Chlamydia: 5 to 20%
Gonorrhoea: 0.2 to 3%
Current practices: Prophylaxy if the woman is under 30 years of age
DOXYCYCLINE 300mg the day before and then 100mg/ day for 2 days or 200mg
for 7 days.
Prescription of METRODINAZOL over 18weeks amenorrhia taking into account
that the risk increases with the length of pregnancy. The conclusion of the Dutch
practice is that all women asking for abortions must be treated.
Different routes of administration
Oi-Shan Tang, MD
Department of Obstetrics and Gynaecology,
The University of Hong Kong, Pokfulam, Hong Kong
Misoprostol is widely used in obstetrics and gynaecology. It is a prostaglandin E1
analogue licensed for oral use. However, vaginal administration has become a common
practice. However, women prefer to take the drug by mouth as this can avoid the
uncomfortable vaginal examination and provide more privacy during medical abortion.
Therefore, other ways of administration like sublingual route have been explored.
A pharmacokinetics study has compared the absorption kinetics of these three commonly
used routes of administration of misoprostol. It was shown that both the sublingual and
oral administrations have the quickest onset of action. Sublingual administration achieves
the highest plasma concentration. The systemic bioavailability as measured by the area
under the curve (AUC) is also highest among the three routes. The AUC360 after oral
administration was only 54 % of that after sublingual administration.
Many clinical studies have shown that vaginal misoprostol performed better than similar
doses of oral misoprostol in medical abortion. This is probably due to the more sustained
serum concentration after vaginal administration. The new sublingual route has been
shown to have a similar complete abortion rate to vaginal misoprostol in first trimester
medical abortion. However, it might be associated with higher incidences of side effects.
This may be related to its higher peak concentration. On the other hand, a short time to
Tmax and a higher Cmax make the sublingual misoprostol a good cervical priming agent. Its
clinical efficacy as a cervical priming agent has been proven. Sublingual misoprostol has
also been used for the management of postpartum haemorrhage. Its unique way of
administration makes it the route of choice in the presence of vaginal bleeding and when
oral intake is not desirable.
In conclusion, pharmacokinetics studies have demonstrated the absorption kinetics of
various routes of administration of misoprostol. More studies are required to find out the
best way of administration of misoprostol for various clinical applications.
University of Aberdeen
Coping with UK Abortion Law
University of Aberdeen, Scotland, UK
When the 1967 Abortion Act came into practice in England, Scotland and Wales, it was seen as a major step forward in Women’s Health. Now almost fifty years later, the Act’s evident limitations inhibit best practice in several respects. Abortion in the UK is illegal unless the conditions of the 1967 Act are met and confirmed by two doctors. In the majority of cases a woman requests an abortion and an abortion is justified because it is safer than having a baby, condition c states “that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated”. This may not be what the Act intended and is certainly not what the GMC now advises in recognising a person’s right to make decisions about her own healthcare.
Furthermore the advent of medical abortion particularly has highlighted the inadequacies of the current Act with regard to safe and effective service provision. Nurses are prohibited from sanctioning and performing abortions. The obverse interpretation of the Act which requires both mifepristone and misoprostol to be given in clinics makes abortion at home (the preferred option of the majority of eligible women) both more inconvenient and uncomfortable than necessary. Within the UK, abortion has now been devolved to Scotland, and although it has been made clear there will be no early attempt to amend current legislation, changes which improve service provision will be considered. This highlights the dilemma of those wishing to improve matters, namely whether to campaign to strike out the laws which make abortion illegal and so recognise a woman’s right to abortion, or whether to interpret and amend current laws to improve service provision, as was very nearly achieved in 2008.
Professor Allan Templeton, University of Aberdeen, United Kingdom
The formulation of the antiprogesterone drug mifepristone in the 1980s led to the development of safe and effective medical abortion as an alternative to surgery. Initially the regimens were used in the early first trimester and second trimester, and increasingly employed the prostaglandin E analogue misoprostol given by a variety of routes, including oral (swallowing), vaginal, sublingual and buccal.
