Increasingly, women are obtaining abortifacient medicines through pharmacies, drug sellers, and online or telemedicine services – particularly where abortion services are restricted or access is difficult. Many of these women are using medical abortion drugs safely on their own, although data on their clinical outcomes are limited. Many clinicians consider the self-use of medical abortion to be dangerous; however, from a strictly medical perspective, mifepristone and misoprostol meet many of the FDA criteria for being available over- the- counter (OTC): an acceptable toxicity profile, unlikely to be addictive, and a low abuse potential.
To demonstrate that medical abortion is appropriate for OTC distribution, a series of investigations would be required by the FDA. This research would need to establish that individuals can understand a Drug Facts Label for medical abortion, assess gestational age as eligible and rule out other contraindications for medical abortion, self-administer the medications according to instructions, and identify complications or need to seek medical care, including for ongoing pregnancy. In the short term, these efforts will help support a wide variety of efforts aimed at improving access to clinic-based medical abortion, and in the long-term, support regulatory approval for an OTC product.
Nathalie Kapp HRA Pharma, Paris, France - firstname.lastname@example.org Background: Pain is a predictable feature of induced abortion in both the first and the second trimester, but pain control regimens available to women vary considerably.
Methods: We searched the PubMed and Cochrane databases for publications of trials comparing methods of pain control during induced abortion.
Results: Few rigorously conducted studies of pain control regimens for medical abortion have been conducted. Five studies conducted in women with pregnancies <9 weeks' gestation found that prophylactic analgesia did not reduce medical abortion pain, including the most recent rigorous trial where prophylactic ibuprofen was administered and dosing was repeated through the abortion process. In second-trimester medical abortion, one study found more pain relief with higher doses of fentanyl delivered through PCA than lower doses; the only adjuvant therapy shown to be associated with decreased opioid use has been diclofenac. During first trimester surgical abortion, more than 40 randomized controlled trials are available. Paracervical block, conscious sedation, general anesthesia and non-pharmacologic interventions decreased procedural and postoperative pain during first trimester abortion. Second trimester surgical procedures generally use conscious sedation or general anesthesia which have not been the subject of comparative trials. The severity of pain experienced by a woman varies considerably, but appears to be influenced by the age of the woman, parity, history of dysmenorrhea, and fearfulness/ anxiety. Prior vaginal delivery and a shorter procedure time are associated with lower levels of pain.
Conclusion: As pain associated with the process of abortion should be expected, medication for pain management should always be offered to women who desire it, and may be combined with non-pharmacologic techniques. Further research is needed to determine the optimal analgesia regimens for first-trimester and second-trimester medical termination of pregnancy. To facilitate comparability of data, researchers should use contemporary medical abortion regimens, outcomes and study instruments to measure pain.
Context: The method of abortion has rapidly changed from surgical to medical termination of pregnancy (MToP) in several countries; today 95% of abortions are MToP in Finland.
Objective: Intensity of pain, need of analgesics, evaluation the adequacy of ibuprofein and paracetamol, and patient satisfaction. Comparison of teenagers vs. adult women. These are the results of an interim analysis of the first 97 patients of the study.
Methods: This prospective study evaluates pain during MToP in early pregnancy (<64 days of gestation). Altogether 120 primigravid women are being recruited. The ratio of teenagers (15-19 year-olds) and adult women (25-35 year-olds) is 1:1.
MToP was carried out according to the Finnish national guideline. The medication consists of 200mg of mifepristone administered at the outpatient policlinic followed by 0,8mg of misoprostol vaginally or orally at 24-72 hours primarily at home. Ibuprofein (600mg) and paracetamol (1g), both up to three times/day were used for pain management. First doses are taken simultaneously with misoprostol and thereafter whenever needed. Pain is measured by visual analogue scale (VAS), which is reported in a diary each time patient needs analgesics.
Results: The highest pain reported by VAS was 78±18 (mean±SD) among teenagers and 66±27 among adult women (p=0,005, VAS 70-100mm); 48% vs. 19% of the patients reported severe pain. Nevertheless 77% of teenagers and 65% of adults evaluated the analgesia as adequate and the overall satisfaction with the care received was high in both groups (VAS 85±12 vs. 85±15; p=0,311).
