Speeches
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Oct. 24, 2008, 02:00
Experiences with prescription-only access
Ines Thonke (Germany)
Pro Familia Bundesverband, Germany
ines.thonke@arcor.de
In contrast to many European countries, the “morning after pill” is as we know only available on prescription in Germany. pro familia’s National Association has established in a survey among counceling offices that prescription-only availability is the main but not the only obstacle that girls and women are confronted with when they need the “morning after pill”. The information gained from practical experience could prove to be useful in objective discussions and sharing experience as to how to improve the provision of safe post-coital contraception to women in Germany.
New data show that about 12 % of women in the age of 20 to 44 have used emergency contraception at least once in their life. The observed frequency of application shows differences in age and marital status, in urban and rural areas and is also depending on educational background.
Our survey shows that the need to see a doctor to obtain a prescription leads to different obstacles.
At weekends and overnight medical care is provided by medical walk-in centres and hospital outpatient clinics.
Hospital provision. A refusal of EC was by no means the exception. This practice is evident among catholic hospitals. A further reason which is cited is that the hospital cannot issue this type of prescription for reasons of cost and as a third reason that duty doctors refuse on moral grounds or justify their refusal by claiming that it is not an emergency. Women who need the “morning after pill” also find that they are charged for gynaecological investigations, pregnancy tests and ultra-sound scans. Additionally girls and women are burdened by the fact that they have to present their private worries several times in the clinic and in some cases they have to endure very lengthy waiting times (up to 3 hours)
Walk-in centre provision. Our survey shows that similar problems are experienced at medical walk-in centres. For girls under the age of 16, often parental agreement is required.
Pharmacy provision. Sometimes women face even more problems in obtaining the medication. Not all pharmacies have the “morning after pill” in stock or their stocks are minimal. In rural areas and with no car, this can quickly result in a lengthy delay before it can be taken.
General problems from everyday practice. Girls and women tell about the high cost which is an obstacle for them and also of their fear of gynaecologists and the difficulty of booking an appointment at short notice.
Conclusion and the need for action. Problems in provision are still being reported in various parts of the country. The shortfall in provision described above represent obstacles which still delay and prevent the "morning after pill" from being taken. The information in medical training and development about the current standard of quality and provision for hormonal emergency provision must be considered a central task in the current options for action. In order to tackle moral and ethical concerns, it is important to provide clearer information about the current findings on effectiveness as EC is still cited in the context of abortion and/or equated with it. Many of the other obstacles mentioned here can be overcome with in-depth training and development of doctors and clear rules for charging in hospitals. Instead of blaming couples for contraceptive use failure they should be encouraged to act responsible when asking for EC.
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Oct. 3, 2014, 02:00
Objectives: The purpose of this pilot study was to ensure that the insertions and early expulsion rates were acceptable in order to plan a larger trial with the IUB.
Methods: This was an observational pilot case series. The inclusion/exclusion criteria were similar to those for non-study patients receiving IUDs. Women aged 18-50 requesting intrauterine contraception were enrolled. Exclusions included recent pelvic inflammatory disease, genital malignancy and anaemia. The main outcome measure was expulsion by the 6-8 week follow-up visit. Ease and pain of insertion as well as complications and side-effects were also recorded.
Results: 50 women had IUBs inserted between January and April 2014 by a single clinician in Canada. Only 6 (12%) had had a previous birth and 16 had had previous IUDs. There were no failed insertions and 43 (86%) insertions were found to be "easy". The mean pain score for insertion was 5.3/10. There were 32 follow-up visits 6-8 weeks post-insertion by May 2014. There were 8 expulsions (one post medical abortion and accompanied by a "gush of blood"), there was one removal for pain and bleeding and no other complications.
Conclusions: Including the first study of 15 women, there are now data on 65 insertions with no problems, so the insertion technique and equipment for IUBs can be considered acceptable. The early expulsion rate appears too high and may require some change in design. The lack of other complications warrants further studies with this innovative product.
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Sept. 14, 2018, 02:00
Objectives: We examined experiences of women who travel from the Republic of Ireland to the UK for abortion care. Irish women’s experiences are poorly understood. Publically shared stories tend to highlight cases of tragic circumstances (e.g., foetal anomalies, minors), eclipsing more ordinary circumstances for seeking abortion. We collected data about experiences of the latter group by using a systematic qualitative research approach.