About ten years ago this approach was also assessed for use in the late first trimester and as a result medical abortion is now used at all gestations, where preferred to surgery. This review will focus on 10 years experience of late first trimester medical abortion at one centre, including efficacy, side-effects and acceptability. It will also illustrate how frequent review has facilitated improvement and development of the regimens used.
Professor Allan Templeton, University of Aberdeen, United Kingdom
Most current regimens for second trimester medical abortion are based on the administration of sequential doses of the prostaglandin misoprostol to women pre-treated with mifepristone, where available. Mifepristone given 24-48 hours prior to the administration of the first dose of prostaglandin will shorten the induction-abortion interval, decrease the dose of prostaglandin required and hence reduce side-effects and analgesia use. Most women will abort within 15 hours, but if not, the regimen can be repeated next day, or surgery undertaken. A dose of mifepristone 200 mgs is sufficient throughout the second trimester.
The initial prostaglandin dose can be administered vaginally or sublingually and subsequent doses given orally if the uterus is contractile but abortion has not occurred. Completion of the abortion will require surgery (usually removal of placenta) in 5% of cases with experience. Comparison with surgery (D and E) has proven difficult, although minor complications are more frequent with medical abortion and patient preference favours surgery. On the other hand the risk of infrequent but serious injury is probably higher with surgery. A number of other issues pertinent to late second trimester and early third trimester abortion including feticide and abortion for fetal abnormality will be discussed in the light of recent RCOG reports.
New developments in medical abortion care at 9-13 weeks
Alan Templeton (Scotland)
University of Aberdeen, Scotland
After considerable experience of a mifepristone-misoprostol regimen for induced abortion in the early first trimester, pilot studies indicated the feasibility of using a similar regimen in the late first trimester. A randomised study was then carried out which demonstrated efficacy and acceptability compared with surgical abortion, and indicated that medical regimen was an effective alternative, acceptable to the majority of women. Subsequent review of experience indicated that approximately half of women will opt for medical abortion at 9-13 weeks gestation, if offered the choice. However acceptability is less than surgery, and decreases with gestation. Similarly the ongoing pregnancy rate is higher at higher gestations. Further randomised study has indicated the efficacy and acceptability of sublingually administered misoprostol at all first trimester gestations, even though the frequency of prostaglandin related side affects is higher. Further developments using the regimen will be reported at the meeting.
Medical methods at later gestations
Allan Templeton University of Aberdeen, Aberdeen, UK - firstname.lastname@example.org
Induced abortion is one of the most common medical interventions. Most abortions are carried out in the first trimester, but there is a continuing need to provide services for those presenting later, about 10% of the total, and including most abortions carried out for fetal abnormality and for medical reasons. Medical, rather than surgical, methods became safe and effective with the advent of prostaglandins and this approach was greatly facilitated with the introduction of mifepristone around thirty years ago. Regimens employing mifepristone and a prostaglandin, usually misoprostol given vaginally or sublingually, are now available at all gestations. From about nine weeks onwards it will be necessary to repeat the misoprostol dosage perhaps two or three times or more, usually at three hourly intervals. Misprostol alone can be used in this way, where mifepristone is unavailable, but the efficacy is much reduced, a higher total dose is needed, the abortion interval is increased and there are more side effects. With the combined regimen the overall incomplete abortion rate is around 5%, necessitating the removal of the placenta (usually) surgically. Trials comparing medical and surgical approaches are few, but point to a greater preference among women for surgical approaches, although a good number choose medical. Pain and bleeding is higher with medical abortion, but the risk of serious injury, although rare, may be higher following surgery. Infection screening and antibiotic policies should be as for early abortion, as should the offer of immediate long-acting contraception.
Economic discrepancies for contraception in Europe
Ines Thonke (Germany)
Pro Familia Bundesverband, Germany
Implementation. A survey was carried out among IPPF Europe (International Planned Parenthood Federation) member organisations. It was carried out 17 sovereign nations of Europe with the emphasis on the situation in the European Union concerning costs and access of contraception. The evaluation of contraceptive costs undertaken here focuses also on the situation in Germany.
