Seville, 21-24 October 2010: „Achieving excellence in abortion care“

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    Global trends in abortion and contraception, Room Giralda I+II
    Chair:
    • Mirella Parachini, IT
    • Eva Rodriguez, ES
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      EU networking in sexual reproductive health and rights

      Åsa Regnér, Secretary General RFSU, Sweden

      Working with gender equality issues and SRHR at the international level is a constant battle, not only to advance the agenda but also to defend progress that has already been made. The International Conference on Population and Development (ICPD) in Cairo in 1994 was a breakthrough. This was the first time an international document, agreed within the UN, pointed to unsafe abortions as a major contributor to maternal mortality. The ICPD affirmed that regardless of national legislation, women must have access to quality services for the management of complications arising from abortion. Access to post abortion care  is an issue that is still being debated at the UN.

      In 1995 the Forth Conference on Women in Beijing sparked a renewed global commitment to the empowerment of women and to gender equality. This time countries around the world agreed to ìconsider reviewing laws which punish women for having illegal abortionsî.  When the same language was put forward by the US this year at the UN Commission for Population and Development -  some countries did not agree and therefore it couldnít be accepted.

      In the European Union we have also seen a development during the last five or six years which points to an increasingly worrying political situation when it comes to SRHR. In 2004, when the ICPD Plan of Action celebrated its 10 anniversary, the EU issued strong and rights based Council Conclusion on the theme. Last year, at ICPDís 15th anniversary, nor the Czech or Swedish presidency dared suggesting the subsequent council conclusions on the agenda in fear of political set-back or conflict.

      Within the EU the  polarization  between on the one side  countries like Sweden, which  prioritizes  these

      issues, the Netherlands and Denmark and on the other side Poland, Ireland and Malta has increased in the last decade. This inability to agree has lead to a split in EUís positions at the UN, resulting in member states negotiating as separate countries and not as the EU on issues on SRHRadmin. This is an obvious failure for the EU as an global actor.

      One reason for the development within EU and globally is an unfortunate mixture of religion and politics.

      Luckily, I think this last year there has been an awakening regarding the slow progress on reducing maternal mortality in the world. The UN Secretary General is particularly concerned about this and has therefore recently launched a Global Strategy and Joint Action Plan on women and childrenís health. In the strategy, the Secretary General points out life-saving interventions such as family planning services and making childbirth safe He underlines that in order to reach MDG 5 on maternal health women need to have access to comprehensive and integrated health services that include skilled care during childbirth at appropriate facilities, HIV prevention and also to safe abortion services (when abortion is not prohibited by law).

      I recently attended the Millenium Development Goal Summit in New York. During the negotiations on the Outcome document the EU was able to take a strong approach on human rights and defended and pushed for wording on for example human rights and gender equality. This resulted in a better document than was first anticipated. However, because of this political division the EU could not push for wordings on reproductive rights or even state the linkages between unsafe abortion and maternal health. Still, we know unsafe abortion is the third biggest reason for maternal deaths. As a result the document doesn´t even mention access to post-abortion care, something that I as mentioned was already agreed upon in Cairo 1994.

      The EU must do better. The EU, including the Commission and all member states, is the worldís largest donor of development aid. The EU is committed to reach the MDGs. This summer the Commission adopted a paper on a twelve point Action plan to reach the MDGs. One important point in the document is to focus on the MDGs most off-track, one of them being MDG5 on maternal health. Progressive and brave policies on issues on SRHR are therefore vital.

      One formal obstacle when advocating for better SRHR policies within the EU is that the EU has no mandate to legislate on SRHR issues like abortion, sexual or reproductive health or sexuality education. Those are political decisions that fall under the so called principle of subsidiary, which means that member states decides on their own.

      There are however some openings to include SRHR in EU politics:

      1. The most obvious being that all member states have committed to implement the ICPD Programme of Action and the Beijing Action Plan and the MDG. In June the Development Committee in EP adopted a report on implementation of MDG in which it clearly states that EU member states and the commission should support policies on safe abortion.

      2. There are also several important areas of EU-competence that touches upon issues of sexual and reproductive health and rights. Trafficking for the purpose of sexual exploitation is one example. Gender equality is another very important area. The EU also has some competence in the area of public health.

      Experiences show that it has been easier to talk about sexual and reproductive rights in the area of HIV and AIDS. Recently (June 2010) the European parliament adopted a resolution on a rights based approach to the EUís respons to HIV and AIDS. The EP calls on the Commission and Member States to ensure the promotion, protection and observance of the human rights, including the sexual and reproductive rights, of people living with HIV and AIDS and other key population. The High Representative / Vice-President, Catherine Ashton, made a very supportive statement in front of the Parliament, committing to fully implementing this resolution.

      3. EU claims to be a protector and promoter of human rights. EU:s inability to push for sexual and reproductive rights is not worthy an institution that is built on the fundament of human rights and democracy.

      Lately we have seen a positive development on a human rights perspective on maternal mortality. It was a major breakthrough in June 2009 when the Human Rights Council of the UN adopted a resolution  (resolution 11/8) stating that preventable maternal mortality and morbidity should be seen as a human rights issue. The human rights argument should be used towards the EU, now more than ever. The adoption of the Lisbon Treaty has strengthened the protection of human rights and hopefully also sexual and reproductive rights.  For example:

      The Charter of Fundamental Rights of the European Union (CFR-EU), 2000, can also be utilised to advance SRHR. Since December 2009, with the adoption of the EU Lisbon Treaty, member countries are bound to follow the Charter's provisions.

      Since the adoption of the Treaty the European Union, as an institution, is also in process to accede to the European Convention for the Protection of Human Rights and Fundamental Freedoms Convention. The process of accession is expected to be finished in 2011.

      The Treaty also gives EU citizens'  a ìright of initiativeî. It means that a million citizens may sign a petition inviting the Commission to submit a proposal on any area of EU competence.  

