Speeches
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Oct. 25, 2008, 04:00
Where should medical abortions take place?
Elisabeth Aubény (France)
10, rue du Docteur Lancereaux, 75008, Paris, France
aubeny@orange.fr
Medical abortion takes places in 2 stages: the administration of mifepristone which inter00:rupts the pregnancy then, 48h later, the administration of a prostaglandin which results in expulsion of the uterine content. Where should these two medicines be provided and taken? Mifepristone is currently bought by the doctor and taken by the woman in his presence. Why should the woman not buy mifepristone herself at the pharmacy with a medical prescription and then take it, like any other medicine, at home? Fear of a black market? Prostaglandins. The regimen for Misoprostol administration varies from one country to another. In many countries administration of misoprostol takes place in a hospital centre, followed by a 3h monitoring period due to fear of serious adverse events including and haemorrhage at the time of expulsion. Experience shows that, for pregnancy of less than 49 DA, this precaution is not medically necessary with a regimen of mifepristone 600 mg + oral misoprostol 400µg. For this reason in Sweden and France the administration of misoprostol “at home”is now authorised. Studies have demonstrated that this approach is also possible up to 63 DA but with a different regime: mifepristone 200 mg + misoprostol 800µg by vaginal or buccal route. This technique is authorised in Sweden and practiced in the USA (900,000 cases) without related problems. This “at home” administration of misoprostol allows avoidance of one consultation and thus simplifies the method. It is very well accepted by the women who chose it: greater intimacy and confidentiality. However, certain women prefer to be in a medical environment at the time of administration of misoprostol and during the hours that follow. It is important that women are able to choose between the two options. From 63 DA until the end of the first trimester medical abortion is not legally authorised anywhere. However, it is sometimes used. In this case, it is essential that the women take misoprostol in hospital and that they are monitored until expulsion has taken place as bleeding may be heavy and pain must be actively managed. Also at these later gestations products of conception are more visible and must be disposed of appropriately. When using gemeprost, this requires to be stored in a freezer, and the administration must take place in a hospital centre.
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Oct. 20, 2012, 04:00
About 15% of pregnancies
terminate spontaneously in the
first trimester .The majority of these miscarriages
are unrecognized clinically.. As the levels of
progesterone fall expulsion of the products of
conception occur spontaneously and resumption
of cyclical ovarian activity with 2-3 months.
Modern methods of medical abortion using
mifepristone and a prostaglandin simulate closely
the mechanisms which occur in spontaneous
abortion suggesting that it is likely that the
majority will resolve spontaneously without further
intervention(Baird 2002) . Blockage of the action
of progesterone with mifepristone results in
powerful uterine contractions which together with
an increased sensitivity to prostaglandin leads to
expulsion of the fetus and placenta.(Baird 2002).
Extensive research over the last 30 years has now
identified a simple regimen (Mifepristone followedby misoprostol) which is highly effective(on-
going pregnancy<1%), is free from serious
side effects and does not require sophisticated
facilities(WHO2003). Several studies have shown
that abortion can be safely delivered by relatively
unskilled health workers (mid-level providers
MLP) who have been trained to follow an agreed
protocol of treatment(Shannon &Winnikoff 2009
Warriner et al2011). By devolving provision of
abortion to MLP the access to abortion should
be greatly widened. As predicted in the original
report of medical abortion with mifepristone and
gemeprost that “this combination would have
particular application in countries where skilled
medical and surgical experience are in short
supply” (Rodger & Baird 1987 ) -
Sept. 11, 2004, 02:00
Who should do the counselling: doctor – non doctor?
Karen Schlie , Family Planning, Hamburg - Germany
The first question arising in this connection is the question of what is at issue in the counselling. As a counsellor having graduated in pedagogic with additional therapeutic qualifications I have to focus on the client’s issues.
What are her needs and wishes concerning counselling prior to an abortion.
- Does she need support in taking her decision or rather an opportunity to reflect whether she has taken the right decision?
- Does she require information about abortion: medical information, the selection of the right method, the procedure, framework conditions or the steps to go – just to mention a few examples?
- Or does the client rather wish information about social/financial support in order to reconsider whether this would influence her decision?