Results. This comparison of contraceptive costs and access in Europe demonstrates the great divergence in absolute price. Prices tend to be aligned with the economic situation in the respective countries; however they highlight the arbitrariness in price-setting, particularly as a number of the richest countries even supply contraceptives free of charge.
Germany always takes second place and for hormonal IUDs is the most expensive of the countries in the survey, while the country in first place is different every time.
In terms of relative prices, shown here as a percentage of income per head, no universal tendencies whatsoever can be identified
Free access to contraceptives for all or for specific groups is offered almost exclusively by countries with high income per head rates and most comprehensively in France and the UK, for example, but all – even the poorest countries in the survey – provide all their citizens free access to medical consultation – which only in Germany is no longer the case.
The fact that Germany is expensive is primarily due to the recently introduction of medical consultancy fees. It is in this respect a new finding, as this last reform catapulted Germany out of the middle ground. The special provision for under-18s and under-20s should also be noted At the same time however it must be pointed out that cancelling free provision of contraceptives to those on social welfare benefits has reduced their access to contraceptives significantly in Germany compared to price levels in the rest of Europe.
Conclusion. It has been shown that it is useful to compile a comparison of contraceptive costs in Europe. Only by making specific comparisons does the particular situation in individual countries (here, the German situation is outlined in greater detail) become comprehensible. It has been substantiated that in the case of Germany the price for contraceptives is in the upper range in terms of an absolute as well as a relative comparison and that the introduction of the Gesundheitsmodernisierungsgesetz (GMG or Healthcare Modernisation Act) in 2003 has created a huge financial burden for clients when compared to the rest of Europe.
The survey should be made available to all European member organisations in the form of a useful and up-to-date factual report on the situation.
Proposals for subsequent work will be worked out.
Experiences with prescription-only access
Ines Thonke (Germany)
Pro Familia Bundesverband, Germany
In contrast to many European countries, the “morning after pill” is as we know only available on prescription in Germany. pro familia’s National Association has established in a survey among counceling offices that prescription-only availability is the main but not the only obstacle that girls and women are confronted with when they need the “morning after pill”. The information gained from practical experience could prove to be useful in objective discussions and sharing experience as to how to improve the provision of safe post-coital contraception to women in Germany.
New data show that about 12 % of women in the age of 20 to 44 have used emergency contraception at least once in their life. The observed frequency of application shows differences in age and marital status, in urban and rural areas and is also depending on educational background.
Our survey shows that the need to see a doctor to obtain a prescription leads to different obstacles.
At weekends and overnight medical care is provided by medical walk-in centres and hospital outpatient clinics.
Hospital provision. A refusal of EC was by no means the exception. This practice is evident among catholic hospitals. A further reason which is cited is that the hospital cannot issue this type of prescription for reasons of cost and as a third reason that duty doctors refuse on moral grounds or justify their refusal by claiming that it is not an emergency. Women who need the “morning after pill” also find that they are charged for gynaecological investigations, pregnancy tests and ultra-sound scans. Additionally girls and women are burdened by the fact that they have to present their private worries several times in the clinic and in some cases they have to endure very lengthy waiting times (up to 3 hours)
Walk-in centre provision. Our survey shows that similar problems are experienced at medical walk-in centres. For girls under the age of 16, often parental agreement is required.
Pharmacy provision. Sometimes women face even more problems in obtaining the medication. Not all pharmacies have the “morning after pill” in stock or their stocks are minimal. In rural areas and with no car, this can quickly result in a lengthy delay before it can be taken.
General problems from everyday practice. Girls and women tell about the high cost which is an obstacle for them and also of their fear of gynaecologists and the difficulty of booking an appointment at short notice.
Conclusion and the need for action. Problems in provision are still being reported in various parts of the country. The shortfall in provision described above represent obstacles which still delay and prevent the "morning after pill" from being taken. The information in medical training and development about the current standard of quality and provision for hormonal emergency provision must be considered a central task in the current options for action. In order to tackle moral and ethical concerns, it is important to provide clearer information about the current findings on effectiveness as EC is still cited in the context of abortion and/or equated with it. Many of the other obstacles mentioned here can be overcome with in-depth training and development of doctors and clear rules for charging in hospitals. Instead of blaming couples for contraceptive use failure they should be encouraged to act responsible when asking for EC.