Altogether 88% vs. 93% would choose MToP again.
Conclusions: Women and especially teenagers undergoing MToP experience strong pain already in early pregnancy. Even though teenagers experience more pain they more often estimate that the combination of ibuprofein and paracetamol is adequate.
Jennifer Kerns, USA
Co-authors: R.Vanjani, L.Freedman, E.A.Drey, K.R.Meckstroth, J.E.Steinauer
Objective: Approximately 3% of pregnancies are affected by a fetal anomaly. Prenatal screening for fetal anomalies is a routine part of prenatal care, and most women given that diagnosis will terminate the pregnancy. We know little about patient preferences for D&E versus induction for fetal anomaly termination. In this qualitative study, we sought to understand the factors influencing women’s choice between D&E and induction, and how their experiences differed.
Methods: We conducted semi-structured phone interviews with 21 women from University of California San Francisco (UCSF) who had undergone a termination within the past three weeks for fetal anomaly or demise. All women had equal access to both methods. We used a generative thematic approach, facilitated by the NVivo qualitative software program.
Results: Of the21 women, 13 (62%) underwent D&E and 8 (38%) underwent induction. Several key themes that emerged from the interviews were options counseling, referral experience, religious attitudes, abortion attitudes and emotional coping style. While some themes were shared across method of termination, others were differentially expressed by those undergoing D&E or induction.
Conclusion: While some aspects of pregnancy termination for fetal anomaly are shared by women, factors and experiences associated with the method of termination are quite different. The decision to undergo D&E or induction is a highly personal one, and women should be offered equal access to both methods. Understanding key themes that drive that decision may aid in counseling women faced with this diagnosis.
Anneli Kero, (co-authors: Marianne Wulff and Ann Lalos), Department of Clinical Sciences, Obstetrics
and Gynaecology, and Department of Social Work, Umea University, Umea, Sweden
Objective: To gain knowledge about women’s experiences, views and reactions regarding having a home abortion (medical abortion with the use of misoprostol at home).
Methods: One hundred women were interviewed one week post-abortion; this yielded both quantitative and qualitative data.
Results: The overwhelming majority of the women experienced wellbeing and were satisfied with their choice of abortion method. They appreciated the privacy and the comfort of being at home which also allowed the presence of a partner. The intake of mifepristone at the clinic was described by many in existential terms as an emotionally charged act, experienced by some as more difficult than expulsion at home. However, relief was the predominant emotional feeling during the expulsion day. Most women did not find it especially dramatic to see and handle the products of conception although some felt uncomfortable at the sight.
Conclusion: Given that they choose this method themselves and are well informed, women are able to handle the abortion process by themselves outside a clinical setting. The option to choose home abortion implies a radical change in empowerment for women. Also allowing them the possibility to take mifepristone at home would increase their privacy and personal integrity even more.
Objective: To gain knowledge about the male partner’s experiences of being present during induced home abortion.
Methods: Twenty-three couples, whose male partner had been present when the woman aborted at home, were interviewed one to two weeks post-abortion.
Results: All mengavesupport to their partner’s decision to have a home abortion, as this gave them the possibility of being near and of caring for her needs on theexpulsion day. In fact, all men took the opportunity to be present and all their partnersconfirmed that they had been supportive. Half the men had been anxious prior to the expulsion, but most considered that their experiences during the expulsion had been ‘easier than expected’ and their dominant feeling was one of relief.
Conclusions: Abortion is an important life event. When taking place at home, it increases the possibility for the couple to share the experience. Sharing an abortion may have a positive impact on those males who lack a sense of responsibility regarding reproductive issues, such as contraceptive use. This could facilitate society’s efforts to involve men as a target group in this field. Designing an abortion policy that caters for the needs of both partners is a challenge.