      In addition the parliamentary assembly of Council of Europe ((PACE)  has adopted a resolution in 2009 on ICPD +15 in which they call on the members states review, update and compare members statesí national and international SRHR policies and strategies and, in the context of reducing maternal deaths, reduce the numbers of unsafe abortions. Already one year earlier the assembly adopted a resolution on "Access to safe and legal abortion in Europe" in which they invite member states to guarantee womenís effective exercise of their right of access to a safe and legal abortion and decriminalize abortion.

      4. The EUs role as international actor, for instance within the UN and through it´s development aid, which I described before.

      There is much need for cooperation between actors who are determined to fight for a woman´s right to decide over her body, to reduce maternal mortality rates, to safeguard access to safe and legal abortions Global politics is not looking too good in this field right now, but some governments are determined to work in a progressive way. I believe it´s important that civil society, human right´s advocates, medical experts and politicians from many countries work strategically together and I am happy to be able to speak about these injustices in front of such a knowledgeable audience. I am convinced, although it sometimes looks difficult, that joint efforts will change the world to the better for women.

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      Global trends in abortion and contraception

       

      Trends in abortion and contraception: Global overview

      Stanley K. Henshaw, USA

      The long-term worldwide trend toward liberalization of laws governing induced abortion has continued in recent years, though at a slow pace, with significant liberalization since 2005 in Colombia, Ethiopia, Mexi-co City, Niger, Portugal, Spain, Thailand and Togo, while new restrictions in a few countries had relatively little impact.  Nevertheless, about 37% of the world’s population lives in countries where restrictions make it difficult or impossible to obtain a legal abortion.

      The World Health Organization estimates that about 42 million induced abortions occur every year, almost half illegally.  Abortion rates are moderate to high in most developing countries, though a few countries with excellent family planning services or little interest in fertility control have low rates.

      Abortion rates have declined in recent years in a majority of industrialized countries with complete statis-tics, especially in Eastern and Central European countries where rates were relative-ly high. Abortion rates in most industrialized countries are in the range of 7 to 16 abortions per 1,000 women aged 15-44.  Rates would be lower in many developed countries if not for immigrants from developing areas that have relatively high abortion rates.

      Trends in abortion rates to a large extent reflect changes in contraceptive practice. The UN Population Division’s estimate of the proportion of married women of reproductive age using contraception increased from 58% in 1998 to 63% in 2009.  In the more developed regions, the proportion of users remained about the same but there was a shift from traditional methods in favor of IUD, condom and pill. In less developed regions, use of all methods increased except male sterilization.  Abortion rates have not necessarily fallen, however, because more couples are seeking to control their fertility.  Worldwide, the most popular methods are female steriliza-tion, IUD, and contraceptive pill, in that order.

      In the United States, a marked fall in the abortion rate of teenagers since 1995 accompanied greater use of hormonal methods, condoms, and dual methods. Increased contraceptive use and a shift from traditional to modern methods have contributed to declining abortion rates in formerly Soviet-bloc countries.

      In the United States, where half of unintended pregnancies result from imperfect use of contraceptives, increasing acceptance of the IUD promises to reduce the high rates of unintended pregnancy and abortion.

      Sildes: Global overview
      PDF-Format (120.03064516129032kB)
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      An overview from Asia

      Nongluk Boonthai, Bureau of Reproductive Health, Department of Health, Ministry of Public Health, Thailand - Co-author: Kamheang Chaturachinda, Women’s Health and Reproductive Rights Foundation

      of Thailand                    

       

      With the largest population of any region of the world,  Asia has the  largest  absolute number of  abortion

       around 26 million per year  Nearly half of the world’s unsafe abortion take place in Asia and almost one third in South Asia alone. Unsafe abortion accounts for 12% of maternal death in Asia worldwide there is a declining trend in abortion between 1995 to 2003. Asia is no exception the rate of abortion declined from 33 to 29/1000 women of reproductive age. At the same time  contraceptive use (CPR) in Asia, as estimated by UN, climbed from an estimate of 65.6 percent in 2000 to an estimate of 68.2 in 2010 and a further estimated  climb to 70 percent in 2020.This climb in CPR is hand in hand with the reduction in UN estimate of  Asia’s  total fertility rate( TFR )from 2.6 in 2000 to 2.4 in 2010 and to 2.2  in 2020.

      Since 1997, 17 countries around the world liberalized their abortion laws, 4 countries in Asia are among them (Bhutan, Nepal, Cambodia, Thailand ). With the population of just over 63 millions, abortion law in Thailand promulgated in 1956 permits abortion if it is done by a physician with the consent of the patient. Grounds for abortion include maternal health as well as pregnancy arising from sexual crimes , pregnan-cy in the  young,  ages under 15 years old. There is no hard national data on unsafe abortion. It is not officially collected. Moreover, abortion is socially controversial, stigmatized and condemned. Poor women lacked access to the safe service and therefore suffered most from unsafe abortion and its complications including sequelae of secondary infertility.

      The number of unsafe abortion is estimated to be somewhere between 300,000-400,000 cases annually, mostly  done “underground”, while there are approximately 800,000 births occurring each year. The cost, economically, physically and psychologically to women and to the nation is unacceptable. In spite of legal freedom to safe abortion access to safe abortion is still limited due to negative attitude of the health care provider. Only a hand full of providers in the govern-ment sector and a few private organizations provide out let for safe abortion in large cities, using  Vacuum Aspiration. Almost all other Thai providers  still use exclusively  dilatation and curettage (D&C).

       Lack of service providers is another problem. There are only 2,000 OB-GYN. and not all are willing to provide abortion. The myth that abortion is illegal plus negative personal and religious beliefs and their unwillingness to provide the service, resulted in poor access to safe abortion. Abortion seekers went to see quacks instead.

      Over the past 50 years many attempts were made to amend the law; all were unsuccessful. The Thai Medical Council and the Royal Thai College of Obstetricians and Gynaecologists (RTCOG) decided to widen the criteria for termination of pregnancy by defining health to include mental aspect. The new regulation was approved in December 2005.

