Sublingual compared with oral misoprostol for cervical dilatation prior to vacuum aspiration.
Annette Aronsson*, MD, Lotti Helström, MD. and Kristina Gemzell Danielsson, MD. PhD
Dept of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
BACKGROUND. Vacuum aspiration is still the most common method in late first and early second trimester pregnancy. Prostaglandin analogues have been successfully used for preparing the cervix before mechanical dilatation and suction curettage since over 20 years to reduce the risk of mechanical injury, incomplete evacuation and haemorrhage. The analogue mainly used today is misoprostol. The most advantageous dose schedule for cervical priming seems to be 0.4 mg misoprostol orally or vaginally given 3 hours prior to vacuum aspiration. However most women prefer the oral route. Recently the possibility to administer misoprostol sublingually has been described. The absorption of misoprostol when given sublingually is equally rapid as following oral treatment but the plasma levels remain elevated for a significant longer time and the effect on uterine contractility is more pronounced.
The aim of the study was to compare the effect of oral and sublingual administration of misoprostol for cervical priming prior to vacuum aspiration.
METHODS. Thirty-two first time pregnant women with 8 to 12 weeks amenorrhoea and admitted to the hospital for surgical termination of pregnancy were recruited. The women were randomly assigned to receive 400 mg misoprostol either orally or sublingually 3 hours prior to surgery.
RESULTS. The degree of baseline dilatation and the cumulative force needed for dilatation of the cervical canal did not differ between the two treatment groups. However, the number of patients in whom a strong force (15 and 20 N with the 8 and 9 mm dilator respectively) was significantly higher following oral than following sublingual treatment. The number of patients with gastrointestinal side effects and need of additional analgesic treatment was higher following sublingual treatment. The opposite was true with regard to the number of patients who had a blood loss at operation of 50 ml or more.
CONCLUSION. It was shown that sublingual administration is more effective than oral administration of misoprostol for cervical priming and associated with less blood loss but a higher frequency of side effects.
Ivar Brod, Pan Am Pharmaceuticals, Inc., New York, USA
Christian Fiala MD, Gynmed Ambulatorium, Vienna, Austria
Misoprostol has been widely used in Ob/Gyn practice since the early days of its appearance on the market. However, Pfizer, the current manufacturer, so far has rejected continuous requests to add these indications. Moreover, in countries like Estonia and Latvia where registration expired, manufacturer refused to prolong it. We believe that the company’s reasons were financial only, since the price of Misoprostol is more than 10 times lower than the price of other prostaglandins, injectable or jelly, produced by this company. This reason overweighs the fact that other prostaglandins (E2 and F2a analogs) can cause heavy adverse effects, like myocardial infarction and bronchospasm, which is not the case for Misoprostol (E1 analog).
The use of Misoprostol in Ob/Gin in USA is based on FDA’s general recognition that off-label use of approved medicine is acceptable, if it’s based on published scientific evidence. Similar recommendations have been accepted by the European Community Pharmaceutical Directive as well as by British National Formulary. There are no such policies in countries of Eastern Europe - Russia and other post-communist countries. Data that is being analyzed is mainly from Russia, which is typical for all of these countries. Existing legislation there does not provide any positive information about the off-label use of medicine. Moreover, in case of Misoprostol, medical authorities periodically issue directions prohibiting the access to it, due to the lack of indication by the manufacturer. The first of such Directive Letters was issued in April 1999 by Russian Ministry of Health forbidding the use of prostaglandins for off-label indications. The last Directive Letter as of July 2003 forbids directly the Ob/Gyn use of Misoprostol. The breach of these directives can be assumed as a criminal case.
One of the biggest problems for countries like Russia, where 60% of pregnant women prefer abortion and 15% of women in reproductive age are sterile, is to conduct a gentle abortion procedure in order to avoid any harm to female’s reproductive system. Many experts acknowledge that medical termination of pregnancy, using mifepristone followed by Misoprostol, is the most merciful abortion method. Mifegyne (mifepristone), known as the most excellent medicine for medical termination of pregnancy, has been registered in Russia in 1999. Ban of Misoprostol use significantly deprived Russian women the right to choose this method of medical abortion.
There is one more serious aspect resulted from Misoprostol ban in obstetrics in Russia. Help to pregnant women during childbirth is particularly important in this country where more than 10% of deliveries present with high risk of complications for mother and a baby. More than 1/3 of those caused by failure to progress in labor. Russian Ob/Gyn specialists found direct correlation between using Mifegyne and Misoprostol and raising the Bishop range from 0-3 to 4-7. As a result, this method was patented and these indications were formulated in the instruction. Misoprostol ban in obstetrics makes it impossible to use this remarkable mode.
The literature supporting Misoprostol Ob/Gyn use is rather vast – more then 400 publications in leading medical journals. Among them there are publications of experts in Russia, Ukraine, Latvia, Lithuania, and others. Moreover, in Russia in 2004 is published a spacious monograph devoted to Ob/Gyn use of Misoprostol. However, most of all reported brilliant results were based on the use of Misoprostol in research institutions, not in general practice.