Meri Khachikyan, “For Family and Health” Pan-Armenian Association, Yerevan, Armenia
Co-author: Ruzanna Abrahamyan
In Armenia, as in all former Soviet countries, induced abortion was the primary means of fertility control
for many years. The most frequently used methods for pregnancy termination are Dilatation and Curettage (D&C) and Electrical Vacuum Aspiration (EVA). More modern methods like medical abortion and Manual Vacuum Aspiration (MVA) are not commonly used. In 2002 the Parliament of Armenia adopted a new law on “Human Reproductive Rights and Reproductive Health” that legalizes induced abortion on request up to 12 weeks of gestation and legalizes induced abortion up to 22 weeks for medical or social reasons. According to official data from the Ministry of Health of Armenia, induced abortions before 22 weeks of gestation constituted 33 percent of all maternal deaths in 2002. In 2005 this had been reduced to 7% of all maternal deaths. Among women that have an abortion, the average number of abortions per lifetime is 2.6 (the survey reached 14-24 year old male and female respondents). Repeat abortions are common due to the lack of post-abortion contraception.
In the National Survey and Case Studies on Sexual and Reproductive Health Knowledge, Attitude, Behaviour and Experiences conducted among young people 16% of sexually active young women reported having had an unintended pregnancy in comparison with 19% of young men. The attempt to self-induce abortion is common. The rates of miscarriages and abortion-related complications are quite high. Most of young women were not happy with the quality of abortion care when having had a hospital-based abortion.
“For Family and Health” Pan-Armenian Association NGO (PAFHA), with support of the IPPF/IF and other donors has established its own clinic in Yerevan to provide sexual and reproductive health services, including comprehensive abortion care in response to the needs of young and poor women who cannot access high-quality care due to financial or social barriers. Since January 2009, the PAFHA has been involved in implementation of the IPPF Global Comprehensive Abortion Care Initiative in partnership with tertiary referral level health facility - Institute of Perinatology, Obstetrics and Gynaecology and a regional clinic that provides services for the town of Vayk and five neighbouring villages in Vayots Dzor region of Armenia. The purpose of the project is to reduce the incidence of abortion complications, and enable poor and young women in Armenia to access high-quality abortion services.
The project used different strategies like capacity building, community participation, and advocacy to improve abortion care and access to high quality abortion services. Within the framework of the project the PAFHA established an effective model of public-private partnership that involves introduction of the quality of care approach, improvement of the systems of clinical information management, improving the referral and follow-up systems. Support from decision makers, health professionals, journalists, community leaders, parents and peer-educators were essential in increasing access to comprehensive safe abortion care.
As an outcome of the initiative significant progress was revealed in the improvement of the quality of abortion care at the PAFHA clinic and its two partner clinics. Furthermore, the IPPF GCAC initiative gave a unique opportunity to PAFHA to introduce international approaches towards quality of abortion care nationally. In June 2010, the National guidelines and standards for providing safe abortion services in line with international recommendations were endorsed by the Ministry of Health. The implementation of a national program on monitoring and evaluating the quality of SRH services, including maternal and abortion care has been initiated.
Marianne Kjelsvik, Norway
According to the law Norwegian women have the right to decide on abortion within a limit of twelve weeks of pregnancy. Out of totally 75 000 pregnancies in Norway each year, 15 000 are terminated. Both in the group of women who decide to keep the foetus and in the group who choose to remove it, many have qualms about the decision. The aim of this phenomenological study was to seek in-depth information on women’s experience when they consider terminating a pregnancy in the first trimester.
Qualitative interviews with four first time pregnant women between 25 and 32 years were conducted. None of them had decided whether to complete or terminate the pregnancy. Each woman was interviewed twice during a period of two weeks to grasp their experiences related to their uncertainty. Data were analysed by using Giorgi’s five step model of analysis.
One main finding was that the women struggled to make “the right decision”. Several experienced disappointment and despair at the lack of understanding of their thoughts, feelings and vulnerability when they involved others in the decision making process. At the same time as they wanted autonomy they needed understanding and acknowledgment both from significant others and from health care providers.