Physiological and reproductive outcomes
Michel Tournaire, Sophie Gaudu, Philippe Faucher (France)
Surgical abortion. The influence of surgical abortion on subsequent reproductive outcome, reported for several decades in the literature can be summarized with seven criteria.
Medical abortion. Despite the increasing proportion of abortion by means of medication, limited information is available regarding the effects of this procedure on subsequent pregnancies.
A recent (2008) metaanalysis including eight studies on reproductive outcome compared the influence of medical and surgical abortion. The incidence of miscarriage and post partum hemorrage was significantly lower for the pregnancy immediatly following a medical abortion. No other significant difference was found.
For the outcome of the future pregnancies, medical abortion may thus be safer than the surgical option.
Second trimester abortion: medical or surgical abortion?
Michel Tournaire, M. Bornes, S. Gaudu, F. Lewin
Hopital Saint Vincent de Paul, Paris, France
The methods for second trimester abortion vary according to countries and institutions.
Medical methods using preparation of the cervix and misoprostol are predominant in
Europe. Surgical dilatation and evacuation requires practitioners trained for this technique.
It is used for almost all second trimester abortions in the USA and is available in some
institutions in Australia, England, France and the Netherlands. Complications are more
frequent with medical method : retention of placenta that needs secondary surgical
removal, hemorrhage with transfusions and rupture of the uterus, risk that is increased in
the cases of previous cesarean section. Surgical method can be complicated by
perforation of the uterus and laceration of the cervix. The risk for premature birth in
subsequent pregnancies seems to be low for the two methods. Emotional consequences
have been found identical with both techniques. The choice of the method is not based on
scientific data but on the practitioner’s experience. If the two methods could be available in the same institution, this would allow, well informed women to participate using their choice.
First Tri deaths: the hidden patterns
Troncoso, E1; Schiavon, R1; Freyermuth, G2;
1 Ipas; 2 Observatorio de Mortalidad Materna, Mexico
In Mexico, public health sector information systems have
signiﬁcantly improved their record keeping and allow us to know
that termination of pregnancy (TOP) mortality accounts for
around 10% of maternal deaths in the last 10 years. Given the
high mortality ratio, maternal deaths are analysed carefully every
year in the Ministry of Health. The goal of this project was to
better understand the 2010 TOP related mortality ﬁles.
During 2010, 9.27% of maternal deaths were due to TOP
(92 cases). Almost 75% of deaths were among women aged 15 to
34 years, younger than those dying from other causes. Twenty-six
percent were single compared with 15% for the other causes.
Ninety percent of women received health care before the death.
The quality of the information of the TOP cases was poor,
regularly a maternal mortality case was 11 elements for the
comprehensive analysis into their ﬁle. In the case of TOP deaths,
only 66% of the ﬁles had verbal autopsies, 23% a necropsy report,
and no one had an ofﬁcial declaration. In some cases, women
were not aware of their pregnancy, and the diagnosis did not
Despite the interest in maternal mortality, TOP has not been
adequately addresed in the current framework and more questions
remain after the revision of the ﬁles. TOP-related deaths require
an adequate response from the health systems.
Erika Troncoso (Ipas Mexico), Olivia Ortiz (Ipas Mexico), Raffaela Schiavon (Ipas Mexico)
Background: Decriminalization of induced abortion during the first trimester of pregnancy in Mexico City has broadened reproductive choices for women since April 2007. The objective of this study was identify the barriers and conditions that impact access to legal abortion (LA) in private clinics.
Methods: Seventeen semi-structured interviews were conducted with women who received a legal abortion in two clinics in Mexico City.