- Are there any specific legal conditions concerning abortion to be observed in different countries?
- Are there any legal conditions for the physician such as her duty to inform about complications?
- Does the client wish any counselling at all?
This range of questions shows that different qualifications are required to provide adequate and professional help for the respective problem.
Therefore I would not ask who should do the counselling prior to an abortion but rather which qualifications the physician or other professional should have.
I work as a counsellor at the family planning centre in Hamburg/Germany. I have a university degree in pedagogics with additional qualifications in social work and psycho-therapy. These are qualifications from which I benefit in my pre-abortion counselling work.
As counselling prior to an abortion is compulsory in Germany, we often have to deal with resistance and fear. Frequently, our clients are insecure and don’t know what they have to expect from the counselling.
In our counselling work we distinguish between clients who have already taken their decision to have an abortion (which is the case for about 80 % of our clients) and those who rather seek support in their decision-taking process (some 20 %). The latter need a therapeutically trained counsellor.
Mostly, both types of clients wish to also receive medical information.
Therefore, medical knowledge about the performance of an abortion and any potential complications is required. In our team at the family planning centre, we have physicians and perform abortions ourselves. If the client has any questions I cannot answer, I can refer her to a physician or can acquire the relevant knowledge myself. Vice versa, the physicians can refer to me or one of my colleagues, if they become aware that the client has not yet taken her decision or is in a crisis due to an inner conflict.
Of course, these opportunities are not available at every institution or clinic; and therefore it is essential to try to establish a good network of cooperation and, if necessary, to take part in specific training.
Regardless of your profession, I think it is important to reflect your own inner processes as well as your practical work. Counselling competence, such as certain communication techniques, might also be of help in the medical context.
Thus, in supporting the client in her choice of the appropriate abortion method you should also talk about her personal situation taking into account her particular needs.
- Are there, for example, small children but nobody who could take care of them?
- Is she afraid of surgical abortion because of past bad experience with operations?
- Does she consider Mifegyne to be a more self-determined way which she would prefer while a surgical abortion might give her the feeling of being in someone’s hands (“there’s someone doing I don’t know what to me”) – possibly due to a history of sexual abuse?
- In case the pregnancy is too advanced for medical abortion so that she has to choose the surgical way, it may be important to reflect whether it is more appropriate for her to get local anaesthesia as she could then participate consciously in the entire process.
- Or would she rather prefer not to live consciously through the surgical abortion process because it might lead to retraumatization due to past experience with violence? Then general anaesthesia might be her choice.
For all these questions it is useful if I as a counsellor can reflect my own feelings while I inform the client about the various methods. Am I able to go with the client and her decision even if I would choose a different method in a similar situation? And by the way, what is my way of informing? Do I conduct the dialogue in a way ensuring that the client can take a self-determined decision about the method she considers most appropriate? Am I the one determining what is “self-determined” or am I rather able to put aside my own concepts of what might be best for the client.
Summarizing I come back to the one central question: What are the qualifications required by a counsellor to deal with abortion, no matter whether she is a physician or another health professional?
In my opinion we are not looking for an either-or solution but rather for an as-well-as solution. This means that physicians and other professionals should cooperate and support each other in order to participate from each other’s competence in striving for the greatest possible benefit for the client.
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Sept. 11, 2004, 11:00
Who should perform medical abortion
Richard Burzelman, Richard Burzelman is an Assistant Director for Reproductive Health with the Provincial Government Western Cape Province in South Africa since 2002. His responsibilities include development of policies, guidelines and protocols for the reproductive health services in the Province. He has been involved with reproductive health since 1997 when he started managing an abortion service at a district health facility in Cape Town. This service became the referring facility for the Metropole Region giving access to all clients up to 20 gestational weeks. At the time access was limited as the “Choice on Termination of Pregnancy”, Act 92 of 1997 was just introduced and very controversial.
The Reproductive Health Sub-Directorate collaborates with the World Population Foundation (WPF) in the Netherlands, the Johns Hopkins University Centre for Communication Programs, and the Reproductive Health Research Unit in Johannesburg and the Women’s Health Research Unit at the University of Cape Town undertaking reproductive health research.
