Speeches
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Oct. 4, 2014, 11:00
Do as we say, not as we do: experiences of unprotected intercourse among Society of Family Planning fellows
Abigail Aiken1, James Trussell2 1University of Texas at Austin, Austin, Texas, USA, 2Princeton University, Princeton, New Jersey, USA - araa2@utexas.edu
Objectives: Despite our role in preventing unintended pregnancy and STI transmission, very little is known about reproductive health professionals’ own experiences of sexual risk-taking. We examined the prevalence and circumstances of unprotected intercourse among Society of Family Planning (SFP) fellows in the United States. Methods: A link to an anonymous online survey was sent via email to 477 SFP fellows. Within the first week, 321 (67%) responded, and we expect around an 80% total response rate. We asked whether respondents had ever and in the past year had unprotected vaginal intercourse when not intending a pregnancy, and if so, how many times, under what circumstances, and at what age the first time. We then asked about unprotected vaginal, anal, or oral intercourse ever and in the past year under three different scenarios: 1) partner not known to be infection-free, respondent infection-free; 2) partner known to be infection-free, respondent not infection-free; 3) partner known to have an infection, respondent infection-free, including the number of times, applicable circumstances and age the first time. Results: Among respondents so far, 46% have ever had unprotected vaginal intercourse when not intending pregnancy; 35% more than 10 times, and 13% in the past year. Sixty percent have had unprotected vaginal, anal, or oral intercourse with a partner not known to be infection-free; 38% more than 10 times, and 22% within the past year. Eight percent have ever had unprotected intercourse with an infection-free partner when they themselves had an infection, and 5% have ever had unprotected intercourse with a partner known to have an STI. Conclusions: Preliminary results suggest that despite a high level of medical knowledge, risk-taking with respect to pregnancy and STIs is common among reproductive health professionals.
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Oct. 4, 2014, 11:00
Cervical preparation before second trimester dilatation and evacuation: a multicentre randomized trial comparing osmotic dilators alone to dilators plus adjunctive misoprostol or mifepristone
Alisa Goldberg2 ,1, Jennifer Fortin2, E. Steve Lichtenberg7 ,8, Eleanor Drey9 ,10, Gillian Dean11 ,12, Paula Bednarek13 ,14, Beatrice Chen15 ,16, Caryn Dutton3 ,1, Sarah McKetta2, Rie Maurer3, Beverly Winikoff6, Garrett Fitzmaurice5 ,4 1Harvard Medical School, Boston, MA, USA, 2Planned Parenthood Leauge of Massachusetts, Boston, MA, USA, 3Brigham and Women's Hospital, Boston, MA, USA, 4Harvard School of Public Health, Boston, MA, USA, 5McLean Hospital, Belmont, MA, USA, 6Gynuity Health Projects, New York, NY, USA, 7Family Planning Associates, Chicago, IL, USA, 8Northwestern University, Chicago, IL, USA, 9San Francisco General Hospital, San Francisco, CA, USA, 10University of California, San Francisco, San Francisco, CA, USA, 11Planned Parenthood of New York City, New York, NY, USA, 12Mount Sinai School of Medicine, New York, NY, USA, 13Lovejoy Surgical Center, Portland, OR, USA,
14Oregon Health Sciences University, Portland, OR, USA, 15Magee Women's Hospital, Pittsburgh, PA, USA, 16University of Pittsburgh, Pittsburgh, PA, USA - agoldberg@pplm.org
Objectives: To evaluate adjunctive misoprostol or mifepristone versus osmotic dilators alone for cervical preparation before D&E at 16-23+6/7 weeks. Methods: This double-blind, three arm multicenter randomized controlled trial compared osmotic dilators alone, dilators plus 400 mcg of buccal misoprostol 3 hours preoperatively and dilators plus 200 mg of oral mifepristone during dilator placement for D&E. Our primary outcome was operative time. Secondary outcomes included initial cervical dilatation, D&E completion on first attempt, need for mechanical dilatation and complications. Three hundred women were required for 80% power to detect a 2 minute difference in operative time within two cohorts: 16-18 6/7 weeks (N=150) and 19-23 6/7 weeks gestation (N=150). Results: We found no difference in operative time between treatment arms in either gestational cohort. Initial dilatation was greater with misoprostol than dilators alone in the early cohort (2.4 vs. 2.0 cm, p=.007), but similar in the later cohort. More subjects in the dilators alone arm required additional dilatation in the early cohort (35.3% vs. 9.8% misoprostol vs. 14.3% mifepristone, p=.003); but not the later cohort. We found no difference in procedure completion on the first attempt. Provider satisfaction with cervical preparation was highest after mifepristone (71.8% vs. 78.8% vs. 86.8%, p<.0001). The dilators alone arm had more cervical lacerations requiring repair (4% vs. 0 vs. 0, p=.02) and more uterine re-aspirations (4% vs. 1% vs. 2%, p=.05). Conclusions: Although operative time did not differ, there may be some benefit to use of adjunctive misoprostol or mifepristone for cervical preparation before D&E.