Methods: Qualitative data were collected using In-Depth Interviews (IDIs) with 25 Irish women who traveled to Liverpool and London for abortion care between February and June 2017. Participants were Irish citizens or permanent residents and received surgical or medical abortion. We excluded minors and foetal anomaly cases. Participants’ age ranged from 19 to 43 years old; 18 of 25 participants were in their 20s. Their reported gestational age was between 6 and 19 weeks. IDIs followed a 13-item Interview Guide with semistructured probes. Topics included: arranging travel, challenges, support network, delays, and privacy.
Results: Data reveal significant hardships in women’s experiences traveling abroad for abortion care, including difficulties arranging travel in an “environment of secrecy” despite readily available information online, maintaining privacy in social and professional circles while waiting to travel, financial constraints, getting time off work, and securing overnight childcare. Financial barriers may lead women to intentionally schedule later appointments to allow time to organize money. Women who borrowed money reported getting bank loans of 900-1500 Euro. Additionally, the use and location tracking capabilities of social media (Facebook, Snapchat, etc.) may generate added stress about retaining privacy in abortion travel.
Conclusion: Irish women who travel for abortion care to the UK overcome significant financial, social, and employment difficulties in a burdensome environment of secrecy in order to pursue abortion services abroad. This study highlights the need to liberalize access to abortion care in Ireland. -
Oct. 3, 2014, 02:00
Reasons that motivate requesting induced abortion and the options that women choose facing a restrictive abortion law in Spain
ACAI Clinics1, Carolina Ribas Barrera2 1ACAI associated Clinics, from all regions, Spain, 2Clínica El Sur, Sevilla/Andalucía, Spain - alberto.ginecenter@gmail.com
Objectives: After the 2010 law on abortion came into force, the objective of the study was to find out what are the motivations to have an abortion and what changes should take place in the women’s situation to make them continue their pregnancies. After presentation of the abortion Bill December 2013, it was important to know, what women think they will do in the future, if the law is restrictive. Method: In 2 different periods (2012 and 2014) 5100 and 6045 women had abortions in 15 ACAI clinics . Besides sociological and medical data, they were asked about the pregnancy (originally not wanted/wanted) and the conditions that should change (socioeconomic, partnership etc.) to make them reject their decision to terminate the pregnancy. In the second period another question was added, what they would do in the future, if the new law does not allow them to perform the abortion. Results: Data for both periods were statistically analyzed. Results for both periods are similar. The variables are: age, nationality (34% and 29 % foreigners), educational level, job (35% and 36.5% jobless), contraceptive method (nothing 36.8% and 47.9%), abortion method (medical 5% and 4.7%), pregnancy condition (wanted/not wanted from the beginning) and circumstances that should change to reject abortion (none 48% and 41%, economic situation 21% and 23%). In case of a restrictive law, 29% would continue the pregnancy, 31% would go abroad and 30% would try an illegal abortion. Conclusions: 95 % of pregnancies that actually end as a legal abortion are unwanted from the beginning. Modern contraception is not widely used by the women. In 60% no changes in the women’s situation could make them take another decision. If the announced law comes into force, more than 99% of 120,000 women asking for abortion in 2012 couldn’t perform it under legal conditions.