Results: The majority of the women interviewed were young, single with higher levels of education. Three women travelled to Mexico City to obtain a LA. The majority of women sought medical advice prior to arriving at the center and changed their decisions due to unfriendly care and lack of trust. Also, the majority of women obtained information on conditions and facilities offering services through the internet, as well were already aware of the legal changes pertaining to abortion. This allowed them to speak more openly on the subject with those most trusted, and even with healthcare providers when seeking consultation. Other factors that facilitated the experience included: being attended by trained medical personnel in legal and sanitary conditions, receiving comprehensive information about the procedure, and experiencing friendly and non- judgmental treatment by health personnel. Finally, establishing a personnel bond with one of the healthcare providers helped the process to be more comfortable. In respect to the barriers, the interviewed group identified what close relatives and friends perceived of them, informed by religious beliefs and moral judgments, as important. Other aspects were difficulties finding specific information on the way different methods work, the effects, and lack of economic resources to be treated immediately. Some women stated fear of feeling rejected by health personnel when requesting care. Women stated having distorted information produced and disseminated by the opposition concerning abortion. In addition, they found that some providers passed judgment or they felt hostility from health personnel in other areas, including prolonged waiting periods. However, these factors did not push them to change their decisions. The women stated their need for emotional support, something that was not considered in LA provision of services.
Discussion: Before arriving at the medical facility, the majority of the women was confronted by many complex and diverse situations and had made decisions as a method of self-defense and survival. Deciding to have a legal abortion served as an opportunity to change or avoid greater repercussions in the woman’s life. Legal abortion services must be aware of these situations because they will have an influence on the experience of the services. The analysis shows how women requesting legal abortion used various criteria to determine how much they trusted the service: both the legality and the expectation of care were used in order to determine who would be their health provider. Finally, this study shows the need to do further research on women’s emotional experiences, aiming to identify the factors that put them at risk in the immediate future with an unwanted or unplanned pregnancy.
Despite South Africa having one of the most progressive abortion laws in the world, unsafe and illegal abortions remain a significant public health problem. Multiple barriers to abortion care provision exist including provider conscientious objection, stigma, healthcare provider shortages, lack of trained providers, and a lack of designated facilities providing abortion services.
In partnership with the Western Cape Department of Health (WCDOH), the RCOG Leading Safe Choices (LSC) programme seeks to improve access to abortion services within the Western Cape by increasing the number of providers willing and able to provide Comprehensive Abortion Care (CAC) services; improving the quality of post abortion family planning counselling and provision; and raising the standing of abortion care professionals. The programme trains and mentors mid-level health care providers (HCPs) in CAC.
Early on in the LSC programme it became clear that although training interventions can make a localised impact in relation to increasing skilled providers and improving quality of abortion care, the overall impact was being hindered by the prevalence of conscientious objection at senior management levels; the failure of the WCDOH to hold designated facilities accountable if they failed to provide CAC services; blockages in the referral pathway of patients and a lack of understanding of multi-disciplinary teams to provide CAC services as women’s rights enshrined in the Choice on Termination of Pregnancy Act and the constitution of South Africa.
In partnership with the WCDOH and using lessons learnt during the programme, a CAC Optimization Strategy was implemented to tackle systems barriers and to improve abortion care services. Following its implementation uptake of CAC training has tripled and 11 new CAC sites have been established in the Western Cape.
This presentation will present the different elements of the Western Cape CAC Optimization Strategy and its vital role in improving CAC services within province.
Objectives: Major barriers in accessing abortion services for women include provider opposition, stigma associated with abortion, poor knowledge of abortion legislation, lack of trained providers, and lack of fully equipped facilities. Many providers display negative and judgemental attitudes towards women, with reports of attempts to dissuade women from undergoing an abortion. The Leading Safe Choices (LSC) programme trains and mentors mid-level HCPs in comprehensive abortion care (CAC) with a focus on surgical abortion. However, recruitment of participants for CAC training proved challenging.
Methods: Values Clarification Workshops (VCWs) were conducted with multidisciplinary HCPs and facility managers.
The objectives of the VCWs included exploring assumptions, myths and realities about unwanted pregnancy; providing accurate legal information about abortion; and understanding the difference between personal views and professional responsibilities. Between March 2017 and March 2018, 18 VCWs were conducted with 272 participants.