Consequently, more awareness of these matters among professionals as well as in society is necessary in order to assure that pregnant women get properly support to make their own decision.
Abortion care over the Internet: New options for women
Rebecca Gomperts (The Netherlands)
Unsafe abortion causes the death of 70 000 women every year. 1 in 300 women undergoing an unsafe abortion dies. These death are totally preventable. Medical abortion with Mifepriston and Misoprostol has a mortality risk of less than 1 per 500.000.
Women on Web is a service which uses telemedicine to help women access mifepristone and misoprostol in countries with no safe care for termination of pregnancy (TOP). After an online consultation, women with an unwanted pregnancy of up to nine weeks are referred to a doctor. If there are no contraindications, a medical TOP is conducted by mail. The presentation will discuss the impact of the online abortion help service by looking at women’s acceptability, efficacy and curettage vacuum aspiration rate after the medical abortion.
Gunilla Kleiverda, MD, PhD, gynaecologist and Elles Garcia, MD, Flevoziekenhuis, Almere, Netherlands
Abortion clinics provide the vast majority (94%) of abortions in the Netherlands. Of the 11807 first-trimester abortions performed in 2008, 10% were medical abortions, the remaining 90% instrumental procedures.
In Almere, a vast-growing city close to Amsterdam, no traditional abortion clinic is present. The local Flevoziekenhuis started therefore an out-patient abortion clinic as a satellite in 2008. The clinic, not located in the hospital, offers possibilities of medical and instrumental abortion, and anonymous and non-anonymous care. Non-anonymous instrumental abortion up to 12-14 weeks is performed in the Flevoziekenhuis. For anonymous abortion and abortion after 12-14 weeks gestation, women are referred to abortion clinics in Amsterdam.
Women were referred either by their general practitioner or by self-referral. In the first year, 616 patients were seen. 127 did not have a termination of pregnancy, because a decision to keep the pregnancy, because of not being pregnant or a non-viable pregnancy. 56 women were referred to abortion clinics because of the wish to have an anonymous treatment or advanced gestational period.
Of the remaining 435 women, 239 (55 %) had a medical abortion, 196 (45%) had an instrumental first trimester abortion. The percentages of women who requested a medical abortion was high compared to national figures. However, rates of secondary aspiration were high as well, 35 (14.6%) in the medical abortion group, 5 (2.6%) in the primary aspiration group. Patient and health-care characteristics related to this high curettage risk will be presented and discussed.
Gunilla Kleiverda, gynaecologist, Women on Waves, Netherlands
Co-authors: Kinga Jelinska, project manager Women on Web, Rebecca Gomperts, MD, director of
Women on Waves
The online non-profit project Women on Web was set up in 2006 with the aim of increasing access to safe TOP and improving maternal health in countries where TOP is not available without restrictions. The website [womenonweb.org] refers women to a doctor who can provide them with a medical TOP using the combined regimen of mifepristone and misoprostol, provided they fill in the online consultation form, meet the specified inclusion criteria and none of the exclusion criteria.
A previous evaluation of the service provided by Women on Web showed a surgical intervention rate of 13.6%, and after maximizing the follow-up, of 6.8%. We will present data about the follow-up of 2323 women who had a medical TOP and spontaneous start of expulsion from February 2007 to September 2008. Of these women, 289 (12.4%) had an additional surgical intervention
Intervention rates varied widely by region, from around 5% in Western Europe (mainly Ireland) up to nearly 15% in Eastern Europe (mainly Poland) and Latin America/Caribbean. The differences will be related to patient characteristics, patient’s acceptability. The reasons and implications of those differences for the medical abortion clinical procedure, public perception of MA and accessibility will be discussed during the presentation.
Acceptability of medical termination of pregnancy
up to 63 days of gestation with home
administration of misoprostol: assessment of
Kopp Kallner, H1; Fiala, C2; Gemzell-Danielsson, K1
1 Department of Obstetrics and Gynaecology, Karolinska Institute 7,
Stockholm, Sweden; 2 Gynmed Clinic, Austria
Objective: The objective of this study was to identify signiﬁcant
factors affecting acceptability of home administration of
misoprostol for medical termination of pregnancy (TOP) up to
63 days of gestation.