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Oct. 3, 2014, 02:00
Women’s experiences and perceptions of simplified medical abortion: a qualitative study in Rajasthan, India
Kirti Iyengar1 ,2, Birgitta Essen3, Marie Klingberg-Alvin1, Kristina Gemzell-Danielsson1, Sharad Iyengar2, Sunita Soni2 1Karolinska Institutet, Stockholm, Sweden, 2Action Research & Training for Health, Udaipur, India, 3Uppsala University, Uppsala, Sweden - kirtiiyengar@gmail.com
The requirement for repeated clinic visits remains an important barrier to access to medical abortion. Home use of misoprostol and alternatives to routine follow-up have been suggested as interventions to simplify the medical abortion, however there is little evidence on women’s experiences on these from low-resource settings. This qualitative study was conducted in Rajasthan, India, and explored women’s experiences and perceptions of home use of misoprostol and self-assessment of outcome of medical abortion. The reasons for preferring home use included inconvenience of travel, lack of confidentiality and child care commitments. After taking home misoprostol, most women continued with their routine household work, although they didn’t go for work outside the home. Most women experienced no major health problems, while some women made an extra clinic visit because of perceived health problems. A majority said that if they have to undergo another abortion, then they would prefer to use misoprostol at home. On self-assessment of the outcome of abortion, many women were fairly certain that their abortion was complete either because they experienced bleeding or expulsion or because their pregnancy symptoms subsided. Despite this, a majority of women found it reassuring to do the pregnancy test, to confirm that their abortion was complete. According to one woman, “if abortion is not done then we remain in confusion, any problem can arise inside the body, so it’s good to do the test”. Despite low literacy levels, the majority of the women were able to interpret the results of a pregnancy test. They felt that that this saved them a visit to the clinic. The checklist was used by many women, largely as a refresher to see how to do the pregnancy test. Our results indicate that home use of misoprostol and self-assessment using a low sensitivity pregnancy test is feasible in low-resource settings.
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Oct. 3, 2014, 02:00
Lessons from the Contraceptive CHOICE Project: The Hull LARC Initiative
James Trussell1 ,2, Katherine Guthrie3 1Princeton University, Princeton NJ, USA, 2The Hull York Medical School, Hull, UK, 3City Health Care Partnership Hull, Hull, UK - trussell@princeton.edu
Objective: To discover whether a hand-out explaining the benefits of intrauterine contraceptives (IUCs) and implants could increase their uptake in Hull, England. Methods: We developed a simple double-sided A4 hand-out. On one side was a script with pictures of copper and levonorgestrel IUCs beside a 20-pence coin and of an implant beside a hair grip. On the other side was the three-tiered effectiveness chart from Contraceptive Technology. The receptionist would give the hand-out to every woman and ask her to read it before seeing a clinician. Then the clinician would ask the woman if she had read it and if she had any questions. Although we implemented the project in family planning (FP), abortion, and antenatal clinics and GP practices, we evaluated it only in FP clinics and GP practices because electronic records are available. Results: There was no impact in GP practices. There was no overall impact in FP clinics. However, only one, the service hub (Conifer House) is open daily (except Sunday) and has permanent sexual health staff on the reception desk. In Conifer House there was an increase in the proportion of women receiving IUCs or implants of 15.2% from October 2011-April 2012 to May 2012-November 2012 (from 31.0% to 35.7%, p=0.0002). The proportion returned to baseline in December 2012-November 2013, when there was a change at reception to reduce waiting times. Conclusion: This was not a formal study, so there was no research coordinator to monitor the project. We think there was no impact among GPs or among peripheral FP clinics because the project was never implemented. And we think the change at reception at Conifer House caused an already overworked staff to stop dispensing hand-outs. This simple, extremely low-cost LARC intervention at Conifer House was highly effective, by far the most cost-effective on record.
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Sept. 15, 2018, 11:00
Objective: To assess the influence of gestational age, maternal age, and reproductive history on the risk for surgical intervention of early medical abortion.
Methods: A nationwide cohort study with eight weeks follow-up of all medical abortions induced at a gestational age <63 days among Danish women through the years 2005-2015. A multiple logistic regression model provided adjusted odds ratios (OR) with 95% confidence intervals (CI) for all the potential risk factors of interest. A division of the data into a training and validation set provided a test of the prediction performance of the model. Reported is the area under the receiver operating characteristic curve (AUC) with 95 % CI.
Results: 86,437 medical abortions were included, 5,320 (6.2%) were surgically intervened. The risk of surgical intervention increased with increasing gestational age (p<0.0001). The risk of surgical intervention peaked among women aged 30-35 years and declined for lower and higher ages (p<0.0001). The OR of surgical intervention among parous women compared to nulliparous was 2.0 (1.7-2.4) for women with a history of failed birth of placenta, 1.5 (1.3-1.6) for women with previous caesarean section, and 1.1 (1.0-1.2) for women with previous vaginal births with spontaneous birth of placenta. A history of early surgical abortion implied an OR of surgical intervention of 1.5 (1.4-1.7), and women with a previous late surgical abortion had an OR of 1.2 (1.1-1.3). Previous medical abortion implied an OR of surgical intervention of 0.84 (0.78-0.90). The AUC was found to be 0.63 (0.62-0.64).
