used for the selection was that these websites had question/answer sections, open not only to buyers but also to all visitors. 20% of all questions and answers registered between January and June 2008 were randomly selected for each one of these websites. The search was done giving a marker to each question and then making a random selection of them using the SPSS. The analysis was performed on 215 cases, which were incorporated into an Excel database. The database included the specific website, questions, dates of questions and answers, and answers from the website. Although the database included information on sex and age of those consulting, as well as weeks of pregnancy and use of misoprostol at the time of the query, these data were not always consistent because of insufficient information at the websites.
The results show that the five most common questions asked by users referred to: how to detect if the abortion was completed (21%); information about the use of misoprostol, including efficacy, risks related to previous abortions, weeks of gestation, and confirmation of pregnancy, among others (17%); routes of administration and dosage (11%); side effects (9.7%); and post-abortion care (7.9%). In addition, 79% of questions were made by women; 41% of those consulting had 9 or less weeks of gestation; and 43% were using misoprostol at the time of the query.
A first conclusion is that the selected websites not only sell misoprostol but also represent a useful source of information about the drug (dosage, gestational limit, side effects). However, these websites do not include accurate information about the evolution of an abortion using misoprostol or what to do in case of failure. This kind of information is only available to those using the question/answer sections and answers from the websites do not always meet the needs of users. Another conclusion is that self-administration of misoprostol without all the necessary information is a common practice among women. Finally, the analysis of the questions made by users demonstrates the need to elaborate documents and other resources that give women complete, accurate and reliable information about MA.
H. Gottenbos
Speeches:
Vadimas Grebinskis
Speeches:
Griep
Speeches:
Elena E. Grigorieva
Speeches:
Linda Grung et al.
Speeches:
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Medical abortion between 9 and 12 weeks gestation: experiences from a nursing perspective
Linda Grung Ertzeid, RN, Ingrid Økland, RN, Line Bjørge, MD, Ragnhild Tveit Sekse, RN, Mette Løkeland, MD
Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
Background: Worldwide most late first trimester abortions are achieved surgically by vacuum aspiration. As the first hospital in Norway, medical abortion between 9 and 12 weeks of gestation was introduced at the Department of Obstetrics and Genecology, Haukeland University hospital, Bergen, Norway. in October 2005. Data from the implementation period has been analysed in detail, and shows that it is an effective and acceptable method for this gestational age (1). When the procedure was introduced women were given the choice between medical or surgical methods for termination of pregnancy. In June 2007 the medical abortion procedure became the method of choice for late first trimester abortions at the Department. The treatment and follow-up requires a close collaboration between different groups of health care providers. The nurses play a central role in treatment and follow-up of this patient group by administrating the medications, monitoring the patients clinically, confirming the terminations and
providing mental support as well as giving information about the procedure.
Method: A multi-competence team consisting of nurses and doctors with special interest was established. Its role was to develop treatment protocols and information materials and to enlighten and motivate the health care providergroups to use the new treatment alternative. At the first consultation at the outpatient clinic the doctor determined the gestational age and the choice of method were decided. The nurses informed the women about the treatment procedures, administrate mifepristone medication, governed misoprostol and pain killers, monitored bleeding, provided mental support and confirmed the termination by visual inspection. They were also responsible for contacting the women if further follow-up were needed. To build nursing competence structured training was made compulsory and given to all the nurses. They needed more knowledge about why conservative treatment should be preferred to surgical, and also be acquainted with the new procedures so they could be able to give a proper information and support to women.
Results: From October 2005 to April 2007 55% (254) of the women requesting abortion with gestational age 63 to 90 days chose medical termination. Initially many nurses found it hard to handle the new procedures, especially to verify the abortion by visual inspection to see that both fetus and placenta had been passed. To master this it was essential and important to give the nurses time for debriefing and for discussions, - like how to motivate each other and how to cope with different emotional reactions. Routines have also been made for new nurses. They were never left alone with this patient group until they felt secure with the procedures. This was important for a successful outcome of the implement of the new method.