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Oct. 4, 2014, 11:00
First trimester abortion in the Arabic world
Selma Hajri NGO, TUNIS, Tunisia - selmahajri@gmail.com
According to a WHO report, 100,000 abortions are performed per year, and 160 to 260 women die each year from unsafe abortions in the North / Middle East region. Unintended pregnancies remain high and the number of abortion seems very important although there is no reliable data. In most Muslim countries abortion, even in cases permitted by law, seems unacceptable to many. Illegal abortion is punishable by imprisonment. In some countries abortion is tolerated in the private sector and abortions are available in private clinics in many Arab countries, in good conditions for the well-off. But given the difficulty of their situation, many women, the poorest, use unsafe and risky methods of abortion.
Only Tunisia in 1973 (14 weeks LMP) and Turkey (1981 until 10 weeks LMP) have legalized abortion in the first trimester without restrictions. The majority of countries in the MENA region, that have the most restrictive laws in the world, have not evolved since independence. Policy changes and growing influence of conservatives are leading to maintenance of negative attitudes among providers and denial by most physicians and state institutions. Moreover, the latest changes with the “Arab spring“ have not improved the situation. Even where abortion is legal it is now increasingly inaccessible. Recently in Turkey the government reduced access to abortion in the public health service. After the revolution, in Tunisia where abortion is free and available in all clinics of ONFP (Family Planning) and public hospitals since 40 years, many family planning clinics and hospital units are stopping providing abortion. When they still provide abortions, new restrictions are appearing on access to abortion with a change in attitude of providers, concerns and "self-censorship", coupled with greater hostility of the medical and paramedical personnel against abortion.
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Oct. 4, 2014, 11:00
Medical abortion with mifepristone + misoprostol at 13 – 22 weeks: how long between the mifepristone and the misoprostol?
Dina Abbas1, Nguyen thi Nhu Ngoc2, Jennifer Blum1, Nguyen thi Bach Nga3, Huynh Kim Chi4, Roxanne Martin1, Beverly Winikoff1 1Gynuity Health Projects, New York, NY, United States Minor Outlying Islands, 2Center for Research and Collaboration in Reproductive Health, Ho Chi Minh City, Viet Nam, 3Hung Vuong Hospital, Ho Chi Minh City, Viet Nam, 4Huynh Kim Chi, Binh Duong Hospital in Obstetrics and Newborn, Binh duong Province, Viet Nam - dabbas@gynuity.org
Objective: To compare a regimen that initiates misoprostol dosing at the same time as mifepristone to a regimen where misoprostol is started 24 hours after mifepristone for termination of pregnancy of 13 – 22 weeks. Method: Double blinded randomized placebo controlled trial where participants received mifepristone either 24 hours before, or at the same time as, misoprostol (repeat doses of 400 mcg buccal every three hours). If abortion was not completed within 48 hours after induction with misoprostol the participant received standard care. Results: 504 women were enrolled in Vietnam. 87.1% of women who received the two drugs simultaneously experienced complete uterine evacuation within 24 hours after induction with misoprostol, compared to 95.1% of women who received misoprostol 24 hours after mifepristone. At 48 hours, this increased to 96% in both study arms. The mean misoprostol treatment duration and total misoprostol doses received was significantly lower in the group that received the misoprostol 24 hours later 9.13 vs. 14.66 (p=.000) and 3.47 vs. 5.44 (p=.000) respectively. Mean duration of the process, defined as receipt of mifepristone to complete abortion, was significantly shorter for women who received the drugs simultaneously 14.66 vs. 33.37 (p< 0.0001). In both groups the side effect profile was similar and overall satisfaction was high (>98%). Results will be presented by gestational age group (13 – 16; 17 – 22 weeks). Conclusion: Preliminary findings suggest that taking mifepristone and misoprostol simultaneously significantly lowers clinical efficacy at 24 hours; results in a longer mean misoprostol treatment duration; and requires more misoprostol doses. However there may be trade-offs as the simultaneous regimen significantly shortens the total time of the overall process and may require fewer clinic visits in some settings. The study provides evidence that allows providers and women to choose among two viable second trimester medical abortion regimens.