We have to stress, that the situation with Misoprostol is special because it is officially recommended to be used in Ob/Gyn by World Health Organization issuing in May 2003 the guidance “Safe Abortion: Technical and Policy Guidance for Health Systems”. We believe that these recommendations allow us to call upon medical authorities in countries of Eastern Europe to acknowledge that Misoprostol was proven to be a prominent drug in Ob/Gyn and to define the way of its appropriate use. Women should not be held hostage by the economic considerations of a private pharmaceutical company in the United States.
Children by Choice - an Australian counselling, information and
education service on issues relating to unplanned pregnancy.
Abstract: Since 1972, Children by Choice has provided counselling, information and education services to women experiencing unplanned pregnancy. We are a unique service in Australia, as we provide the only specialist pro-choice counselling, information and referral service on all unplanned pregnancy options. (There are many anti-choice pregnancy counselling services in Australia). Our service has also assisted women to access abortion through financial subsidies and travel arrangements. Children by Choice has a proud history of activism on abortion law reform and expanding women's access to abortion services. This poster presentation will outline the history and services provided by Children by Choice, and discuss the current status of abortion access and laws in Australia.
Cait Calcutt, Coordinator
INDUCED ABORTION IN GESTATIONS FROM 19 TO 24 WEEKS OR MORE WITH 200 mg of MIFEPRISTONE + MISOPROSTOL + OXITOCIN
*J.LL Carbonell Esteve, *L. Várela, et al
*Clínica Mediterránea Medica Valencia, Castelló (Spain)
INTRODUCTION: Although some authors perform the D and E up to 22-23 weeks gestation, it is not advisable to use it beyond 19-20 weeks, since the risks and difficulties increase considerably with gestation. To determine a suitable protocol with maximum possible safety and efficacy is one of the burning scientific topics in termination of pregnancies of second late trimester and third trimester. Without any doubts mifepristone and misoprostol are indispensable in such protocol.
MATERIAL AND METHODS: They were administered mifepristone 200 mg orally 24-48 hours before vaginal administration of 800 µg of wet misoprostol + 2 dilapan shafts according to cervical conditions. 3-4 hours later the cervix was evaluated and if shafts were loose, a second dose of 600 µg of vaginal misoprostol was inserted or it was performed an artificial rupture of membranes (dilation 2-3 cm) and oxitocin infusion was established (6-8 drops by minute in a solution of 500 cc of ClNa with 30 U.I. of oxitocin). In an hour basis the cervix was examined and several medications were used to relieve pain and ripening the cervix. General sedation was used at expulsion. A complete hemogram with fibrinogen and TPTA 2 hours late were performed. Patients with cesarean section or previous uterine scar were not excluded.
RESULTS: 90 subjects between with 19 to 23.5 weeks gestation were successfully interrupted with the above protocol; 2 of them (20,4 and 20,5 weeks gestation) were failure cases at 32 and 31 hours, respectively, and were terminated by D and E. Only 30% of the cases received mifepristone before 24 hours. They were malformed 52.4% and 47.6% were voluntary abortions. The most frequent malformation was Down’s syndrome. The mean expulsion time was 5.5 hours, range 1.30-25 hours. There was a moderate hemorrhage by an atone uterus and the patient was discharged the following day, and an uterine rupture that forced to perform an urgent hysterectomy in a patient with a 19 years old cesarean section.
DISCUSSION: The use of mifepristone previously to the administration of prostaglandins improves significantly the cervical conditions and reduces in 50% the mean expulsion time, allowing that more than 60% of the cases can be discharged 6 hours post expulsion of the fetus and therefore to spend the night at home. Patients with previous cesarean section should be object of a different protocol, perhaps with less and maybe repeated doses of misoprostol. In the international bibliography there is reported a case of uterine rupture using a single 200 µg dose of vaginal misoprostol. It is urgent to determine with randomized clinical trials a proper dosing protocol for cases with previous uterine scar.
IS SPAIN A DEMOCRATIC COUNTRY CONCERNING RIGHTS TO ABORTION?
J.LL Carbonell Esteve
Clínica Mediterránea Medica Valencia, Castelló (Spain)
The answer without a doubt TO this question is NO. Given that, in 98,99% of the abortions in our country, the woman should be authorized by a psychiatrist to carry out her abortion. The supposition of serious danger for the woman's psychic health that contemplates the Spanish law of abortion is the “legal strainer” for which is carried out more than 90% of those almost 70.000 annual abortions of social character or for free will of the woman. Therefore, this not is tinged since in the practice the legal strainer that supposes an insult and confiscation of the sovereignty and the woman's freedom, allows that in the reality the abortion in our State is practically FREE as in other countries of the truly democratic Europe. Also, more than 60% of the cases the woman should pay the cost of her abortion.
More than 2.500 judicial diligences have opened up crime of illegal abortion of course and more than 20 trials have taken place so far for the same reason, since the promulgation of the abortion law in 1985. In the last sentence of the Supreme Tribunal of the year 2003, after 10 years of judicial prosecution and provisional freedom for 2 doctors from different clinics and for the own woman that aborted, and concluded that the abortion was “legal” although a psychiatry specialist did not authorize it but by a general doctor Specialist in Public Health (Dr. J. Carbonell). The woman was acquitted and alone the doctor that practiced the abortion was condemned (Dr. J. Vives) for a supposed crime of professional negligence.