      More works still need to be done. The negative attitude of the physicians toward abortion has to be changed.  The use of D&C has to be replaced by vacuum aspiration. Therefore, to increase access, trainings on safe abortion using vacuum aspiration are being conducted. The Women’s Health and Reproductive Rights Foundation of Thailand (WHRRF) a non-profit, non-governmental organization. It is established to eliminate unsafe abortion and promoting safe abortion in Thailand through advocacy research, education and training by using the most up to date abortion technology. It has been  collaborating with the Department of Health and the RTCOG, have carried out training workshop on prevention of unsafe abortion and use of MVA (Manual Vacuum Aspiration) through our established training centers in the 4 regions of the country. The 3 day- training include conceptual training, socio-economic, legal impacts of unsafe abortion , value clarification manual skill in using MVA on simulated first trimester pregnant uteri model using HAWAIIAN PAPAYA fruit. During the last years we have trained physicians and nurses from provincial and regional hospitals in all regions over Thailand. We have also organized the First International Congress on Women’s Health and Unsafe Abortion in January 2010 (IWAC 2010). There were over 600 attendees from over 62 countries worldwide attended. The second congress is planned for January 2012.

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      The legal framework for abortion in Latin America: going forward and backwards

      Monica Roa, Programme Director of Women’s Link Worldwide, Mexico

      The legal regulation of abortion continues being a highly debated topic in Latin America. Even though the discussion did not move for years, two milestones in 2006 gave a renewed strength to those that want to promote or restrict access to legal and safe abortion in the region. One of the milestones takes place in Colombia on May 2006, when the Constitutional Court declared that the total criminalization of abortion is a violation of women’s rights to life, health, integrity, dignity and non-discrimination. The Court recognized women have the right to have an abortion performed at the public health system, when the woman’s life or health (physical or mental) is in danger, when pregnancy resulted from rape or incest, and when there is a diagnosis of a malformation incompatible with life outside the uterus.

      The other milestone occurs in Nicaragua in October 2006 when the legislative assembly eliminated therapeutic abortion, leaving a complete ban on abortion in force. Since then, debates in favor and against abortion regained force and paved the road for advances and regressions that could be characterized in the following manner:

      Revision of current laws and promotion of the Health exception:

      - Case KL vs Peru at the Human Rights Committee

      - Abortion on the ground of mental health

      Using the health exception already existing in many latin american criminal codes:

      -Processes to liberalize abortion on the woman’s demand during the third trimester

      - Mexico City – law declared constitutional by the Supreme Court

      - Uruguay – President Tabare Vasquez’ vetos a law approved by Congress

      - Argentina – currently discussing a law at the national legislative

      Processes to give constitutional protection to the right to life from the moment of conception:

      - El Salvador: pioneering the movement to legally recognize the fetus as a human person

      - Mexican states (18): the conservative reaction to the liberalization in Mexico City

      - Republica Dominicana: the constitutional protection of life from the moment of conception

      - Kenya: importing the strategy to Africa

      - National laws to declare the day of the unborn

      Criminal prosecutions:

      - El Salvador: women condemned to 30 years for homicide

      - Guanajuato: women condemned to 30 years for homicide

      - Brasil: process against 10.000 women whose medical records were removed without due process

      - Argentina: judges and attorneys working to implement legal abortion are being prosecuted for promoting

        the commission of crimes

      Disrupting the implementation of legal abortion:

      - Colombia: conscientious objection as a weapon to sabotage legal abortion

      - Argentina: fetous ombudsmen try to impede the provision of legal abortions

      - Peru: not adopting regulations and protocols for the provision of legal services

      Interim measures at the Inter American System for HHRR:

      - Case X and XX vs Colombia: protection for the physical and mental Health of a minor who was denied a

        legal abortion

      - Case Amalia vs Nicaragua: protecting the life of a woman who was denied treatment for cáncer due to

        her 10 weeks of pregnancy.

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      The Evolution of Abortion Access in Europe: “Where is the 'European standard'

      Christian Fiala, MD, PhD, Gynmed clinic, Vienna, Austria

       

      Europe is far from united when it comes to abortion and a ‘European standard’ is not in sight.
      The historical timeline of legalizing abortion reveals the reluctance of most countries to do so, even  though abortion laws originated centuries ago in monarchies, dictatorships, and war-leading countries. In 1920, the former Soviet Union became the first modern nation to change its laws, with Portugal the most recent in 2007. But abortion remains illegal in Ireland, Poland, and Malta until today.


      Huge variations exist in allowable gestational limits (12 to 24 weeks) as well as other access restrictions like waiting periods (from none to 3, 5, or 7 days), written permission from two doctors, obligatory counselling, and more. All such restrictions are rooted in tradition and morality, with no scientific evidence of any benefit. But negative consequences are well-documented, such as women being forced to delay the procedure or travel long distances to find care. Consequently, countries with the easiest access to abortion have the lowest average gestational age at the abortion, and vice versa.


      Countries in Western Europe do provide coverage of abortion as part of universal healthcare, with the exception of Austria. However, the regulations vary widely, unlike the straightforward funding of procedures for other medical treatments.


      Given these huge underlying differences, it is no surprise that the frequency of abortions also varies widely between countries. The abortion rate is not linked to legal restrictions, but rather mirrors the use of effective contraception. Switzerland, The Netherlands, and Belgium lead the way, while most Eastern European countries, together with Sweden and the UK, sit at the bottom with abortion rates 3 times higher.


      Three main reasons explain the persistence of high abortion rates: lack of sexual education, difficulty in accessing contraceptives, and failure to use effective contraceptives regularly. The last aspect is a new phenomenon that explains the high abortion rate in Sweden.


      The slow historic process of women and couples gaining reproductive and sexual autonomy continues. Despite religious and conservative forces doing everything possible to prevent it, most people are determined to control their own lives, including their sexuality and reproduction. The most recent step forward was in Spain, where until last year women seeking abortion were intimidated by a requirement to obtain a psychiatric diagnosis, but can now receive an abortion on request. 

      In 2008 the Council of Europe issued a report, requesting all member states not only to "decriminalise abortion" but also to "guarantee women's effective exercise of their right to abortion and lift restrictions which hinder, de jure or de facto, access to safe abortion". This landmark report came decades after most countries had already legalised abortion, although all of them had left some restrictions in access. However for the first time in history a European political body has decided on a common European recommendation. It will be interesting to see how long it takes for all European countries to apply and to put into practice what seems to be a basic human right, self determination about one's own body.