Qualifications:Registered Professional Nurse/Midwife (Accoucheur) with Diplomas in Psychiatric Nursing, Operating Room Nursing, Nursing Administration, a Certificate in Termination of Pregnancy and a post-graduate BA Nursing Degree.
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Making safe, legal abortion services available to all women is likely to require that all levels of professional health care service providers i.e. the traditional gynecologist, trained physician, and mid-level health professionals participate in the services.
Medical doctors trained in abortion services are not available in many parts of the developing world. This necessitates training of mid-level providers who are not physicians to deliver quality abortion care.
These mid-level providers refers to a range of non-physician clinicians – midwifes, nurse practitioners, clinical officers, physician assistants, and others who are trained to provide basic, clinical procedures related to reproductive health, including bimanual pelvic examination to determine pregnancy and positioning of the uterus, uterine sounding, transcervical procedures, and who could be trained to provide early abortion services.
A previous study in the USA seemed to indicate that complication rates between physicians and other mid-level health care professionals show no difference in first trimester abortion procedures. A study in SA and Vietnam looking at whether there are any differences in medical outcomes between physicians and mid- level providers providing first trimester abortions is currently being completed.
Operations research being undertaken in SA to determine the acceptability and feasibility of medical abortion findings will be presented to policy makers later in the year.
In South Africa, the provision of first trimester surgical terminations have been delivered by registered midwifes since the implementation of the “Choice on Termination of Pregnancy Act” no 92 of 1996. An amendment to the Act later this year will include medical abortions as an added choice for women in the first trimester of pregnancy. In this talk, emphasis will be placed on the South African situation, as an example for other developing countries where there is a shortage of abortion care providers.
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Oct. 23, 2010, 02:00
Why different intervention rates after online medical abortion and why do they matter?
Gunilla Kleiverda, gynaecologist, Women on Waves, Netherlands
Co-authors: Kinga Jelinska, project manager Women on Web, Rebecca Gomperts, MD, director of
Women on Waves
The online non-profit project Women on Web was set up in 2006 with the aim of increasing access to safe TOP and improving maternal health in countries where TOP is not available without restrictions. The website [womenonweb.org] refers women to a doctor who can provide them with a medical TOP using the combined regimen of mifepristone and misoprostol, provided they fill in the online consultation form, meet the specified inclusion criteria and none of the exclusion criteria.
A previous evaluation of the service provided by Women on Web showed a surgical intervention rate of 13.6%, and after maximizing the follow-up, of 6.8%. We will present data about the follow-up of 2323 women who had a medical TOP and spontaneous start of expulsion from February 2007 to September 2008. Of these women, 289 (12.4%) had an additional surgical intervention
Intervention rates varied widely by region, from around 5% in Western Europe (mainly Ireland) up to nearly 15% in Eastern Europe (mainly Poland) and Latin America/Caribbean. The differences will be related to patient characteristics, patient’s acceptability. The reasons and implications of those differences for the medical abortion clinical procedure, public perception of MA and accessibility will be discussed during the presentation.
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Sept. 11, 2004, 09:00
Why do we need medical abortion when surgical abortion works so well?
Pierre Moonens, MD, Boardmember of the “Fédération de Centres de Planning Familiaux” and of “Gacehpa”, Belgium. Co-founder and Vice President of Fiapac
In the French spoken part of Belgium, we have a 25 years old experience of performing abortions in family planning clinics, using the aspiration’s technique under local anaesthesia. We are very pleased with this way of working. Description of disadvantages and advantages of this technique.
- How did we introduce the medical abortion technique in our Centres?
- Which protocol are we following for medical abortions?
- Which are the changes introduced in our daily work by this new technique?
- In which particular situations are preferring one method or the other?
- Which changes could be introduced in the protocol of medical abortion to improve the women’s rights ?
- Some ethical principals that should not be forgotten in our work of “abortion practitioners”.
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Oct. 25, 2008, 11:00
Women’s choices: Why do they opt for medical abortion?