It is hope that this serious situation changes with the new abortion law that the PSOE, at the moment in governs has committed openly as necessary to promulgate, so that it puts an end to this situation of serious artificial lack of defense, so much for doctors as for women themselves.
MIFEPRISTONA 200 MG + 600 µg OF SUBLINGUAL VERSUS VAGINAL MISOPROSTOL FOR SURGICAL ABORTION BETWEEN 12 TO 20 WEEKS GESTATION.
J.LL Carbonell, L. Várela, et al.
Clínica Mediterránea Medica. Valencia, Spain
INTRODUCTION: The use of vaginal misoprostol for ripening the cervix before second trimester abortions performed with the technique of Dilation and Evacuation (D and E), has represented a significant advance in the practice it of such procedure. Few carried out studies exist, using 200 mg of mifepristona before the administration of misoprostol. One of the legal indications of mifepristone is its use as a sensibilizing agent to the action of prostaglandins for second trimester abortions. To study the efficacy of sublingual versus vaginal misoprostol was the object of this study.
MATERIAL AND METHODS: 600 women with gestations between 12 to 20 weeks were randomly allocated to receive 200 mg of oral mifepristone and 15-48 hours later 600 µg of sublingual or vaginal misoprostol. Vaginal misoprostol (group 1) was inserted by doctors into the vaginal fornix and the buccal tablets (group 2) were placed by subject themselves sublingually and the other tablets inside the cheeks. In both groups, D and E was performed between 1 and 1.30 hours after the administration of misoprostol. Patients with previous cesarean section were not excluded. It was measured: 1) effect of mifepristone 2) achieved dilation, 3) side effects of misoprostol, and 4) duration of post abortion bleeding. The effect of mifepristone was assessed, before and after treatment, by means of vaginal exam detailing: position, length, consistency and dilation of the cervix.
RESULTS: So far they 200 women were treated with this protocol. In 91% of patients, the cervical conditions were improved after the administration of mifepristone. There was not any side effect of interest. The mean dilation reached was of 12 and 13 mm, in groups 1 and 2, respectively. Nausea, vomiting, chills/fever were present in 7,8% and 15%, vomiting 3% and 4,5%, fever/chills 30% and 36%, in groups 1 and 2, respectively. These signs and symptoms were always of moderate and acceptable intensity as referred by 91% of patients. After the administration of misoprostol and before the D and E there were 4% and 5% in groups 1 and 2, respectively, of spontaneous expulsions, that is to say pharmacological abortions.
DISCUSSION: Comparing with the well-known experience the fact of administering mifepristone 200 mg previously supposes an important advance in what concerns to the improvement of the cervical conditions for the realization of a D and E, so that once administered the misoprostol the necessary time of wait to perform the D and E decreases in about f 50%, otherwise they begin to take place pharmacological abortions. The reached dilation is very superior to the one obtained with the administration of misoprostol alone, being the dilation softer and physiologic, also shortening the surgical and anesthetics times. The sublingual route has practically demonstrated to be as effective as the vaginal one, that which represents a considerable advance in what concerns to the patient's comfort. More studies should be carried out in order to demonstrate the efficacy and safety of sublingual administration of misoprostol that presents fewer incidences of side effects due to the elimination the enterohepatic course and with similar dilatory efficacy as the vaginal route.
VAGINAL MISOPROSTOL 800 µG EVERY 12 HOURS FOR SECOND TRIMESTER ABORTION.*
J.LL. Carbonell Esteve,a J. Rodríguez,b et al.
aClínica “Mediterránea Medica”, Valencia Spain.
bHospital Docente Gineco-Obstetrico “Eusebio Hernandez”, Havana, Cuba
INTRODUCTION: Since Bugalho et al. published in 1992 the first study using doses of 800 µg of misoprostol for second trimester abortion, so far numerous studies have been carried out using different dose and administration intervals. Some of them have used 200 mg of mifepristone 48 hours before misoprostol and they have obtained significantly shorter expulsion times. An appropriate protocol to carry out abortions of more than 12 week gestation regarding efficacy and safety is yet to be determined.
MATERIAL AND METHODS: Subjects with a previous uterine scar were excluded. A total of 269 women between 12 and 20 weeks gestation received 800 µg of vaginal misoprostol every 12 hours up to a maximum of 3 doses. Side effects, duration of bleeding, expulsion time, etc. were measured. Success was defined as the complete expulsion of the fetus and placenta without curettage after expulsion.
RESULTS: Complete abortion occurred in 245/269 (91.1%, 95% CI 87%-94%). After the first misoprostol dose aborted 66,5% of subjects; 19% of subjects aborted after the second misoprostol dose; and 5,6% aborted after the third dose, totalling 91,1%. There were 24 (8.9%) failure cases according to protocol. Mean vaginal bleeding time was 15.7 ± 4.1 days. Chills, nausea and vomiting were the most frequent side effects, all of them mild and transient. There 13 blood transfusions due to vaginal bleeding.
CONCLUSIONS: Of the 13 transfusions, only 1.1% were correctly indicated, the rest of them were unnecessary according to hemoglobin values. The administration of 800 µg misoprostol doses every 12 hours could be to valid alternative for abortion beyond 12 weeks gestation, especially in those countries where mifepristone is not yet available.