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Oct. 4, 2014, 11:00
Feasibility of a self-performed urinary test for the follow-up of medical abortion: the Betina study
Danielle Hassoun1, Ines Perin2 1Private Practice Office, Paris, France, 2Gynaecology Department, Delafontaine Hospital, Saint Denis, France - sbarbeau@gecem.com
Background: Medical Termination of Pregnancy (MToP) implies a follow-up visit (14 to 21 days after mifepristone intake) to verify the effectiveness of the abortion procedure and the absence of any complication. Studies have shown that a level of hCG in the serum less than 1000 IU, two weeks after the intake of the mifepristone means the success of the method in 90% of the case. Objectives and method: We set up an observational study among French specialized centres either private practice offices, academic hospital centres or family planning facilities. The objectives were to assess the benefit of a self-performed urinary semi-quantitative test in the follow-up of MToP, assessing the feasibility, acceptability and user-friendliness of the test as well as the women’s capacity to interpret it correctly. Concordance between qualitative results from the test and quantitative values from the blood hCG measurement was also assessed. Results: 322 women were included by 17 centres (47% private practice, 35% hospital practice, 18% family planning centers) from May to October 2013. The mean age was 28.1 ± 6.4 years. 82% (N=264) of patients attended the follow-up visit and 13% (N=42) of patients were lost to follow-up. 69% (N=183) patients had performed the two tests on the same day ± 1 day. Concordance between urinary test and hCG blood measurement was 94.5% [90.2%; 97.4%]. A large majority of women (90%, N=198)) read the urinary test correctly whatever the levels of hCG. Performing the test at home was found reassuring for 40% (N=71) of them, and satisfactory for 26% (N=46) of them but 3% (N=5) considered it to be alarming and 12% (N=46) unsettling. Conclusion: The semi-quantitative urinary test shows good concordance with plasma level. Proposing a urinary test for the women to control the success of the procedure appears to be relevant, efficient and safe.
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Oct. 4, 2014, 11:00
Women´s experiences of second trimester medical termination of pregnancy and their feelings and thoughts about viewing the fetus
Inga-Maj Andersson, Kristina Gemzell-Danielsson, Kyllike Christensson Karolinska Institutet, Stockholm, Sweden - inga-maj.andersson@ki.se
Objectives: To explore women´s experiences of second trimester medical termination of pregnancy and their feelings and thoughts about viewing the fetus. Method: A cross-sectional and descriptive study using both a questionnaire and semi-structured interviews for data collection. Thirty-one women filled out the questionnaire and among them 23 women were later interviewed. The questionnaires were analyzed by descriptive statistics. The answers from the questionnaires were followed up in the interviews. The interviews were recorded, transcribed verbatim and then analyzed with qualitative content analysis to identify common themes. Results: Indication for the abortion was fetal malformation or unintended pregnancy. Independent of the reason for the abortion similar feelings were expressed by the women. After having divided the feelings into positive or negative, we found that 57 % of the women had chosen both positive and negative feelings, and 40 % of the women had chosen just negative feelings. Concerns for a suffering fetus and a curiosity of what it would look like or what kind of person it could have been were expressed. Thoughts that viewing the fetus would cause increased grief or mental weakness in the future were expressed by some women. The analysis of the interview texts revealed five themes mirroring the women´s experiences, thoughts and feelings related to the abortion: "Not knowing what to expect", "To suffer", "To manage", "To get support" and "To remember", each theme is divided into subthemes to clarify the meaning. Conclusions: Women undergoing second trimester abortion need to have time and the opportunity to reflect on their feelings and thoughts in connection with the abortion. Independent of the indication for the abortion feelings of grief and sadness are seen as well as feelings of having killed their child. It is important to listen to the woman´s individual needs and give the opportunity to view the fetus if the woman wishes regardless of the reason for the abortion.