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    Contraception, Room Giralda I+II
    Chair:
    • Sharon Cameron, GB
    • Raymonde Moullier, FR
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      Christian Fiala, MD, PhD, Gynmed clinic, Vienna, Austria

       

      During her 35 years of fertility, a woman experiences an average of 15 pregnancies and 8-10 deliveries, resulting in 6-8 surviving children that she breastfeeds for 2 years each. Then she finally arrives at menopause, if she is still alive. This is natural fertility, undisturbed by artificial interventions. Understandably, such abundant fertility is far too much for most people, men included. Therefore, women desperately sought ways to reduce fertility to the best of their ability.

      It was not until the last century that this goal was finally reached. The first step was to understand how fertility works, which was accomplished with the discovery of fertile days by Knaus and Ogino in the 1920s. The second step was to provide means of effective fertility control with hormonal contraception and safe IUDs in the 1960s. With the introduction of effective contraception, the dream of humanity - to separate fertility from sex - came true. Obviously, this could only be done with pro-active and artificial interventions to overcome the natural course of maximum fertility.

      50 years later, much of the world's population not only enjoys sexual freedom as a consequence of effective artificial contraception, but also an impressive standard of living and an unprecedented degree of self-determination. But instead of enjoying this advance, an increasing number of people reject effective contraceptive methods. They don’t want to ‘pump hormones in their body’, don’t want to have a foreign body (IUD) in their uterus, or don’t want to mess around with diaphragms or condoms. Instead they strive for a ‘natural’ way, which has never existed on this earth. Such futile striving can only be understood as a search for a lost paradise.

      As health professionals, we must revive and reinforce the knowledge that limiting natural fertility can only be done by using an effective and ongoing means of artificial contraception. We need to develop ways to achieve that goal.

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      News in emergency contraception

      Kristina Gemzell Danielsson, MD, PhD, Professor Dept. of Obstetrics &.Gyneacology,

      Karolinska University Hospital / Karolinska Institutet, Stockholm, Sweden

      Unintended pregnancy is a global reproductive health problem. Emergency Contraception (EC) provides women with a safe means of preventing unwanted pregnancies after having unprotected intercourse. While 1.5 mg of levonorgestrel (LNG) as a single dose has been the gold standard EC regimen, a single dose of 30 mg ulipristal acetate (UPA) has recently been approved for EC use up to 120 hours of unprotected intercourse with similar side effect profiles as LNG. The main mechanism of action of both LNG and UPA for EC is delaying or inhibiting ovulation. However, the ‘window of effect’ for LNG EC seems to be rather narrow, beginning after selection of the dominant follicular and ending when luteinizing hormone peak begins to rise, whereas UPA appears to have a direct inhibitory effect on follicular rupture which allows it to be also effective even when administered shortly before ovulation, a time period when use of LNG is no longer effective. These experimental findings are in line with results from a series of clinical trials conducted recently which demonstrate that UPA have higher EC efficacy compared to LNG and thus represents a new evolutionary step in EC treatment.

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      OC without prescription

      Ali Kubba MB ChB FRCOG FFSRH, London, United Kingdom

      OCs are the most studied drugs of the modern age. Their non-contraceptive benefits are signi-ficant but largely unknown to users. Their adverse effects are uncommon so most women are eligible to use OCs. The EBM tool for prescribing is the WHO Medical Eligibility Criteria. These are highly adaptable to checklists that users themselves or pharmacists/web based providers can use to select safe use.

      Self selection or facilitated self selection for OC use, increases access and cuts costs for the user and the healthcare system. I will be discussing models of delivery and the experience from a small project in South London.

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      Why are contraceptives not used ?

      Prof. Dr. med. Johannes Bitzer, Switzerland

      Head of Department of Obstetrics and Gynecology University Hospital Basel

      Introduction: Contraceptive compliance describes the application of a contraceptive method in accordance with the prescription and/or the specific behavior given or described by a medical professional. Non compliance is the discrepancy between the „real“ use or behavior and the „ideal or prescribed“ use or behavior.

      From the literature and clinical experience it is well known that this discrepancy is high reaching up to 50% of contraceptive users which do not comply. We wanted to explore the reasons for this considerable non compliance.

      Methods: Search of the literature to unwanted pregnancy. abortion, discontinuation, reasons for non-compliance, solution strategies

      Results: Several studies show a rate of 40-50% of unplanned pregancies; almost half of the unplanned pregnancies  are  teminated.  Discontinuation  of  contraceptive methods lies around  50%  during the first

      year of use. The reasons are:

      Method related factors:          - Side effects

      Person related factors:          - Cognitive factors (lack of information, irrational beliefs)

      Emotional factors:      - Ambivalence regarding the wish for a child, sexual or relationship

                                            conflicts, behavioral problems (forgetting etc)

      Environmental factors:          - Lack of accessability, distress, overload

      Four major strategies to improve compliance can be distinguished:

      a) Development of long acting methods independent of the user’s behavior

      b) Diminution of side effects and improvement of quality of life during use

      d) Adding heath or therapeutic benefits to the contraceptive effect of methods

      e) Improvement of counselling quality by including motivational interviewing techniques

      Conclusion: Non compliance is one of the major challenges in contraceptive care. The reasons are multi-dimensional and include person related, method related and environmental factors. Strategies to improve compliance have therefore to target different levels: Improving tolerability, health benefits and user friendliness of methods on one side and improving quality of counseling by intergrating communication techniques like information giving and motivational interviewing on the other hand. 

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    Workshop A ICMA/Eastern European Alliance for Reproductive Choice (EEARC) Abortion in Eastern European Countries: Challenges, Perspectives and Solutions, Arenal
    Chair:
    • Rodica Comendant, MD
    • Irina Savelieva, RU
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      Challenges and perspectives in advocacy of safe abortion

      Daniela Draghici, Roumania

      Central and Eastern Europe (CEE) is a region where abortion rates remain high, despite efforts to encourage contraceptive use and secure supplies of modern methods. Strategic assesments in Roumania, Moldova, Russia, and Ukraine have shown that abortion remains the preferred method of fertility conrol because it is often cheaper than contraception and widely available. Abortion, however, remains of low quality; unsafe abortions account for 24% of maternal deaths (WHO, 1998).