Results: Uptake of CAC training increased with the introduction of VCWs. In the 15 months prior to the introduction of VCWs (December 2015 to February 2017), 35 providers attended CAC training with 5 being signed off as competent to provide services. In the 12 months following the introduction of VCWs (March 2017 – March 2018) the number of CAC trainees increased to a total of 81 with 19 being signed off as competent after receiving mentorship at their facilities. Since the introduction of VCWs, 11 new CAC sites have been established in the Western Cape. We suggest that VCWs have contributed to this.
Conclusion: Increased uptake of CAC training suggests VCWs have led to improvements in the provision of, and access to, abortion care services. VCWs should be conducted with multidisciplinary teams including facility managers and attendance at VCWs should be a pre-requisite for undertaking CAC training to enable health care providers to offer holistic, respectful and woman centred abortion care.
Fatal ﬂaws in a recent meta-analysis on
termination of pregnancy and mental health
Steinberg, J; Trussell, J; Hall, K; Guthrie, K
Ofﬁce of Population Research, Princeton University, USA
Similar to other reviews within the last 4 years, a thorough review
by the Royal College of Psychiatrists, published in December 2011,
found that compared to delivery of an unintended pregnancy,
termination of pregnancy (TOP) does not increase women’s risk
of mental health problems. In contrast, a meta-analysis published
by Coleman in September 2011 in the British Journal of
Psychiatry claimed to ﬁnd that TOP increases women’s risk of
mental health problems by 81% and that 10% of mental health
problems are attributable to TOP. Like others, we strongly
question the quality of this meta-analysis and its conclusions.
Here we detail seven errors in this meta-analysis and three
signiﬁcant shortcomings of the included studies because policy,
practice, and the public have been badly misinformed. These
errors and shortcomings render the meta-analysis’ conclusions
invalid. In this case there was a complete failure of the peer-
review process and editorial oversight.
Lessons from the Contraceptive CHOICE Project: The Hull LARC Initiative
James Trussell1 ,2, Katherine Guthrie3 1Princeton University, Princeton NJ, USA, 2The Hull York Medical School, Hull, UK, 3City Health Care Partnership Hull, Hull, UK - email@example.com
Objective: To discover whether a hand-out explaining the benefits of intrauterine contraceptives (IUCs) and implants could increase their uptake in Hull, England. Methods: We developed a simple double-sided A4 hand-out. On one side was a script with pictures of copper and levonorgestrel IUCs beside a 20-pence coin and of an implant beside a hair grip. On the other side was the three-tiered effectiveness chart from Contraceptive Technology. The receptionist would give the hand-out to every woman and ask her to read it before seeing a clinician. Then the clinician would ask the woman if she had read it and if she had any questions. Although we implemented the project in family planning (FP), abortion, and antenatal clinics and GP practices, we evaluated it only in FP clinics and GP practices because electronic records are available. Results: There was no impact in GP practices. There was no overall impact in FP clinics. However, only one, the service hub (Conifer House) is open daily (except Sunday) and has permanent sexual health staff on the reception desk. In Conifer House there was an increase in the proportion of women receiving IUCs or implants of 15.2% from October 2011-April 2012 to May 2012-November 2012 (from 31.0% to 35.7%, p=0.0002). The proportion returned to baseline in December 2012-November 2013, when there was a change at reception to reduce waiting times. Conclusion: This was not a formal study, so there was no research coordinator to monitor the project. We think there was no impact among GPs or among peripheral FP clinics because the project was never implemented. And we think the change at reception at Conifer House caused an already overworked staff to stop dispensing hand-outs. This simple, extremely low-cost LARC intervention at Conifer House was highly effective, by far the most cost-effective on record.