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Oct. 4, 2014, 02:00
Improved access to safe abortion in Ukraine: Comprehensive Care for Unwanted Pregnancies project results, 2009-2013
Anastasiya Dumcheva1, Galina Maistruk2 1World Health Organization, Kyiv, Ukraine, 2Charitable Foundation "Women Health and Family Planning", Kyiv, Ukraine - ada@euro.who.int
Introduction: Before 2009, most of the pregnancy terminations in Ukraine were unsafe, which contributed from 8.5% to 16.0% to the maternal mortality in Ukraine over the period from 2003 to 2009. To address this issue, Comprehensive Care for Unwanted Pregnancies (CCUP) project was introduced in 2009 in partnership with Swiss Agency for Development and Cooperation, MoH Ukraine, NGO "Women Health and Family Planning", and WHO. Objective: The project goal was to improve availability, accessibility and quality of safe abortion in Ukraine. Methods: The project included activities at the national - improving legislation, monitoring and evaluation system, and regional levels - strengthening capacity of health care professionals, improving quality of abortion services and enhancing communication in five pilot regions of Ukraine. Results: Over the period from 2009 to 2012, the contribution of unsafe abortions into overall maternal mortality in Ukraine has steadily decreased from 9.2% (12 cases) to 4.6% (3 cases). The main reason for the overall decrease was the development and endorsement of new national legislation documents - organizational and clinical protocols, which adapted WHO recommendations on safe abortion. The percentage of women undergoing safe abortion methods in the first trimester (medical abortion, manual or electrical vacuum aspiration) vs unsafe (dilatation and curettage) has increased in pilot regions from 25-32% in 2011 to 53-75% in 2013 (variability is due to the regional context and time of project start in the region). The percentage of women who received local vs general anaesthesia has increased from 11% in 2011 to 29-37% in 2013. By the end of 2013, most of the women received pre- and post-abortion counselling sessions (82-95% compared 59-62% in 2011). Conclusion: The project interventions contributed to the overall decrease of abortion-related maternal mortality in Ukraine. Interventions piloted at the regional level are acceptable for healthcare professionals and women and can be disseminated nationwide.
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Oct. 4, 2014, 02:00
Adherence of health workers in the Republic of Kazakhstan to the use of hormonal contraceptives
Nadezhda Kobzar, Nafisa Mirzaraimova, Hadi Leimoyeva Kazakhstan-Russian Medical University, Almaty, Kazakhstan - nafisa.mirzaraimova@mail.ru
The number of abortions has reduced by 29% in the period 2000-2013 in the Republic of Kazakhstan (RK). However, abortion rate remains very high per 1000 of fertile age women: 2000 - 30.9, in 2013 - 20.8. Study goal: Identification of the incidence of hormonal contraceptive use in the RK. Study materials:Reports of the MoH RK covering female population health for 2000-2013, reports of pharmacies featuring sales volumes of hormonal contraceptives in the RK for 2004-2013. Study outcomes and their discussion: High rate of abortion per 1000 of fertile age women in the RK is due to low use of contraceptives. Thus, only 30.4% of reproductive age women used contraceptives in 2000, while in 2013 their proportion amounted to 38.2%. Within the structure of contraceptives used in 2000-2013 the first place belongs to IUDs. Regardless of their proved high efficiency the rate of use of hormonal contraceptives among women remains low in the RK. The given indicator made up 2.1% in 2004 and in 2013 - 2.2%. Conclusions: 1. Though abortion numbers have gone down in the RK its rate per 1000 of fertile age women remains rather high; 2. Use of contraceptives for unwanted pregnancy prevention is low. 3. Within the structure of contraceptive use in 2000-2013 the first place belonged to IUDs; 4. The use of state-of-the-art hormonal contraceptives remains inadequate, which implies that abortion remains the principal family planning method.