Swedish teenager’s perception of teenage pregnancies, abortion, sexual behaviour and contraceptive habits
a focus group study among 17-year-old female high school students
Maria Ekstrand, RN*, Margareta Larsson, RNM**, Louise von Essen, PhD***,
Tanja Tydén, PhD****
** Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
*** Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
****Department of Public Health and Caring Sciences and Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
Background: Sweden has the highest abortion numbers among the Nordic countries. Since 1995 the abortion rate among teenagers has increased with nearly 50 %. We therefore undertook a study to gain knowledge about female teenagers´ perception of teenage pregnancies, abortion, sexual behavior and contraceptive habits.
Methods: Six focus group interviews with 17-year-old girls in Sweden were conducted. The interviews were tape recorded, transcribed and analyzed via manifest content analysis.
Results: Negative attitudes towards teenage pregnancies and supportive attitudes towards abortion were expressed. Risk taking behavior such as negligence in contraceptive use and intercourse under the influence of alcohol were suggested as main reasons behind the increasing abortion numbers among Swedish teenagers. The contemporary, sexualized media picture was believed to influence adolescents in their sexual behavior. Liberal attitudes towards casual sex were expressed. Girls were perceived as more obliged than boys in taking responsibility for contraceptive compliance and avoidance of pregnancy. The apprehension that hormonal contraceptives cause negative side effects was widely spread and the participants were found to have limited knowledge about e.g. abortion and fetus development. The majority were unsatisfied with the quality of sexual education provided by the schools.
Conclusion: Possible reasons for increased abortion numbers among teenagers in Sweden could be liberal attitudes towards casual sex in combination with negligence in contraceptive use, increased use of alcohol followed by sexual risk taking, fear of hormonal contraceptives and a deterioration of sexual education in the schools.
Keywords: Attitudes, teenage pregnancies, abortion, sexual risk taking, contraceptives
Christian Fiala (A)
Easy access to safe and effective contraception as well as to legal and safe abortion – both free of charge for those in financial need: no other intervention in human history has had a similarly strong effect in improving women’s health and survival. But it is not women alone who profit from this cultural achievement: men too feel the positive impact of a better health of their mother, sister, partner or daughter. Not to talk about children who need their mother. And even society as a whole is benefiting from improved health status of women. It is safe to say that we would never have reached the high standard of living we currently enjoy, if half of the population would still be at serious risk of health and even life.
We have succeeded in making most of Europe a safe place for women. But there is still a lot to do. A few countries still have no legal access to voluntary abortion: Ireland, Nothern Ireland, Portugal, Malta and Poland. But even in those countries which have a provision for legal access, an unacceptable number of various obstacles do exist resulting in an unnecessary delay in access to abortion. And there is even a high number of women in Europe who have no access to medical abortion, 15 years after it’s first marketing in France.
Looking beyond Europe, most parts of the world still stick to medieval European laws on reproductive health. These laws had been introduced by the former colonial powers and have not been changed so far. Consequently women in their daily life run a high risk for the terrible consequences of illegal abortion, including death.
It is in this context that the association of FIAPAC has been founded, following the congress “Abortion Matters” in Amsterdam in 1995. During this congress it became obvious how much there is to do to overcome the prevailing barriers in access to contraception and abortion and to guarantee a standard of care in “reproductive health”. A few professionals working in the field, recognised the urgent need for regular meetings on this topic. The association was founded thanks to their engagement. Since, 5 congresses have been organised with an increasing number of participants.
This conference would not have been possible without the engagement and support of many dedicated individuals. The FIAPAC board which has already organised 5 other conferences, has planned since two years. Very important, the team of our clinic which has calmly managed the additional workload while continuing to run the clinic and being dedicated to every single patient. These are mainly Barbara Laschalt, Leila Akinyemi and Margot Schaschl. Some of you may remember being in contact with Florian Hahn who has done all the registrations with admirable patience. Finally I would like to thank the friendly staff of the technical University.
Nobody is perfect although all of us have tried to come as close as possible. But some mistakes may have occurred during the preparation of the congress and some are probably going to occur during these 2 days. May I kindly ask you for you to forgive us and please let us know or note them on the evaluation form.
My special thanks go to the pharmaceutical companies who understand that our patients need a reliable and safe contraception after the abortion. It is my hope that more contraceptive producers will be present at the next congress.
There are some special events I would like to briefly mention:
We are working very hard to open a museum of contraception and abortion. It will be located very centrally in Vienna. Furthermore all items will be displayed on the website, together with old books. Unfortunately we did not succeed to open the museum until this congress. But we brought 4 panels displaying a small part of what the museum will be. You may have a look in the entrance hall.
I would like to take the opportunity to kindly ask you to donate or let us any historic objects or publication.
There is a list of films dealing with abortion, which will be displayed during these days. They cover a long range of time from 1929 to a new one about the impact of the policy by President Bush. The films are very touching and make clear why we engage in this field. Please find the films on the separate program. It has not been easy to bring together all these films together. Therefore a website abortionfilms.org will soon be online with a list of different films dealing with abortion. Please let us know in case you know of any other important film on abortion.
There is the training model for vaginal ultrasound during early pregnancy and medical abortion. We have worked hard to finalise in time and you may be able to try it during the congress for a small fee. This is a new device allowing training without a patient. This system is routinely used in Germany since some time, but it can be used for training for medical abortion and early pregnancy. Tomorrow there is also a presentation about this device.