Methods: This study was conducted in a University Hospital
Outpatient Family Planning Clinic. Women who were in good
general health, above 18 years of age, with no contraindication to
medical TOP, requesting medical TOP with home administration
of misoprostol and with pregnancies up to 63 days of gestation as
evaluated by ultrasound were asked to participate. Women
received 200 mg of mifepristone in the clinic and were instructed
to self-administer 0.8 mg of misoprostol vaginally at home 36–
48 hours later. Women ﬁlled in questionnaires which were
answered after the TOP and at follow up. Patients also ﬁlled in
daily symptom diaries. Follow-up was 2 weeks later with physical
examination and low sensitivity urine-hCG according to clinical
practice. All factors extracted from the questionnaires which could
potentially affect acceptability were analysed using multivariate
Results: In total, 395 women who opted for home administration
of misoprostol for medical TOP were recruited. We found that
the presence of a partner/friend during the TOP affected
acceptability in a positive direction (P = 0.021). In contrast,
having a positive low sensitivity urine hCG at follow up affected
acceptability negatively (P = 0.002), although most of these
women had a successful and complete TOP. In contrast to other
studies on medical TOP, we could not ﬁnd an inﬂuence of age,
gestational length or the requirement of extra pain medication on
overall acceptability of the procedure.
Conclusions: Home administration of misoprostol for medical
TOP up to 63 days of gestation is highly acceptable. Women
should be encouraged to have a partner/friend present during the
TOP if possible as this affected acceptability of the procedure in
this study. In order to further increase acceptability of home
administration of misoprostol, focus of future research should be
directed towards increasing the number of complete TOPs in a
shorter time frame.
The efficacy, safety and acceptability of medical termination of pregnancy provided by standard care by physicians or by nurse-midwives: a randomized controlled equivalence trial
Helena Kopp Kallner, Rebecca Gomperts, Eneli Salomonsson, Monica Johansson, Lena Marions, Kristina Gemzell-Danielsson Karolinska Institutet, Stockholm, Sweden - email@example.com
Objective: To assess nurse-midwife provision of early medical termination of pregnancy (TOP) in a high resource setting where ultrasound examination for dating of pregnancy is part of the protocol. Method: We performed a randomized controlled equivalence trial in a Univerity Hospital Family planning outpatient unit. 1180 women seeking early medical TOP were randomized, without any prior examination, to counselling, examination and treatment by either nurse-midwife or gynaecologist. Ultrasound was performed in all cases by the allocated provider. Primary outcome was efficacy defined as successful completion of TOP without need for vacuum aspiration. Secondary outcomes were safety, defined as need for hospitalization or blood transfusion, and acceptability, defined as preferred provider were the women to have a medical TOP in the future. Results: A total of 481 women in the nurse-midwife group and 457 women in the physician group were available for final analysis. The effectiveness of provision of medical TOP by nurse-midwife providers was superior to that provided by physicians (risk difference 1.6%, confidence interval 0.2-3.0% which was within the set margin of equivalence). There were no significant differences in safety parameters. Women examined and counselled by a nurse-midwife were significantly more likely (p<0.001) to prefer seeing a nurse-midwife for the consultation were they to have another medical TOP in the future. Conclusions: These findings show that nurse-midwife provision of early medical TOP in a high-resource setting where ultrasound is part of the protocol is effective and can be safely implemented with high acceptability among women.
Helena Kopp-Kallner, Karolinska Institute, Sweden
In 1997 home administration of misoprostol was shown to be a safe option up to 56 days gestation (Schaff et al J Fam Pract, 1997. 44(4): p. 353-60) and studies of efficacy of home administration of vaginal administration of misoprostol at home for medical abortion have recently included women with pregnancies up to 63 days gestation (Westhoff et al Analgesia during at-home use of misoprostol as part of a medical abortion regimen. Contraception, 2000. 62(6): p. 311-4, Creinin et al Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion: a randomized controlled trial. Obstet Gynecol, 2007. 109(4): p. 885-94, Kopp Kallner et al Home self-administration of vaginal misoprostol for medical abortion at 50-63 days compared with gestation of below 50 days. Hum Repr 2010 May;25(5):1153-7).