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Oct. 4, 2014, 02:00
Making medical abortion woman-centered and accessible in Kazakhstan: a study of 600 mcg sublingual misoprostol following 200 mg mifepristone for abortion up to 70 days’ gestation
Ingrida Platais1, Tamar Tsereteli1, Galina Grebennikova2, Beverly Winikoff1 1Gynuity Health Projects, New York, NY, USA, 2Kazakhstan Association on Sexual and Reproductive Health, Almaty, Kazakhstan - iplatais@gynuity.org
Objective: To assess whether the option to take mifepristone at home is feasible and acceptable to women with pregnancies up to 70 days' LMP seeking medical abortion in Kazakhstan. Method: Typically, medical abortion in Kazakhstan consists of four visits. This study consisted of two visits. During their initial visit, women were given the option to swallow mifepristone at the clinic or take it home, and all women were instructed to take misoprostol at home. The follow-up visit was scheduled two weeks after mifepristone. This open-label study enrolled women with pregnancies ≤70 days' LMP. The study regimen consisted of 200 mg mifepristone, followed by 600 mcg misoprostol 24-48 hours later. Results: As of April 2014, 106 women were enrolled. Ninety-eight percent of women had successful abortions. All women took mifepristone and misoprostol at the scheduled time, and no woman took mifepristone after 70 days' LMP. No serious adverse events were reported. Most women (99.0%) reported that the ability to plan when the abortion would occur was important for them. More than half of the women (61.3%) chose to take mifepristone at home, citing compatibility with home and family duties as the top reason for their choice in location of mifepristone administration. For clinic users, the presence of a provider was the most common reason for their choice. Almost all women (99%) were satisfied with the abortion procedure and most (98.1%) would choose medical abortion in the future. Most home users (90.8%) said they would choose to take mifepristone at home again if they needed another abortion, whereas only 12.2% of the clinic users would choose to take mifepristone in the clinic again. Conclusion: An outpatient medical abortion procedure up to 70 days’ gestation using mifepristone and misoprostol, taken at a place of women's choosing, is safe, effective and acceptable.
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Oct. 4, 2014, 02:00
Prescription of contraceptive methods in relation to repeated abortions: a longitudinal population study
Helena Kilander1, Siw Alehagen1, Linnea Widen1, Karin Westlund1, Johan Thor1, Jan Brynhildsen1 1Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 2Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 3Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 4Department of Obstetrics and Gynaecology, Norrköping, Sweden, 5Jönköping Academy for improvement and welfare, Jönköping, Sweden, 6Obstetrics and Gynaecology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden - helena.kilander@lj.se
Background: Use of long-acting reversible contraception (LARC) has been reported to reduce the risk of repeated abortion compared with use of other contraceptive methods. Swedish women have a long tradition of using intrauterine devices in comparatively large numbers. Despite good access to LARC, Sweden has a high proportion of repeated abortion. Objective: To study the prescription of contraceptive methods in relation to an abortion in a Swedish population and relate them to the likelihood of repeated abortions. We hypothesized that the prescription of LARC after abortion leads to reduced number of repeated abortions compared with other prescribed contraceptive methods. Method: A retrospective cohort study of women seeking abortion at three Swedish hospitals during 2009. The medical records of these women were scrutinized from the date of the index abortion during 2009 to the 31st of December 2012. The study population comprised 1032 women. Results: A total number of 266 (25%) women requested abortion(s) during the follow-up time. Oral contraceptives were prescribed to 43. 6% of the women and LARC were prescribed to 32.4% at the time of the index abortion. Prescription of LARC was associated with a reduced number of repeated abortions compared with prescription of oral contraceptives (OR 0.39 CI 0.26-0.56). Conclusions: The results of this study show that use of LARC is associated with reduced repeated abortion compared to other contraceptives. Implication: Abortion care needs an increased focus in motivating women and professionals to switch from oral contraceptives to LARC.