Concerning the program, one small mistake has made it in the final version. Please note that tomorrow we will start at 14 00 and not at 14 30 as stated in the printed program.
Before giving the word to the next speaker I would like to make a short remark on the role of men in this debate.
As we all know, men cannot become pregnant nor can they have an abortion. Preserving the reproductive health of women is nevertheless in our very own interest and we directly feel the consequences.
It is therefore our duty to ensure a legal framework and easy access to standard of care abortion services so that women, who after all got pregnant by us, can terminate an unwanted pregnancy without unnecessary delay and suffering.
To further improve women’s health has been the motivation for all of us to come together. We are looking forward to exchange experiences, listen to each other, learn from each other and find ways to further improve the standard of care of our patients or clients. The success of the congress depends mainly on your engagement. We have been careful in the planning to let enough time for “networking” between the presentations. I hope we will use this opportunity and make these two days an occasion worth to remember.
Please let me underline how much we appreciate the support, moral and financial of the city of Vienna. Reproductive health is not an empty word in this city, as shown by the impressive engagement in this field. I am therefore very happy to announce Sybille Straubinger, member of the local parliament who is representing the city
The adoption of the Emergency Contraceptive Pill in Sweden
M Larssona*, K Eureniusa, R Westerlingb, T Tydéna,b
aDepartment of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
bDepartment of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
Margareta Larsson, RNM, PhD (in May)
Aim To examine the adoption of the emergency contraceptive pill (ECP) in Sweden before and after the deregulation in 2001 and to evaluate a community-based intervention including a mass media campaign and information to women visiting family planning clinics in one of two cities in mid-Sweden.
Method Waiting room questionnaires were administered to abortion applicants in the two cities during 2000(N=361), 2002(N=187) after deregulation of ECP and 2003 (N=448) after the intervention. The main outcome measures were; knowledge, attitudes and practices of ECP and exposure to the intervention.
Results The overall response rate was 88%. General awareness about ECP had increased from 83% to 92%, and the proportion of women who had ever used ECP increased from 22% to 35% over time. Almost two-thirds (63%) of the targeted women had noticed the information campaign and one out of three (33%) who had visited a family planning clinic during the intervention year recalled being given information about ECP. Media and friends were the most cited sources of information on all occasions. The belief that ECP could have a negative influence on regular contraceptive use decreased over time from 36% to 25%. The majority of women (58%) would have used ECP if it had been available at home. Women’s knowledge of how to access ECP had improved after the intervention and the percentage of women who had an abortion within the previous year had decreased.
Conclusion ECP is gradually becoming a more widely known, accepted and used contraceptive method in Sweden .
The dynamic of meaning in requested legal abortion
Bernadette Mattauer (F)
I worked as a psychologist in the birth control centre of the hospital in Montpellier, France, for 15 years. A unique clinical experiment has been led by three psychologists working together in this area.
The counselling process sets the memory in motion, even though at first the person remains immersed in the immediacy of her request.The counselling process opens a space within which the complexity of the circumstances and of a frequently ambivalent decision can be questioned.
The situations that stand out as sources of unwanted pregnancies are periods of change, in which relationships are being modified and sometimes disturbed:
-emotional changes : teenage, pre-menopause, couples in the process of joining or splitting). Changes due to a series of failures or more or less recent experiences of loss, of whatever kind.
-professional changes, which result in a reorganization of tasks and social relations.
In the process towards womanhood, it seems that abortion is frequently associated with the shaping of one’s identity, together with the problematics of castration.
Abortion would be an ideational representative as it were, being both addition and cut, assertion and separation. The abortion often works as the ‘representation’ of an unsuccessful separation process in the route towards womanhood. The present act of separation, the actual experience of loss, sometimes act as a symbolic way of re-enacting a previously unsolved bereavement. Thus refusing a pregnancy has a parting function. Being pregnant can stand for the part-object of ‘completeness’, a phantasy whose function it to repair and/or to fill in.
Beyond the arguments uttered and their usual motivations, the analysis of many women’s itineraries has enabled us to grasp and shed light on some unconscious motivations.
These two obviously antagonistic moments: the pregnancy and its termination are yet interconnected.
The dynamic of meaningof those events, whether they are experienced as apparently trivial or felt tragically, never leaves women indifferent. A terminated pregnancy is never a non-event. But that pregnancy was not aimed at giving birth, and is seldom rooted in the desire to have a child. Therefore it is not synonymous with rejecting a child.
The aim of our study is to convey the idea that a terminated pregnancy can at times contribute to reshaping a woman’s identity through symbolic work.
Providing safe surgical and medical abortion services in low-resource and legally restricted environments: The Latin American Abortion Provide Network
Dee Redwine, MPH, regional Director for Latin America and the Caribbean, Planned Parenthood Federation of America- International, PPFA-I
Heather Blank, associate Regional Director for Latin America and the Caribbean,PPFA-I
In Latin America and the Caribbean, Planned Parenthood Federation of America-International (PPFA-I) focuses on establishing and strengthening safe abortion services through partnerships with women’s organizations that advance sexual and reproductive rights and health services. Many of these agencies in Latin America and the Caribbean suffer from a sense of isolation, as they provide life-saving services under severely restricted legal circumstances, in politically difficult and dangerous situations.