In Europe, medical abortion was introduced and used in clinics and most countries have not adapted their legislation or interpretation of legislation to home use of misoprostol for medical abortion. When medical termination of pregnancy was introduced in the U.S. in the year 2000, home administration of misoprostol became the standard treatment.
Home use of misoprostol has so far been studied only after administration of mifepristone. The regimen is identical to that used in medical abortion in clinics and efficacy rates are identical to medical abortion in clinics. The most frequently mentioned reasons for medical abortion are perception of a more natural course and higher safety, avoidance of surgery or general anaesthesia and having more privacy and autonomy. Women often object to the number of visits required for a medical abortion. Women are required to visit the clinic three or four times to have a medical termination performed, depending on mandatory waiting periods and number of follow-up visits (Winikoff, Acceptability of medical abortion in early pregnancy, Fam Plann Perspec 1995, 27(4): p. 142-8, 185).
Home use of misoprostol is therefore an attractive treatment option for many women requesting medical abortion. Acceptability does not depend on gestational age or parity and has been been shown to be high among women and their partners (Kopp Kallner et al Home self-administration of vaginal misoprostol for medical abortion at 50-63 days compared with gestation of below 50 days. Hum Repr 2010 May;25(5):1153-7).
Women should be carefully counselled and given realistic expectations as to pain and bleeding. They should be provided with written and oral instructions for the procedure. Measures should be taken to confirm that the pregnancy has been successfully terminated.
Unplanned pregnancy- a common reason for
Kopp Kallner, H
Karolinska Instiutet, Department of Obstetrics and Gynecology,
Danderyd Hospital, Stockholm, Sweden
Objectives: The primary objective of this study was to investigate
what proportion of ectopic pregnancies arises as a consequence of
unplanned pregnancies and the proportion of women receiving
contraceptive counselling after treatment.
Background: Ectopic pregnancy is a potential life threatening
condition. It has a negative impact on future fertility which is
often desired. It is often forgotten that an ectopic pregnancy can
be a consequence of an unplanned pregnancy.
Methods: This was a retrospective study of a total of 68 patients’
electronic medical records. Inclusion criteria were a certain
diagnosis of an ectopic pregnancy and ﬁrst visit at Danderyd
Hospital AB between 1 June 2011 and 30 November 2011.
Results: Fifty-four percent of the ectopic pregnancies were a
consequence of an unplanned pregnancy, 31% were planned and
information was missing for 15% of the patients. In the group of
patients with unplanned pregnancy 70% of the patients in need of
counselling on future contraceptives did not get it upon
Conclusions: A large proportion of ectopic pregnancies are a
result of unplanned pregnancy. The individual and the healthcare
system have a lot to gain by ectopic pregnancy prevention which
can be achieved by increased use of contraceptives which protect
patients against all unplanned pregnancies. Patients with
unplanned ectopic pregnancies should receive counselling on
future contraceptives after ﬁnished treatment.