Mette Løkeland, Line Bjørge (Norway)
Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
mette.loekeland@helse-bergen.no
Background. Norway has abortion on request, completely free of charge and easily accessible at every gynaecology ward up to 12 weeks of gestation. Up until April 1998 when medical abortion with mifepristone and misoprostol were implemented for pregnancies terminations performed at less than 9 weeks gestational length all first trimester abortions were performed surgically at Haukeland University Hospital. In 2003 medical abortion was made the method of choice for early first trimester abortions. Medical abortion for 9-12 weeks of gestation was implemented in 2005 and made method of choice in 2007. If there are personal or medical reasons the surgical method will be used instead. In 2006 97.3% of all the abortions up to 9 weeks and 54.5% of those between 9-12 weeks were performed medically.
Choice versus medical recommendations. A woman’s choice is dependent on different factors. Her personal experience, experiences of people she knows and relates to, what she believes is the best method and what health personnel advise her to. Most women do not have a strong opinion but will generally prefer what health personnel recommend them to do.
The success rate of medical and surgical abortion methods are the same.The general medical view is that conservative treatment should always be preferred to surgical when the methods give equivalent treatment outcome. Surgical abortion in a safe and legal environment preformed by skilled personnel has few complications. In comparison medical abortion has a lowere complication rate ; especially the severe complications are few. Medical abortions should therefore be offered as the method of choice.
To make an informed consent and be able to choose a method one need thorough information.Our experience is that women who opt for surgical abortion often do so because their family doctor or others who have no knowledge of medical abortion have told them that it would be the best method for them. They will normally change their opinion when informed about medical abortion. Less women opt for surgical abortion today than ten years ago.
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Oct. 24, 2008, 09:00
Women’s experience of home-abortion
R. Hjertberg, M. Jahnson, M. Jarkander-Rolff, K. Lindelöw, I. Rosengren (Sweden)
Octaviakliniken, Stockholm, Sweden
ragnhild.hjertberg@octavia.ptj.se
Background. Medical abortion with the use of the antiprogestin mifeprostone combined with a prostaglandin has been approved in Sweden since 1992. Misoprostol has been shown to be the most optimal prostaglandin analogue and since 2006 it is possible to perform the abortion at home which is both safe and efficient. (Gemzell Danielsson et al). There has been an increasing demand from women to perform medical abortion at home.
Objective.To evaluate women’s experience of home-abortion and also to evaluate if our routines with counselling, possibility of advice on the telephone met the women’s need of safety.
Methods.100 questionnaires regarding given information, feeling of safety, acceptability, and complications, were given to women who chose to use misoprostol at home. Response rate was 56%.
Results. Mean age 34 yrs (18-46). The information regarding the procedure given from doctor and nurse was sufficient (98%). 85 % felt very safe and 15% rather safe in the home-setting. 100% had enough time for questions before the abortion and 98 % were satisfied with the telephone-contact during the day. 83% had good and 8% had sufficient analgesics during the day. The procedure went as expected although 44% found it not as painful as anticipated.
Conclusions. Home-abortion with the use of misoprostol presents a good alternative for many women. It is safe and has a high acceptability. However it demands enough time for detailed counselling and good routines at the clinic as well as written information to the women.
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Oct. 25, 2008, 11:00
Women’s experiences: Are they satisfied?
Annie Bachelot (France)
Unit INSERM-INED 822, Hôpital de Bicêtre, 82 rue du Général Leclerc, 94 276 Le Kremlin-Bicêtre Cedex, France
annie.bachelot@inserm.fr
This study aimed to document women’s experience of a home-use medical abortion and to compare it to women‘s experience of a hospital-use of misoprostol administration.
A total of 43 women participated in in-depth interviews, 4-6 weeks following their abortion, after their follow-up visit. For 12 women this abortion was not the first one.
Home-use of misoprostol affords women more privacy, comfort and control of their abortions, allowing someone familiar to provide support. The partners‘ participation seemed very important for women. But the home procedure can also create more anxiety than the hospital procedure, especially concerning the need for hospital admission in case of excessive bleeding, or the success of abortion. Women expressed their need for more explanations from clinicians. The different aspects of private status, “medical ability transfer” and social recognition of such abortions were explored.
Both home and hospital procedures should be available to allow women to make their own choice.