Unsafe abortion in Latin America and the Caribbean can be described as nothing less than a public health crisis. The correlation between access to safe, legal abortion and maternal mortality in the region is shocking: approximately 20 percent of maternal deaths in Latin America and the Caribbean are due to unsafe abortion, a higher proportion than in any other region of the world. In 1995 there were 4.2 million abortions in Latin America and the Caribbean region, 4 million of which were illegal. Except for Eastern Europe, Latin America has the highest global abortion rate (37 abortions per 1,000 women aged 15-44) and abortion ratio (27 abortions per 100 pregnancies) (AGI, 1999).
The average Latin American woman is likely to have at least one abortion in her lifetime, with women in some countries, such as Peru (AGI, 1999), having an average of nearly two abortions. Since the vast majority of these procedures are performed illegally and most likely under unsafe conditions, women are taking enormous risks to prevent unwanted childbearing. This situation results in approximately 800,000 hospitalizations per year in the region.
Access to safe abortion services is critical to preventing maternal mortality and morbidity. In developing countries, regardless of the legal status of abortion, it is poor women in rural areas and poor young women who are most at risk of undergoing unsafe abortion, and most likely to die. However, in various Latin American countries, there are a growing number of health care providers who are committed to combating this trend. In areas where women are most likely to die from an unsafe abortion, client-centered sexual and reproductive clinical services must be provided for poor and marginalized women – the very ones who are most likely to face an unwanted pregnancy, seek out an untrained provider, and most likely to suffer severe consequences.
The reproductive health provider network supported and facilitated by PPFA-International is a forum to link these providers in a mutually constructive and supportive way, in order to regularly exchange ideas and expertise. They represent 8 different Latin American countries.
All of these providers offer life-saving services under extremely difficult circumstances, in both geographic and legal terms. From the rural areas to the rapidly expanding urban slums, these providers offer high-quality health services to those most in need. The network offers a forum in which critical mutual support can be lent to those working in this harsh environment as well as an opportunity for the exchange of information and expertise.
The specific goal of the network is to strengthen and expand sexual and reproductive rights through improved and increased access to services coupled with advocacy efforts in countries where the political and social climate is very restrictive. In order to reach this goal, the network facilitates the professional support needed by local groups working to reduce restrictions on abortion and improves services where they exist, as well as increases the sense of solidarity among service providers in the region.
Furthermore, the group is working to increase access to medical abortion throughout the region through the integration of a misoprostol-only regimen of early first trimester medical abortion. This is being piloted in order to decrease the consequences of unsafe abortion, and create alternative pathways for women to access safe abortion.
Throughout Latin America, misoprostol is cheap, easily accessible, and badly mis-used. From physicians to pharmacists, off-label use of misoprostol for pregnancy termination is increasingly common. Misoprostol has been shown to have a high rate of efficacy for abortion, but it must be used with the correct dosages, within certain gestational age ranges, and with clear instructions for follow up for the woman in order to be successfully used. Even so, given the severe legal restrictions on abortion in the region, a widely disseminated protocol for misoprostol, either for clinic- or home-based use, could radically change not only how abortion is viewed, but also prevent women from resorting to other invasive, highly dangerous forms of abortion.
Women’s experience of the abortion process - a semi-qualitative survey
Sarah Robotham, Julie Porksen and Helen Axby, Marie Stopes International UK
Background: Marie Stopes International is the largest UK provider of abortion services outside of the NHS, performing over 50, 000 procedures in 2003. UK clients come to Marie Stopes through NHS referrals or privately, whilst others are private clients from overseas. Differing timescales in the process leading up to having an abortion are reported, however no systematic study of client experiences has been carried out.
Objectives: This survey explores women’s experiences of the abortion process in order to: determine preferences in regards to abortion service provision; understand the timescales women experience; determine the acceptability of the latest clinical guidelines for women accessing termination of pregnancy services.
Design and Methods: Information was gathered from c.100 clients accessing termination of pregnancy services at MSI centres in the UK. A mix of interviewer administered questionnaires and self-completion questionnaires were used. Open questions were analysed by content analysis.
Results: Results will be available end of August, 2004, and will cover the following areas: decision making; experiences of NHS vs private clients; client preferences; obstacles faced; opinions on clinical guidelines.
Conclusions: To follow from results.
Misoprostol with and without mifepristone in advanced pregnancy cases
Eva RodriguezMD, ACAI – Sevilla, Spain
Objectives To establish the effect of mifepristone on pharmacological late abortion (more than 16 weeks) performed with misoprostol and the effect of factors such as misoprostol dosage.
Subjects and methods: Retrospective study (753 subjects) comparing fails and time of induction in two groups, with (325) and without (428) mifepristone by means of survival analysis and the effect of others factors by means of non-parametric tests.
Results: Lesser time of induction was observed in the group with mifepristone (rate of finalization 0,0634, statistically different from rate of control group: 0,0906), without more adverse effects. Lesser time of induction with misoprostol each 3 hours and greater in primipara.
Conclusions: The late pharmacological abortion goes better adding mifepristone to misoprostol. The dosage of misoprostol each 3 hours is slightly better than the use each 4 hours.