      Characteristics include: unsafe technologies, low level of motivation and training of providers, no counseling or choice of methods, and no post-abortion free contraception. Manual Vacuum Aspiration (MVA) and Medical abortion (MA) drugs are registered in several CEE countries; nevertheless, access to these methods is very limited especially for vulnerable groups (youth, low income families, HIV positive women, etc).

      The Eastern European Alliance for Reproductive Choice (EEARC) purports to raise awareness, sensitize providers, motivate women’s groups, develop new evidence-based training curricula, and to improve access to and quality of safe abortion, including medical abortion services. EEARC has a multidisciplinary membership structure and works to collect and disseminate evidence-based information on safe abortion,  including medical abortion, through country reports shared across the network. The Alliance is actively increasing its membership and promotes exchange of advocacy strategies and educational materials across the network.

      Through presentations at national and international conferences, members of EEARC have raised awareness about the need for better access to safe abortion services, including medical abortion, especially to audiences of providers and women's organizers. This presentation will review EEARC's network development, awareness raising, and advocacy activities and discuss their impact in a challen-ging environment, including their success in building of broader support for safe abortion, including medical abortion that has been demonstrated among healthcare providers and women's organizations. The Alliance is working as a catalyst to coalesce advoca-cy efforts to counteract restrictions recently imposed by governments and parliaments in CEE countries. Country examples from Lithuania, Moldova, Roumania, Russia, and Ukraine will be presented in the context of regional challenges in maintaining abortion rights amidst an increa-sing conservative opposition movement.

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      Title: The experience of use of medical abortion for HIV-infected women at home in Ukraine

      Posokhova Svitlana

      ABSTRACT TEXT

      Women with HIV have a right to decide about their reproductive choice. There is no reason why HIV positive women cannot use medical abortion. HIV positive women may be at higher risk of reproductive tract infections from retained products of conception, but this may occur with medical or surgical abortion.

      The aim of our study was to assess the efficacy and acceptability of home administration of misoprostol for early medical abortion up to 63 days of amenorrhoea for HIV-infected women.

      Methods. This case-control study included 68 cases of medical abortion in HIV-infected women who did not receive antiretroviral therapy. About 20% of women lived in the rural regions. Among of them 10 (14.7%) of women had previous cesarean sections  Medical abortion was used the first time in 89.7% of women, the second time – 8.9%, the third time – 1.4%. About 2% of women came back to the hospital after misoprostol because they were worried (25% of them had previous cesarean section).

      Results. The method was effective in 95.5% of cases. Three failures (4.5%) were recorded which included incomplete abortion (1.5% of cases), heavy bleeding (1.5% of cases), continuing pregnancy (1.5% of cases). In case of complications we performed vacuum-aspiration. We did not have cases of serious infections after medical abortions. The complete abortion has occurred after taken of misoprostol in the first 3 hours in 46.9% of cases, after 6-9 hours – in 49.4% of women, at the third day – in 2.6% of women and at the fifth day – in 1% of women.

      Conclusion

      Our study shows very high results of success and minimal complications of medical abortions in HIV-infected women at home (95.5% of cases). More than 80% of women were satisfied. Our data suggest that the use medical abortion at home is the safe effective alternative to surgical abortions for all women.

       

       
    Workshop B Technical details of 1st trimester surgical abortion, Santa Cruz
    Chair:
    • Marijke Alblas, ZA
    • Thea Schipper, NL
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      Anaesthesia: local vs general

      Andre Seidenberg, Switzerland

      Local anaesthesia as the safest analgesic method for a surgical abortion up to 12 weeks could fall into oblivion in many high standard countries. WHO (2003), British (RCOG 2004) and French (ANAES 2001) official guidelines recommend to favour local in preference to general anaesthesia.

      These guidelines refer mainly to an old but very large American CDC study on mortality (Peterson 1981, Lawson 1994). Nevertheless the evidence to favour local in preference to general anaesthesia was confirmed by several new studies with morbidity parameter as end points (Osborn 1990, Thonneau 1998, Pons 2004).

      Deaths from abortion are very rare in developed societies with good access to legal medical care. In the US 8.5 deaths per 1 million abortion were registered in the CDC-study. Nearly four times more death cases were recorded after general than after local anaesthesia. In-depth analysis of the large data set revealed this disadvantage of general anaesthesia, both among those woman whose death was directly caused by the anaesthesia as well among those whose died through causes not directly connected to the analgesic technique. Confounding factors like sterilizations, pre-existing diseases or gestational age had no crucial influence: general anaesthesia remained 2.5 times riskier than local anaesthesia.

      No doubt general anesthesia techniques have improved during the past 3 decades. E.g., Halothane had undesired effects on the uterus. Nevertheless, the younger studies exhibit more perforations of the uterine wall, cervical lesions and severe bleedings through general anaesthesia than through local anaesthesia (Soulat 2006, Osborn 1990).

      Even so, we want to point to the fact that local anaesthetics could be lethaly overdosed. Experience and good surgical technique are of high importance for surgical abortion (Hern 1990). The technique of local anaesthesia for surgical abortion was described in a dissertation monograph by Ambassa 2007. Independent of the lower costs, many women prefer to have an abortion under local anesthesia rather than under general anesthesia, when given the choice (Bachelot 1992). 

      Sildes: Anaesthesia: local vs. general
      PDF-Format (446.4233870967742kB)
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      Verifying successful aspiration, routine ultrasound etc.

      Ellen Wiebe, Canada

      Most of the common complications of surgical abortion (such as incomplete abortion leading to bleeding, pain and infection, missed ectopic pregnancy, and failed abortion) can be avoided if the procedure has been verified to be completed. The National Abortion Federation Clinical Practice Guidelines state that “either tissue exam or ultrasound must be used to confirm evacuation” in all cases but that tissue exam should be used when no fetal pole has been seen by ultrasound pre-op and also in second trimester cases. This presentation will go through the practical details of verifying completion of the abortion through tissue examination, post- and intra-op ultrasound as well as using serial beta HCG measurements for cases with inadequate tissue.