Conclusion: In addition to gestational age, our study shows maternal age, previous delivery, and history of induced abortion to be risk factors for surgical intervention of early medical abortion. However, all these risk factors do not predict surgical intervention well, possibly indicating the subjective nature of the decision to surgically intervene a medical abortion. -
Oct. 4, 2014, 11:00
The efficacy, safety and acceptability of medical termination of pregnancy provided by standard care by physicians or by nurse-midwives: a randomized controlled equivalence trial
Helena Kopp Kallner, Rebecca Gomperts, Eneli Salomonsson, Monica Johansson, Lena Marions, Kristina Gemzell-Danielsson Karolinska Institutet, Stockholm, Sweden - helena.kopp-kallner@ki.se
Objective: To assess nurse-midwife provision of early medical termination of pregnancy (TOP) in a high resource setting where ultrasound examination for dating of pregnancy is part of the protocol. Method: We performed a randomized controlled equivalence trial in a Univerity Hospital Family planning outpatient unit. 1180 women seeking early medical TOP were randomized, without any prior examination, to counselling, examination and treatment by either nurse-midwife or gynaecologist. Ultrasound was performed in all cases by the allocated provider. Primary outcome was efficacy defined as successful completion of TOP without need for vacuum aspiration. Secondary outcomes were safety, defined as need for hospitalization or blood transfusion, and acceptability, defined as preferred provider were the women to have a medical TOP in the future. Results: A total of 481 women in the nurse-midwife group and 457 women in the physician group were available for final analysis. The effectiveness of provision of medical TOP by nurse-midwife providers was superior to that provided by physicians (risk difference 1.6%, confidence interval 0.2-3.0% which was within the set margin of equivalence). There were no significant differences in safety parameters. Women examined and counselled by a nurse-midwife were significantly more likely (p<0.001) to prefer seeing a nurse-midwife for the consultation were they to have another medical TOP in the future. Conclusions: These findings show that nurse-midwife provision of early medical TOP in a high-resource setting where ultrasound is part of the protocol is effective and can be safely implemented with high acceptability among women.
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Oct. 4, 2014, 11:00
Medical abortion provided by nurse-midwives or physicians: a cost-effectiveness analysis
Susanne Sjöström1, Helena Kopp Kallner1, Emilia Simeonova2, Andreas Madestam3, Kristina Gemzell-Danielsson1 1Karolinska Institutet, Stockholm, Sweden, 2John Hopkins University, Baltimore, USA, 3Stockholm University, Stockholm, Sweden - susanne.sjostrom@ki.se
Objective: To make a cost-benefit analysis of medical abortion provided by nurse-midwives and physicians. Study Design: A cost-effectiveness analysis is conducted based on a previously performed randomized controlled equivalence trial comparing efficacy, safety and acceptability of medical abortion performed by nurse-midwives or physicians in a high-resource setting. Materials and methods: Direct and indirect costs associated with the standard and intervention treatment have been calculated and an incremental cost-effectiveness analysis is performed. Equivalence in effectiveness was established for the primary and secondary outcomes in the original study, the outcome measures were complete abortion, and safety in terms of hospitalization, blood transfusion and acceptability. Direct costs include salaries including general payroll tax, rent, training of providers and costs for consultation (second opinions). Since the patients received the same treatment there was no difference in costs of disposables, ultrasound or medication. Indirect costs include women’s loss of salary and alternative cost for consultants (second opinions). Benefits emerging from increased prescription of long-acting contraceptives (LARCs) and also possible utility such as decreased waiting time for abortion seeking women from first contact to consultation/ treatment will be considered. All costs were taken from Karolinska University hospital where the parent study was conducted. Results: Preliminary results are that medical abortion provided by nurse-midwifes alone is more cost-effective than the standard treatment involving both nurse-midwives and physicians. The savings are mainly derived from lower salary costs for nurse-midwives but also from less total time for the visit.