Beyond unmet need: desired versus actual use of contraception
Princeton University, Princeton NJ, USA
Two studies have examined what method of contraception women were using and what method they preferred to use. One was among postpartum women in Texas and the other was among women attending an antenatal clinic or an abortion clinic in Hull, England. In Texas, 800 postpartum women who wanted to delay childbearing for at least two years were followed prospectively. At 6 months postpartum, 13% of women were using an IUD or implant, and 17% were sterilised or had a partner who had had a vasectomy. Twenty-four percent used hormonal methods and 43% relied on less effective methods such as condoms and withdrawal. However, 78% reported that they would like to be using either a long-acting reversible contraceptive method (LARC) or sterilisation. In Hull 76% and 6% of pregnancies among women in the abortion and antenatal clinics were unplanned, respectively. In this group, among those not using contraception, 31% were unable to obtain the method they wanted. Among those using a method 33% stated it was not the method they wanted; of these 75% would have preferred sterilisation, the implant, injectable or intrauterine contraceptive.
Contraception: why it fails
James Trussell1,2 1Princeton University, Princeton NJ, USA, 2The Hull York Medical School, Hull, UK - firstname.lastname@example.org
In this presentation, I discuss the difference between contraceptive failure rates during perfect use and during typical use. I examine the logical error that many investigators make when computing failure rates during perfect use. I then highlight the impact of simultaneous use of two methods. I next explore the reasons for observed differences in correctly computed failure rates during perfect use and during typical use. Next I discuss reasons for the “creeping Pearl” (Pearl indexes for oral contraceptives approved by the FDA have increased over time). Finally, I report on the results of clinical trials of two new contraceptive patches and the stark implications for pharma and regulatory agencies.
Sustainability of medical abortion services in the Caucasian region
Tamar Tsereteli Gynuity Health Projects, Tbilisi, Georgia - email@example.com
Caucasian women, as residents of former Soviet republics, have had widespread access to legal abortion for almost one hundred years. Abortion rates are high, and many women rely on abortion as their primary means of fertility regulation. Current laws provide for abortions up to 12 weeks’ gestation without restrictions, and up to 22 weeks’ gestation for broad medical and selected socioeconomic grounds. Until recently, surgical abortion was the only option available to women in Caucasian countries. Very few doctors were trained in medical abortion provision, most women did not know what medical abortion was or had an incorrect understanding of the procedure and there were no recommended national protocols doctors could consult if they were interested in providing the service. In addition, mifepristone was not always available: if registered at all, it often was unavailable outside of the capital cities. In 2006, Gynuity Health Projects launched a series of collaborative activities in Armenia, Azerbaijan and Georgia with the goal of increasing the availability of safe abortion services and access to medical abortion. Activities included training for doctors and nurses on medical abortion, clinical research studies, dissemination meetings to present study findings, development of Information, Education and Communication (IEC) materials for women and assistance in developing national protocols. In some cases data generated from the clinical studies supported mifepristone registration and informed national protocols. Between December 2011 and June 2013, Gynuity conducted studies in Armenia and Georgia to assess ongoing provision of medical abortion services and evaluate the quality of care provided at former research sites. This presentation will describe how programme components have contributed to sustainability of medical abortion in the Caucasian region.
In Georgia during last decade medical service providers became decentralized and universal health care provision were launched. These changes in health system triggered increase in number of health providers and proportionally need for regulation of service provision and financing.
Non-preventable abortion in Georgia is legal and provision of service is distributed to primary and secondary health providers. Law of Georgia on health care allow abortion on request up to 12 weeks of gestation therefore mandates 5-day mandatory waiting time between consultation and abortion procedure. State policy regarding abortion is to increase childbirth while women’s choice and health is unsatisfactory level.
Despite liberal policy there still is low accessibility and availability to safe abortion services which is caused by uneven distribution of service providers that provide abortion service, ununiformed referral system, and diminishing number of abortion provider physicians (church influence, conscientious objection). As a result, women are forced to travel for service.
In Georgia unsafe abortion is widespread in spite of medical activity regulation on physician and medical facility levels. Due to no medical service quality appraisal, it is impossible to track standards of service provision and identify medical facilities where quality is not sufficient. For example, system does not track service providers where only D&C method is used or how frequently it is used. If consider D&C method, along with general anesthesia, no counseling, no post-abortion family planning and etc. as unsafe way of abortion service provision. Two above-mentioned issues make it difficult to prevent unsafe abortions.