Use of contraception and attitudes towards contraceptive use in Swedish women: a nationwide survey
Helena Kopp Kallner1, Louise Thunell4, Jan Brynhildsen3, Mia Lindeberg2, Kristina Gemzell-Danielsson1 1Karolinska Institutet, Stockholm, Sweden, 2MSD, Stockholm, Sweden, 3Linköping University, Linköping, Sweden, 4Lund University, Lund, Sweden - firstname.lastname@example.org
Objective: To describe contraceptive use and attitudes towards contraceptive use in Sweden. Secondary objectives were to investigate knowledge of contraceptive methods and how women handle unplanned and unwanted pregnancies. Method: We performed a national telephone survey of women aged 16-49 years. The survey contained 22 questions with answers being of both spontaneous and multi-choice character on demographics, contraceptive use, knowledge of and attitudes towards contraception, the importance of monthly bleeding and experience of unintended pregnancy. Main outcome measures were distribution of use of contraceptive methods and non-use of contraception among Swedish women and prevalence and outcome of unintended pregnancies. Results: A total of 1001 women participated in the survey. Of all women, 721/1001 (72.1%) women currently used contraception, 268/1001 (26.8%) women did not use contraception and 12/1001 (1.2%) had stopped using contraception sometime in the last 12 months. A total of 781 (78%) women had never experienced an unintended pregnancy whereas 220 (22%) women had had at least one unintended pregnancy. Users and non-users alike stated that one of the most important characteristics of a contraceptive method is its effectiveness. Conclusions: A large proportion of Swedish women do not use contraception. Furthermore, a large proportion of women have experienced at least one unintended pregnancy. Increasing awareness of contraceptive effectiveness and promoting use of all contraceptive methods and especially long-acting reversible contraception is a possible way forward in the effort to reduce the rates of unintended pregnancy, unwanted pregnancy and termination of pregnancy.
How will we be able to secure the right for abortion? Around the world, in a lot of countries where abortion is legal, women have great difficulties to have access to abortion. A few countries have regulations that state CO is not permitted for health care providers working in the field of reproductive health (Sweden, Finland, Iceland).
Is this an actual solution for other countries? In most countries, individual CO is written in the abortion law and in medical law, and in Belgium, abortion providers agree to this.
Which woman wants to be treated by a team that has a negative feelings towards abortion? Anti-choice health care workers obliged to work in the field of abortion could make it a traumatic experience!
In countries where CO is permitted, our actual fight should focus on the following:
The state should ensure that abortion services are available in each region (in hospitals or in outpatient facilities) and make sure women know where to go. Public hospitals should offer an abortion service if they want to keep their state funding. Public hospitals should not have the “right” of conscience. Objector status of doctors should be public and quick referral to an abortion service mandatory. Providers, who work in abortion services, should choose to do so (conscientious commitment) so that women are treated with respect and empathy.
Doctors performing abortions should not be discriminated and should be dismissed from other tasks who need to be taken over by conscientious objectors. Women’s rights movements should encourage feminists to become doctors and young doctors to perform abortion and be proud to do so. We need to do a charm offensive to show that working in abortion care permits rich human encounters with women grateful to be able to decide about their future life.
Expanding providers and task sharing
Helena Kopp Kallner
Karolinska Institutet, Stockholm, Sweden
In many countries the access to medical doctors in abortion care is limited either by a general shortage of medical doctors or by the unwillingness of medical doctors to be involved in abortion care. Specially trained, midlevel providers can often perform services generally performed by physicians. In abortion care the evidence in support of midlevel provision of surgical and medical abortion and postabortion care is increasing.
In some countries midlevel providers perform primary vacuum aspiration for surgical abortion and in low resource settings midlevel providers supply medication and information and thereby perform medical abortions. Medical abortion provided by midlevel providers in a low resource setting has been evaluated in a large randomised trial in Nepal and was found to be safe and effective.
In high resource settings abortion is usually provided after an ultrasound provided by a trained physician. However, access to appointments for ultrasound may, in fact, increase the waiting time to have an abortion. In a large randomised trial it has been shown that trained midlevel providers can perform early medical abortion including the ultrasound as part of standard care as effectively and safely as physicians.
Women in countries where abortion is illegal often self induce abortions surgically or medically. Denied health care due to complications contributes to maternal morbidity and mortality. Midlevel providers who supply postabortion care including manual vacuum aspiration for incomplete abortion have been shown to be safe and effective. In a large randomised trial it has been shown that trained, midlevel providers can perform postabortion care as effectively and safely as physicians in rural as well as in urban settings in Africa.