Conclusion: Late first trimester medical abortion is an effective and acceptable method for termination of pregnancies. During the study period the numbers of procedures performed has increased and today more than 75% of all the abortions performed at this gestational age are performed medically. The key factors for the successful implementation were planning, delegation of treatment responsibility and motivation and follow-up of the nurses. Interdisciplinary cooperation on procedures and methods and increased knowledge has given the nurses professional confidence, competence and more responsibility for patient care provided for the women who choose abortion.
Andreja Štolfa Gruntar
Speeches:
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Early medical abortion as the first choice method at the University Department of Obstetrics and Gynaelacogy in Ljubljana, Slovenia
Andreja Štolfa Gruntar and Bojana Pinter, Department of Obstetrics and Gynecology, University Medical
Centre Ljubljana, Slovenia
Medical abortion was introduced as a method of first trimester induced abortion 20 years ago, when as one of WHO collaborating centres in the area of reproductive health our Department of obstetrics and gynecology was offered the possibility to carry out the studies investigating the efficacy and safety of abortion inducing drugs, although the drugs had not been registered in Slovenia.
Until 7 years ago medical abortion was performed only in women enrolled in various WHO studies. However, when the direct import of the needed drugs (mifepristone and misoprostol) became possible, we started to perform early medical abortions on a regular basis in women who decided on this method for early abortion of an unwanted pregnancy. Knowing the method well we wanted it to become the predominant method of early abortion. But since there was no agreement among gynecologists that it should be the method of choice for an early abortion, women still choose the method they prefer. Dilatation and curettage under general anesthesia is still the most frequently used method, although some women decide on endometrial aspiration without anesthesia, too.
The reasons why women decide on a surgical abortion under general anesthesia are: not being aware of what is being done, fear of pain, gynecologist's advice. Many gynecologists still advise their patients the abortion done under general anesthesia, because it has been done successfully for years, and as they are still sceptical about medical methods due to the lack of knowledge and personal experience.
Our intention is to increase the percentage of medical abortions among the eligible women wanting to end an unwanted pregnancy. Due to the aforementioned reasons our aim has not been achieved yet. There are around 1500 early abortions to end an unwanted pregnancy at the Department per year (e.g. 1546 in 2006, 1334 in 2008). Of these there are 13,5% endometrial aspirations without anesthesia, 55,6% surgical abortions under general anesthesia, and only 30,9% medical abortions. Obtaining good results with medical abortion and spreading the knowledge among patients and gynecologists, and with efficient motivation for medical instead of surgical procedure, the rates of early medical abortion to end an unwanted pregnancy have been slightly increasing, but the rates could be further improved. So in March 2010 we organized a seminar to promote medical abortion as the first choice method and to exchange experience with other abortion-care practitioners in the rest of Slovenia.
Edith Guibert
Speeches:
Janesh Gupta
Speeches:
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Preventing infection in abortion care
Janesh Gupta MD, Professor of Obstetrics and Gynaecology
University of Birmingham, Birmingham Women’s Hospital, England, UK
There is controversy of whether prophylaxis treatment or a “screen and treat” policy should
be adopted for preventing infective complications when women undergo abortion. There is
currently compelling evidence that indicates that a universal policy of prophylaxis
treatment to ALL women undergoing abortion should receive antibiotics. It is also a cost-
effective policy. This is the policy adopted in the UK and the evidence will be presented. -
The future would be to expand this service to the legal gestation age of 23+6 weeks. This service has exponentially expanded over the past 3 years to cater for women with complex co-morbidities, which require a multi-disciplinary team involvement. I shall present the unit’s case load, complexities and methods of achieving a safe outcome with the focus for ensuring a high uptake of long acting reversible contraceptives.