      Sildes: Verifying successful aspiration, routine ultrasound
      PDF-Format (9076.354838709678kB)
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      Very early surgical abortion

      Patricia Lohr, MD, MPH, Medical Director bpa, United Kingdom

      The availability of highly sensitive pregnancy tests means women are now able decide very early in pregnancy if they want to have an abortion, often before an intrauterine gestation can be visualised on ultrasound. Medical abortion with mifepristone and misoprostol is one method of terminating very early gestations; however for some women a surgical option will be preferable. This talk will review safe and effective means of performing surgical abortion before 7 weeks gestation and discuss the risks and benefits as compared to medical abortion with mifepristone and misoprostol.

    Workshop C Pre-abortion examinations/workup, Giralda I+II
    Chair:
    • Oskari Heikinheimo, FI
    • Anne Vérougstraete, BE
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      Decline in rates of serious infection following medical abortion regimen changes

      American practice and overwiew of the Clostridium infections

      Mary Fjerstad, N.P., M.H.S., Senior Clinical Advisor, Medical Abortion Ipas, USA

      Co-authors: James Trussell, Ph.D, Iriving Sivin, M.A., E. Steve Lichtenberg, M.D., M.P.H. and Vanessa

      Cullins, M.D., M.P.H, M.B.A.

      Background: From January 1, 2005 through June 30, 2008, we tracked 227,823 women having medical abortion at Planned Parenthood clinics in the U.S.  In the first time period, January 1, 2005 through March 31, 2006, the medical abortion regimen used was mifepristone 200 mg followed 24-48 hours later by misoprostol 800 mcg vaginally. There was not a standardized practice for testing or treatment of infection. During this period, among the Planned Parenthood data, the rate of serious infection was 0.93 per thousand medical abortions. Serious infection was defined as those requiring IV antibiotics in the emergency department, hospitalization, surgery necessary to remove an infected organ, or death. In early 2006, Planned Parenthood changed the route of misoprostol administration from vaginal to buccal and required either routine provision of antibiotics or universal screening for chlamydia and treatment of positive cases. In July 2007, Planned Parenthood required routine antibiotics as part of the medical abortion regimen.

      Methods: This was a retrospective analysis based on mandatory reports of number of medical abortions provided each quarter and reports of adverse events mandated by the Food and Drug Administration under Subpart H approval of mifepristone.

      Results: Rates of serious infection dropped significantly after the joint change to buccal administration of misoprostol and to either: 1) testing for sexually transmitted infection or 2) routine antibiotics. There was a 73% decline seen by instituting these changes to a rate of serious infection from 0.93 per 1000 abortions to 0.25 per thousand.  The subsequent change to routine provision of antibiotics led to a further significant reduction in the rate of serious infection- a 76% decline, from 0.25 per 1000 abortions to 0.06 per thousand.

      Conclusions: The maximum contribution of the change to the buccal route of misoprostol could be as high as 67% (if screen-and-treat were completely ineffective), and as low as 0%. It seems unlikely that screen-and-treat was completely ineffective, because at least some who test positive would have been treated in time to prevent serious infection. The maximum contribution of routine use of antibiotics could be as high as 100% (if the switch to buccal administration of misoprostol were completely ineffective) and no lower than 33%.

      The rate of serious infection after medical abortion declined by 93% after a change from vaginal to buccal administration of misoprostol combined with routine administration of antibiotics.

      Although there have been 9 deaths in North America; 8 caused by Clostridium sordellii and one caused by Clostridium perfringens, there have not been reports elsewhere in the world of infection-related mortality following medical abortion. 

      Sildes: Decline in Rates of Serious Infection Following Medical Abortion Regimen Changes
      PDF-Format (102.14677419354838kB)
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      Diagnosing gestational age, viability and location

      Christian Fiala, MD, PhD, Gynmed clinic, Vienna, Austria

       

      The best method to diagnose a pregnancy depends on gestational age and on the setting.

      hCG in serum or urine is highly reliable in diagnosing a pregnancy and the only way of doing so in very early gestation. But it gives very little information about gestational age and tells us nothing about viability or location of the pregnancy. In very early pregnancy, before it can be seen on ultrasound, it is useful to have a baseline serum hCG for comparison at follow-up. 

      Ultrasound examination (abdominal is sufficient in most cases) is very fast and gives a very reliable result about gestational age and location. But it can only be done in pregnancies over 6 weeks gestation. It also needs a trained provider and the machine might be expensive in some settings. Bi-manual examination is cheap and easy to do but unreliable in early pregnancy.

      Therefore a combination of ultrasound and hCG testing is most reliable.

       

      Blood grouping (Rhesus)

      This is done in most places in Europe and North America because we want to find those women who are rhesus negative and give them an Rh-immunoprophylaxis. Rhesus negativity is a Kaukasian trait usually not found elsewhere. However there is no evidence for the need of Rhesus-prophylaxis for a first trimester abortion. Foeto-maternal blood transfusion seems unlikely given the small amount of fetal blood, especially in very early pregnancy.

      So far only the health authorities in Sweden (Board of Health and Welfare) have issued a recommendation not to give Rh-prophylaxis in medical and spontaneous abortion.

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      Post-abortal infection - prevention strategics

      Dr. Sharon Cameron, United Kingdom

      The reported incidence of post -abortal infection (in countries where abortion is legal ranges from 1% to10%, depending on the population, diagnostic criteria used to define infection, use of peri-abortal antibiotics and the method used. Prospective comparative studies have suggested that medical abortion may be associated with an overall lower risk of infection, possibly because it is less invasive procedure. The presence of chlamydia, gonorrhoea or bacterial vaginosis in the lower genital tract at the time of abortion has been shown to be associated with an increased risk of post-abortal infection.  Strategies for preventing post- abortal infection include (i) a screen-and-treat policy (ii) universal antibiotic prophylaxis or (iii) a combined approach, of both screening and prophylaxis. Meta-analysis of randomised trials have shown that antibiotic prophylaxis at the time of abortion is associated with a reduction in the risk of subsequent infection of around 50%. Furthermore, antibiotic prophylaxis has been shown to benefit women who have negative pre abortion genital swabs and is less costly than the other strategies. However, failure to test for sexually transmitted infections pre-abortion and to identify infected women, perpetuates the risk of re-infection by an infected partner. This is important since it is believed that re-infection with chlamydia may increase the likelihood of complications such as tubal infertility. 