Cultural and linguistic mediation
Giovanna Scassellati and Teresa Perales, San Camillo-Forlanini Hospital – Rome
Since 2002, at the gynaecological ambulatory of the DH/DS 194 there is a service of cultural mediation. This service, supported by the Rome municipality, is particularly useful in order to establish continuative relationships with foreign women with the aim of clarifying the motivations of voluntary abortion and enacting preventive measures for abortion. 1.120 women were examined in the year 2002, 1.315 in 2003, and 407 in the first four months of 2004. The service is precious because often medical and paramedical personnel lacks adequate time for such activities, since an interview with a patient requires around 40 minutes on the average in order to be useful and explicative. Furthermore, the service is a useful tool to understand the real motives that drive foreign women to resort to abortion.
Giovanna Scassellati, Daniela Valentini, and Maurizio De Felice,San Camillo-Forlanini Hospital – Rome
Since January 2004 we executed 34 THERAPEUTIC TERMINATIONs using Misoprostol for vaginal application with a dosage of 600 mg and continuing, after 8 hours, with a dosage of 200 mg every hour. In all cases we never exceeded the total dosage of 800 mg. 30 of the 43 patients have easily reached the expulson within the first 12 hours with a maximum of 24 hours. We performed 2 Ceaserian cuts as a result of a lack of response to the induction (one in a woman with a pulmonary neoplasia at the 4th stage and the other without cervical dilatation in a woman that had already undergone a Ceaserian cut). The vaginal application has proved to be better than that per os, with greatly reduced side effects.
The utilization of misoprostol per os in therapeutic termination
Giovanna Scassellati, MD,San Camillo-Forlanini Hospital – Rome (Italy)
From January 2000 to December 2003 we peformed 223 THERAPEUTIC TERMINATION with Misoprostol at the following dosage: 600 mg per os every 3 hours with a maximum of 3 applications a day. Of the total, 220 cases ended in a vaginal delivery and 3 required the execution of an operative delivery (Ceasarian Cut) because of a lack of response to induction. The utilization of Misoprostol has reduced the times of abortive labour that in some cases ends within 24 hours since the beginning of the treatment. Side effects, whenever present, were contained (vomit, diarrhoea, fever). [Only one patient showed an allergical reaction that imposed an immediate stop of the treatment.]
What do women want in Italy?
Giovanna Scassellati, Maurizio Bologna, Maurizio De Felice, Daniela Valeriani andAntonietta Turi, San Camillo-Forlanini Hospital – Rome, Italy
In the year 2003, 500 women using the services of DH/194 filled a questionary:
- 80% of them responded that prefer medical abortion, although they did not have a thorough knowledge of the technique, because they want to avoid any kind of surgery;
- they find the present bureaucratic procedure extremely long and inquiring;
- foreign women, especially Rumanian, live hospital procedures with great annoyance because they are not culturally accustomed to undergo presurgery analyses and the interview with the anaesthetist.
Collection of induced abortion data in Italy and its results
Angela Spinelliab, Michele Grandolfoa, Marina Pediconia, Ferdinando Timperia, Silvia Andreozzia, Mauro Bucciarellia, a Istituto Superiore di Sanità, Rome; b Agenzia di Sanità Pubblica della Regione Lazio, Rome
In 1978, a law was passed in Italy which set forth the regulations governing the procedures for obtaining an induced abortion. According to this law, pregnant women may request an abortion during the first 90 days of gestation, for health, economic, social, or familial reasons. To obtain an abortion, the woman must first obtain a certificate attesting to the state of the pregnancy from her general practitioner, a private physician or a public maternal-child health clinic. The abortion is performed free-of-charge either at a health care structure in the National Health Care System or in a private structure with a contract from the regional health authority
Since 1980, the Istituto Superiore di Sanità (Italian National Institute of Health) has maintained a surveillance system for legal induced abortions. This system is based on quarterly reporting by the regional health authorities. For each induced abortion, a standardized form is completed in the hospital where the procedure is performed. This form contains data on major socio-demographic characteristics of the woman (age, place of birth, citizenship, education, occupation, marital status, reproductive history) as well as details about the procedure (weeks of gestation, whether the procedure is elective or performed on an emergency basis, where the certificate was issued, type of procedure and location where it was performed, duration of stay, and immediate complications). The Istituto Superiore di Sanità examines data quality and performs data analysis of trends, geographic distribution, and characteristics of women undergoing abortion. These analyses are performed by the ISS, in collaboration with the Ministry of Health and the National Statistics Institute (Istat), and presented annually to Parliament by the Minister of Health. Thanks to this surveillance system, Italy has very accurate and timely abortion data which is used to monitor the phenomenon and to suggest areas for research and intervention for prevention .
After the legalization of abortion in 1978, there was an initial increase in incidence, with a peak of 234,000 abortions performed in 1982 (abortion rate=17.2 per 1000 women ages 15-49 years, abortion ratio=380.2 per 1000 live births). Subsequently, there has been a steady decline, with 130,000 abortions performed in 2002 (abortion rate=9.3/1000). This reduction represents a decline of 46% over the past 20 years, with an estimated 100,000 fewer abortions in 2002 compared with 1982.
The incidence of abortion in Italy is similar to that of other countries in north-western Europe (where rates range from 6.5/1000 in the Netherlands to 18.7/1000 in Sweden), but it is much lower than in Eastern Europe (where rates are around 50/1000) and in the United States (22.9/1000).