Women searching for abortion services encounter accessibility and availability barriers that are Not enough Abortion Providers, Cost and Travel, Judgmental Gatekeepers, Conscience Clauses, Bad Referrals, Anti-choice Organizations (church), which makesprevention of unintended pregnancy difficult, leading to high abortion rates, low quality.
Jema Turk, F.Preskill, G.Patel, U.Landy and J.Steinauer, USA/Canada
Objectives: The Kenneth J. Ryan Residency Training Program in Abortion and Family Planning (Ryan Program) provides technical and financial support to help US and Canadian obstetrics and gynecology (ob-gyn) residency programs comply with the Accreditation Council for Graduate Medical Education mandate to integrate abortion into training. Since 1999, 54 Ryan Programs have been established in 28 states and in two Canadian provinces. A total of approximately 1600 residents have been trained through the Ryan Program since its inception. Our objective was to describe the clinical and departmental impacts in the Ryan Programs.
Methods: All 54 Ryan training programs are systematically reviewed through pre- and post-rotation surveys completed by residents, and through annual reports, site reviews, and yearly on-line surveys completed by Ryan Program directors, department chairs, and residency program directors. Programs and residents undergo extensive evaluation during the first two years of active funding. Thus, the data discussed here represent evaluation pursued in the first two years of program existence.
Results: A total of 746 residents have completed pre- and post- rotation surveys to date, giving a total response rate of 70%. On average, residents spend 15 days in clinics providing abortion and/or contraception care. The location of training varies between in-hospital clinics (45%), out-of-hospital clinics (40%), and a combination (15%). During the Ryan Program rotation, residents provide pregnancy options counseling, routine and complex contraceptive services, cervical preparation, and perform first-trimester manual uterine aspirations and electric uterine aspirations, medication abortions, and second-trimester dilation and evacuation procedures. Comparing pre- with post-rotation surveys, residents’ self-assessed competence in first and second-trimester uterine aspiration increases significantly, as well as the intention to provide all techniques of abortion after residency. In addition, residents, Ryan Program directors, department chairs and residency program directors describe a variety of benefits beyond residents’ skills in abortion care. These include residents’ skills in counseling, contraception, ultrasound, and outpatient surgery; improved continuity of care for patients; and improved appeal of the residency programs to medical student applicants.
Conclusions: The Ryan Program has been successful in integrating abortion and family planning into 54 (21% of all) US and Canadian ob-gyn residency programs. These rotations have led to approximately 1300 ob-gyns graduating with proficiency in abortion care, and over 75 percent plan to include these skills in their subsequent practice. In addition, the Ryan Program’s successes have contributed to reinforcing the importance of training in family planning as a central part of obstetrics and gynecology.
Jema Turk, H.Steele, M.Fulton, U.Landy and J.Steinauer, USA/Canada
Objectives: To describe the US-based fellowship in family planning.
Background: In 1991, the Fellowship in Family Planning was established at the University of California, San Francisco to promote advanced training in contraception and abortion. The Fellowship in Family Planning provides two years of post-residency training in clinical care, research and policy training. The fellowship also requires an international placement in a low-resource setting and completion of a masters degree in clinical research or public health and is available to graduates of either obstetrics-gynecology or family medicine residency training.
Methods: The fellowship is assessed yearly through annual reports completed by faculty and fellows, bi-yearly site visits, and regular audits of fellowship publications.
Results: The Fellowship in Family Planning has grown to include 21 medical schools throughout the United States. To date there are 118 graduated fellows and 38 fellows currently in training. Fellows develop expertise in abortion care and complete a median of 168 first-trimester uterine aspiration and 102 second-trimester D&E procedures over two years, in addition to developing skills in contraception and maintaining non-family planning skills. Fellowship directors and graduated fellows have generated a wealth of research addressing some of the most critical questions in family planning, with over 120 peer-reviewed publications in 2009. Fellows have participated in international placements in 39 countries in four continents. Twenty-four (20%) graduated fellows have gone on to direct abortion training programs in residency programs.
Conclusions: The development of a fellowship in family planning in the US has led to a cadre of subspecialists and consultants in abortion and family planning clinical care and research who have become the leaders in training and research in the US.