      Sildes: Post-abortal infection. Prevention strategies; screening v. prophylaxis incl. surgical -medical abortion European practice
      PDF-Format (131.05645161290323kB)
    Workshop D Free communications, Nervión
    Chair:
    • Kristina Gemzell-Danielsson, SE
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      Abortion and psyche - Myths on abortion and mental disorder

      Lena Lennerhed, Professor in History of Ideas, Södertörn University and President of RFSU, the Swedish

      Association for Sexuality Education, Sweden

      In the presentation, the assumption that abortion leads to trauma or has other mental aftereffects, will be discussed. In particular, the theory on the so-called PAS, Post Abortion Syndrome (or PASS, or Post Abortion Stress Syndrome), and its impact on public debate on abortion in several countries since the 1980´s, will be focused.  PAS is not included in the International Classification of Diseases ICD or the Diagnostic and Statistical Manual of Mental Disorders DSM, and never was or is an acknowledged diagnosis or condition. The PAS theory plays a central role in the rethoric of many anti choicegroups.

      It will be shown, from swedish examples, that beneath psychiatric arguments often lies ethical ones; that trauma or disorder are related to the killing of the fetus and that this is unethical, and that these arguments sometimes goes back to religious ones. In addition, some references will be made to scientific studies on the issue. A result shared by many psychologists, psychiatrists, gynecologists and sociologists is that distress after abortion is moderate and temporary and that more severe reactions are rare. There are also studies showing that predominant reactions are relief and mental growth.

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      Abortion care - the staff perspective

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

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

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

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

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

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

      Sildes: Abortion care: the staff perspective
      PDF-Format (1551.249193548387kB)
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      An in-depth study of abortion and repeat abortion: young women’s decision-making, experiences, feelings and post-abortion behaviour.

      Lesley Hoggart, Principal Research Fellow School of Health and Social Care, Univ. of Greenwich, UK

      This paper reports on a research project (Hoggart and Phillips 2010) that studied teenage abortion and repeat abortion in London, UK. This research set out to explore factors that might help explain what are currently viewed as disproportionately high rates of teenage abortion, and repeat abortion, in London. This required gathering data on sexual behaviour leading to unintended and unwanted teenage pregnancies; on teenage experiences of abortion; and on post-abortion sexual behaviour.

      Utilising a qualitative methodology, interviews were conducted with three groups of participants: focus groups with 14-16 year old girls in London schools; in depth interviews with sexual health practitioners; and in depth interviews with teenagers that had terminated pregnancies. The theoretical approach adopted was to examine how abortion decisions and experiences are mediated by value systems, and localised cultural and social norms (Harden and Ogden, 1999,  Henderson, 1999, Hoggart et al., 2006, Lee et al., 2005, Lie et al., 2008, Pearson et al., 1995).

      One of the key findings of the research was that the mindset of pregnant teenagers and the extent to which they make an abortion decision by and for themselves may influence their feelings and sexual behaviour following the abortion. Abortion is viewed as ‘immoral’ by many young women in the UK, and this view can make abortion decision-making difficult and stressful. Feeling that abortion is ‘immoral’ is likely to contribute towards any feelings of regret and/or guilt that young women may have following an abortion.

      The research also indicates that young women who are able to make their own decision for their own reasons are more likely to establish an effective contraceptive regime following an abortion, than young women who may have been reluctant to end their pregnancies and do not have any plans for their own futures. The research findings have important implications for post-abortion services. They suggest that complex issues would need to be explored around the time of the abortion in order to offer an appropriate individualised post-abortion service.

      Sildes: An in-depth study of abortion and repeat abortion
      PDF-Format (473.63709677419354kB)
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      Barriers to access&use of contraception in immigrant women presenting for abortion

      Ellen Wiebe, Canada

      Background: About half of the women presenting for abortion in Vancouver are immigrants and most of these are from Asia. In previous studies of contraception and ethnicity, we found that the contraceptive practices and attitudes of immigrant women differ from those reported by other Canadian women. Specifically, we found that among Chinese and Korean immigrant groups in Vancouver, women expressed a deep suspicion towards hormonal methods of contraception, such as birth control pills, and were reluctant to use them. This study examined the experiences, attitudes and beliefs of immigrant women with regard to contraception in order to identify difficulties involved in accessing contraception in Canada.  Our main concern was to understand more about the barriers for women accessing contraception prior abortion and if there were more barriers for immigrant women.

      Method: This was a survey of women presenting for abortion using a questionnaire asking about women’s usage and experiences of both hormonal contraceptives and natural family planning methods, their attitudes towards medical contraceptive methods (hormonal and intrauterine), any barriers to contraceptive access they have encountered and the sources of information women rely on to make their contraceptive decisions. The site was an urban abortion clinic and the questionnaires were available in English, Chinese and Punjabi. Data was entered into an SPSS database for statistical analysis. The analysis included an examination of the differences in contraceptive practice, experience, and attitudes between immigrant women and other Canadian women, as well as a needs assessment.

      Results: Of the 1000 subjects planned for this study, we have data on 143 at the time of writing this abstract. Of the 77 immigrants, 64% had previously used hormonal contraception compared to 94% of the 62 non-immigrants (p=<.001); 71% of the immigrants compared to 88% of the non-immigrants believed hormonal birth control was safe (p=.02); 25% of immigrants compared to 12% of non-immigrants had some problems accessing contraception; 30% of immigrants compared to 15% of non-immigrants had become pregnant “counting safe days” (p=.04).