As with many other health conditions, there are major differences within Italy between regions and geographic areas: in 2001, the abortion rate was 9.6/1000 in the North, 10.7/1000 in the Center, and 8.8 in the South. The declining rates over time have been observed in all areas of the country, with a trend toward convergence. The greatest decreases have occurred in those regions where women obtain the required certification through maternal-child health clinics rather than from their general practitioner or private physician. In addition to the legal abortions described above, the ISS has estimated, using mathematical models, that illegal abortion persists, with an estimated 21,100 performed in 2000. These illegal abortions are not equally distributed throughout the country and are more common in the South. As is the case with legal abortions, illegal procedures have also decreased dramatically over time. Applying the same mathematical models, it has been estimated that in 1983 there were approximately 100,000 illegal abortions. The estimated number of illegal abortions has thus decreased by 79% since the early 1980s.
From other studies, it has been observed that in most cases, abortion is not considered to be the family planning method of choice, but instead results from the failure to control fertility using contraception. More than 70% of women who undergo abortion report that they were using some method of contraceptive at the time of conception (primarily coitus interruptus).
The finding that the number of repeat abortions is lower than that estimated by mathematical models that assume no changes in contraceptive behavior, support the hypothesis that the observed reduction in induced abortion is the consequence of a greater diffusion and more effective use of contraception.
There do appear to be some subpopulations in which abortion rates are higher: women with children, those with lower levels of education, and housewives. The most consistent declines in abortion rates are seen among married women, among women aged between 25 and 34 years of age, and in those with children.
In recent years, there has been an increase in the number of abortions requested by immigrant women. Among the 132,234 abortions in 2001, 25,094 (19.4%) were performed on foreign citizens, a large increase from the 9,850 observed in 1996. This increase is most likely due to the rising number of immigrant women in Italy; the resident permits, for example, according to the data of the National Statistics Institute (Istat), have increased from 678,000 in 1995 to 1,500,000 in 2002. Based on estimates of the population of immigrant women aged 18-49, Istat has calculated that the abortion rate for immigrant women was 30/1000 in 2000, three times higher than that observed in Italian women. Indeed, the increase in the numbers of immigrant women may be the main cause of the recent leveling-off of the abortion rate in Italy. If the analysis of trends is limited to 1996-2001, years for which the information on citizenship is most complete, the number of abortions in Italian women declined from 127,700 in 1996 to 106,166 in 2001.
In conclusion, the reduction of induced abortion appears related to the improved use of contraception and to the important role of the maternal-child health clinics. The social-demographic characteristics of the women who have had abortions in recent years imply that further reductions are undoubtedly possible, especially if the maternal-child health services can be further strengthened.
Psychosocial background factors and mental health-consequences of
induced abortion in Austrian women
Erika Baldaszti and Beate Wimmer-Puchinger
Ludwig Boltzmann Institute for Women’s Health Research, Vienna, Austria
Objective:The aim of this study was to gain knowledge about the role of psychosocial conditions, contraceptive use, partnership and sexuality in the decision-making process about unplanned pregnancies of Austrian women seeking abortion. Furthermore aspects of choosing medical or surgical abortion and the prevalence of post-abortion depression are addressed.
Materials and methods:350 women who underwent surgical abortion and 227 women choosing medical abortion answered a questionnaire after abortion; as controls 400 women continuing pregnancy answered after week 12 of gestation. A follow-up questionnaire was administered three months after abortion.
Results:Women who decided to terminate pregnancy were found to have more often instable partnerships. At the time of conception 40% of women undergoing an abortion had not used any contraceptive method, of those who did, 50% had used condoms; dissatisfaction with contraception was high. Comparing the medical to the surgical method of abortion satisfaction of women with both procedures is high. Depression score assessed by means of HAD Depression Scale was not increased at time of abortion or three months after. At time of abortion half the participants felt sure about their decision for termination of pregancy, three months after abortion two thirds of the women had the feeling that the decision for abortion was right.
Conclusions:Once more our results indicate that prevention of abortions is a matter of making contraceptives more accepted and easily obtainable for all groups in society. All women surveyed in this study decided to terminate pregnancy after a thoroughly reflexion about the basic conditions of their life. This can be seen as the main reason that mental health consequences after abortion like feelings of guilt, fear or depression were within a normal range.
New law about abortion in Switzerland
Danielle Wyss, Family planning counsellor in Lausanne, PLANeS – Swiss Foundation for Sexual and Reproductive Health.
Since 2002, Switzerland has a new regulation about abortion, called « régime du délai ». Abortion is legal within the first 12 weeks of pregnancy. Before an abortion is performed the doctor has to inform and counsel the woman and give her the addresses of specialized counselling centres where she can receive more information and help. Young women under the age of 16 have to visit a counselling centre before an abortion can be performed. The costs of the abortion are covered by the health insurance.
First experiences in Switzerland with this new law will be presented, i.e. the fact that the decriminalisation has – according to statistics – not increased the number of abortions. Nevertheless, prevention should be developed, particularly in regard to migrant women, and the collaboration with doctors should be reinforced. Furthermore, the first consequences of this law on the implication of family planning centres will be discussed.