Quickstarting implants after medical abortion
Helena Kopp Kallner
Karolinska Institutet, Stockholm, Sweden
Given the choice, the majority of women in the first trimester choose medical rather than surgical abortion. In Europe, and globally, a significant proportion of women having an abortion have had one or more previous abortions. Long acting reversible contraception reduces subsequent abortions in women. In studies, women resumed sexual intercourse quickly and are thus at risk for unintended pregnancy if effective contraception is not provided. Immediate postabortion initiation of long acting reversible contraception is therefore desirable and recommended by guidelines.
Implants are the only long acting contraception which can be provided at the same time as the initial abortion medication. However, theoretically treatment with a progestin could affect the binding of mifepristone to the progesterone receptor.
Several pilot studies have reported implant insertion at the time of mifepristone in medical abortion. In addition, there is one randomised study performed in Mexico and the United States and one randomised study performed in Sweden and Scotland. Women were randomised to implant insertion at the time of mifepristone ingestion or at follow up. These studies show that implant insertion at the time of the mifepristone is safe and acceptable for women. In addition, the efficacy of the medical abortion is not affected. In the study from Mexico and the United States insertion rates differed between countries and no difference could be shown in unintended pregnancy at the 6 month follow up. The study from Sweden and Scotland had similar insertion rates to women recruited in the United States. There was a significant difference in unintended pregnancy at the 6 month follow up between the immediate and delayed insertion group.
Thus, immediate insertion of implants is safe and acceptable and may prevent subsequent abortions as early as 6 months postabortion.
Therapieschema und Abläufe in der Klinik
Blanka Kothé (Germany)
Dieser Teil des Workshops richtet sich an alle Professionen, die mit medikamentösen Schwangeschaftsabbrüchen aus medizinischer Indikation zu tun haben: PränataldiagnostikerInnen, GynäkologInnen, HumangenetikerInnen, Hebammen, ArtzhelferInnen, Krankenschwestern/-pfleger, psychosoziale BeraterInnen etc.
Diese Professionen kommen mit Fragen der Indikationsstellung, der klinischen Umsetzung, den rechtlichen und institutionellen Rahmenbedingungen in Berührung. Darauf will der Workshop klärend eingehen.
Grundlagen der psychosozialen Beratung und Begleitung von betroffenen Frauen/Paaren in dieser besonderen Situation sollen dargestellt werden und die Möglichkeit gegeben werden, sich darüber auszutauschen.
Zusätzlich wird medizinisches Wissen u.a. aus langjähriger klinischer Erfahrung zum Einsatz von Mifegyne und Cytotec mit Besonderheiten der Anwendung im 2. Trimenon vermittelt und der Ablauf in der Klinik geschildert.
Themen wie Fetozid, psychiatrische Indikation, verdrängte Schwangerschaft und ein Exkurs zum aktuellen Stand der rechtlichen Situation können Raum haben.
Access to contraception is a reproductive health
right. While sex ‘just happens’, women need to
go through several hoops to obtain contraception.
Regulations, protocols and guidelines drive
service provision but do affect the perceptions
of both users and providers. Evidence-based
de-medicalisation of contraception may remove
personal and systematic barriers to effective use of
family planning methods. Emergency contraception
is a case study in this area. Other models of care
have emerged in the last decade. These include
over and under the counter oral contraception,
vending condoms and emergency contraception
and web based services. Themes emerging
from such models suggest that research, service
provision and advocacy schemes should aim to
push the boundaries of contraceptive regulation
towards user-friendly non-medicalised care.
Ali Kubba MB ChB FRCOG FFSRH, London, United Kingdom
OCs are the most studied drugs of the modern age. Their non-contraceptive benefits are signi-ficant but largely unknown to users. Their adverse effects are uncommon so most women are eligible to use OCs. The EBM tool for prescribing is the WHO Medical Eligibility Criteria. These are highly adaptable to checklists that users themselves or pharmacists/web based providers can use to select safe use.
Self selection or facilitated self selection for OC use, increases access and cuts costs for the user and the healthcare system. I will be discussing models of delivery and the experience from a small project in South London.
President of the Organizing Committee of the International Seminar President of the Russian Society of Obstetrics and Gynecology Director of the Research Centre of Obstetrics, Gynecology and Perinatology