Kate Guthrie
Speeches:
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The impact of implants and intrauterine
contraceptives provided at an index surgical
termination of pregnancy (Jan–June 2008) on
repeat termination of pregnancy within 3 years:
an audit
Latham, F1; Guthrie, K2; Trussell, J1
1 Hull York Medical School; 2 Community Health Care Partnership
Hull, UK
Background: Implants and intrauterine contraceptives have lower
failure rates and higher continuation rates than the other
reversible methods of contraception. We hypothesised that the
patients who chose these long lasting reversible methods after
their index surgical termination of pregnancy (STOP) would have
a reduced incidence of subsequent termination of pregnancy
(TOP) in comparison to those who chose other reversible
methods (injections, oral contraceptive pills, patch, ring and
condoms).
Methods: Index cases were recorded retrospectively from theatre
registers at Hull Royal Infirmary for all STOPs between January
and June 2008. Type of contraception chosen at procedure was
recorded: Implanon, Mirena, IUD, Depo-Provera, Sterilisation and
‘Other’ (oral contraceptives, patches, rings, condoms). The
hospital information system for the subsequent 3 years was
searched for another TOP (surgical or medical). The data were
analysed. A secondary objective was to record contraceptive
choices in two age groups (<25 and ‡25 at index STOP).
Results: Women choosing Implanon, Mirena and IUDs had a
significantly lower repeat TOP rate than those choosing other
reversible methods at 2 (3.4% vs. 9.3%, P = 0.008) and 3 (6.8%
vs. 12.4%, P = 0.04) years. As age increased, use after an index
STOP of Implanon decreased (32% vs. 8%) and Mirena increased
(13% vs. 41%) significantly.
Conclusion: A 50% increase in the uptake of implants and
intrauterine contraceptives would decrease the repeat TOP rate
within three years by 16%. -
UK Faculty programme
Katherine Guthrie City Health Care Partnership CIC, Hull, UK - k.guthrie@nhs.net
Training in abortion provision is within the postgraduate specialty training programmes of the Faculty of Sexual and Reproductive Healthcare (FSRH) and the Royal College of Obstetricians and Gynaecologists (RCOG). These cover medical abortion and 1st trimester surgical abortion. The RCOG programme does not cover local anaesthetic procedures. The College has an optional advanced programme to cover local anaesthetic procedures and later gestations for surgery. The Faculty also has a training programme accessible to doctors and nurses who wish to undertake further training in this field. Conscientious objection within the National Health Service plus the shift in the provision of care to non-NHS providers has created a challenge in accessing training.
Anja Guttinger
Speeches:
Frida Gyllenberg
Speeches:
-
Objective: To study the effect of a public program providing long-acting reversible contraceptive (LARC) methods at no-cost on the risk of unintended pregnancy.
Methods: The City of Vantaa in the Helsinki metropolitan area (approximately 220,000 inhabitants) implemented a program entitling all women their first LARC method at no-cost in January 2013. During 20132014, altogether 9,685 women entitled to a no-cost LARC visited a public family planning clinic and 2,035 women initiated a no-cost LARC. Lacking data on intendedness of pregnancies, we used induced abortion as a proxy for unintended pregnancy. In this register based cohort study, we used Poisson regression to estimate the risk of abortion among women who chose a LARC method (no-cost group) and among women who visited the clinics, were entitled to a LARC but chose otherwise (visitor group), and in an age matched population cohort (1:4) consisting of non-sterilized women entitled to LARC method (n=36,399). The follow-up started on the date of LARC initiation (no-cost group), date of visit (visitor group) or at start of follow-up for the population controls. Follow-up ended at start of gestation, date of sterilization or move abroad, or on 31.5.2016.
Results: In the full model we adjusted for age, age2, previous pregnancies and abortions, and socioeconomic status. The Incidence Risk Ratio for abortion among women initiating no-cost LARC was 0.27 (95%CI 0.170.39) compared to the matched population control. The abortion rate among visitors did not differ from the population controls (IRR 1.09, CIs 0.951.25).
Conclusions: Among women seeking counseling on contraception, initiation of a LARC method is associated with a significantly lower need of subsequent abortion.