      Conclusion: More immigrants were using less effective methods of contraception when they got pregnant and they had more difficulties accessing contraception prior to the abortion. When the data is complete, we will be able to understand more about which groups of immigrants have the most difficulties. By determining the extent of inadequate information about contraception and barriers in access to contraceptive methods in immigrant women, we may be able to help plan solutions.

      Sildes: Barriers to access and use of contraception in immigrant women
      PDF-Format (976.5967741935484kB)
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      D&E versus induction for second-trimester termination for fetal anomaly: a qualitative study

      Jennifer Kerns, USA

      Co-authors: R.Vanjani, L.Freedman, E.A.Drey, K.R.Meckstroth, J.E.Steinauer

      Objective: Approximately 3% of pregnancies are affected by a fetal anomaly. Prenatal screening for fetal anomalies is a routine part of prenatal care, and most women given that diagnosis will terminate the pregnancy. We know little about patient preferences for D&E versus induction for fetal anomaly termination. In this qualitative study, we sought to understand the factors influencing women’s choice between D&E and induction, and how their experiences differed.

      Methods: We conducted semi-structured phone interviews with 21 women from University of California San Francisco (UCSF) who had undergone a termination within the past three weeks for fetal anomaly or demise. All women had equal access to both methods. We used a generative thematic approach, facilitated by the NVivo qualitative software program.

      Results: Of the21 women, 13 (62%) underwent D&E and 8 (38%) underwent induction. Several key themes that emerged from the interviews were options counseling, referral experience, religious attitudes, abortion attitudes and emotional coping style. While some themes were shared across method of termination, others were differentially expressed by those undergoing D&E or induction.

      Conclusion: While some aspects of pregnancy termination for fetal anomaly are shared by women, factors and experiences associated with the method of termination are quite different. The decision to undergo D&E or induction is a highly personal one, and women should be offered equal access to both methods. Understanding key themes that drive that decision may aid in counseling women faced with this diagnosis.

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      Medical abortion overtaking surgical in Norway

      Mette Løkeland, Department of Obstetrics and Gynecology, Haukeland University Hospital, Norway

      Co-author: Line Bjørge

      Norway has abortion on request, completely free of charge and easily accessible at every gynaecology ward up to 12 weeks of gestation. Health personnel have the right to opt out form performing the procedure but not to treat the patients. Each clinic is obliged to make sure they have enough staff that is willing to do the procedure.

      Medical abortion with mifepristone and misoprostol was introduced for abortion up to 9 weeks gestation in 1998. Gradually medical abortion has become an option at the majority of all gynaecology wards in Norway. In 2005 medical abortion for gestational age 9-13 weeks was introduced and is now available in all the five health regions.

      At Haukeland University Hospital medical abortion was made the method of choice for early termination of pregnancy up to 9 weeks gestation and in 2007 for terminations of pregnancy at 9-13 weeks gestation. Medical abortion was made method of choice due to the general medical view that conservative treatment should always be preferred to surgical when the methods give equivalent treatment outcome. If there are personal or medical reasons the surgical method will be used instead. Home use of misoprostol was introduced as a voluntary choice in 2006 for terminations up to 9 weeks gestation.

      Since 1998 the percentage of all abortions in Norway performed medically has increased every year. In 2007 the amount was 45.3% and the preliminary figures for 2008 show 55.9%. This give us reason to think there is a change in Norway from surgery to medical abortion.

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      Situations of abortion and criminal abortion in the southern part of Thailand

      Chunuan Sopen, Ph.D., Asst. Prof. Faculty of Nursing, Prince of Songkla University, Thailand

      Co-authors: Kosunvanna Siriratana, Sripotjanart Wattana, and Jitsai Lawantrakul (Asst. Profs,

      Faculty of Nursing, Prince of Songkla University), Jitti Lawantrakul MD, Obstetrician & Gynecologist,

      Hatya Hospital, Uaiporn Pattrapakdikul ,Nurse Specialist, Nursing Division, Songklanagarind Hospital

      Abortion is a major public health concern in the developing countries.  Accurate measurement of the type

      of abortion has proven difficult in many parts of Thailand. Thai health care providers need information on the incidence of both legal and illegal abortion to provide the needed services and to reduce the negative impact of unsafe abortion on women’s health.

      The purposes of this descriptive study were to:

      1) survey the incidence rate of legal and illegal abortion in the southern part Thailand

      2) identify causes, complications and impacts of abortion

      3) explore the decision making before conducting unsafe abortion.

      This study was carried out in 2007 in 6 governmental hospitals. The samples consisted of 402 women with abortion.  In addition, twenty women with unsafe abortion were deeply interviewed about the decision making process before conducting abortion. The structural instruments were used for data collection. The content validity was judged by 5 experts. Descriptive and content analysis were used.

      Results showed that more than one-third of women had unsafe abortion (35.7%). Forty-two percent of women with abortion were in young women under 24 years of age (n = 168).  Causes of abortion were social problem (34.08%), family problems (26.12%), and women’s health problems (21.64%). Nearly one-third of women had severe abdominal pain (29.6%), fever (18.4%), and anemia (15.4%), and shock (4.5%).  Half of women had only psychological problems (50.5%). The majority of subjects made their own decision to terminate their pregnancy (n = 119) and almost half of them performed unsafe abortion by themselves (n = 71).

      Most women in the interviewed group would like to terminate their pregnancy as soon as possible (n = 14). After they had completed abortion they felt released and then they felt guilty. They suggested that the public hospital should provide safe abortion for women with unplanned pregnancy. These study findings indicated that most of women with unsafe abortion experienced psychological and economical problems; thus, health care providers should offer the counseling program to reduce women’s problems and to improve their quality of lives.

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

      termination of pregnancy in Cape Town, South Africa

      Marijke Alblas, Independent Consultant, South Africa

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

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

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

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

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

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

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    Late abortion, Giralda I+II
    Chair:
    • Blanka Kothe, DE
    • Mirella Parachini, IT
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      Care - special considerations

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

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

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

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

      the abortion.

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

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

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      Second trimester medical sbortion

      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.

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