Speeches
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Oct. 14, 2016, 09:30
PS01.1 Improving the journey through medical abortion.
Rebecca Gomperts1 ,2
1Women on Web, Toronto, Canada, 2Women on Waves, Amsterdam, The Netherlands, 3Karolinska Institute, Stockholm, Sweden
Women on Web, a telemedical abortion service was founded 10 years ago and today answers 10,000 emails per month. Telemedicine has a great potential to improve the journey though medical abortion especially for women in rural and remote areas, as well as urban areas with a shortage of health care providers or where access to abortion is legally restricted.
So far scientific research has been published about three telemedical abortion services Women on Web (WoW), Willow Women’s Clinic and Planned Parenthood of the Heartland. Lately several new telemedical abortion services were initiated including one in Australia by the Tabbot Foundation and in the USA by Gynuity.
In this talk I will present
- Examples of women who contacted Women on Web because they could not obtain regular abortion services even if they are living in countries where abortion is “legal” and “available” due to economic and social circumstances and domestic violence.
- Criminal prosecution of women using Women on Web in a high resource setting.
- Criminal prosecution of women using Women on Web in a low resource setting.
While these cases are caused by the local, legal context it shows clearly that, even if telemedical services can give access to medical abortion in places where this is not available, we have to continue to work on changing abortion laws and making sure local, safe abortion services will become more easily accessible even in countries where it seems abortion services are available as they are still not available for those women who are in the most vulnerable social economic situations. To improve the journey through medical abortion for women we have to improve it for all women.
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Oct. 14, 2016, 02:00
CS04.2
Intrauterine contraception after medical abortion
Ingrid Sääv1 ,2, Kristina Gemzell Danielsson1
1Karolinska Institutet, Stockholm, Sweden, 2Norrtälje Hospital, Norrtälje, SwedenBackground: Today a large proportion of early abortions are medical terminations, in accordance with the woman's choice. Intrauterine contraceptives (IUC) provide highly effective, reversible, long-acting contraception but the effects of timing of IUC insertion after medical abortion are not well known. Routine insertion after the first menstruation means an obvious risk of a new pregnancy.
Methods: Women undergoing early medical abortion with mifepristone and misoprostol up to 63 days gestation and opting for IUC were randomised to early insertion (day 5-9 after mifepristone) or delayed (routine) insertion (at 3-4 weeks after mifepristone). The primary outcome was the rate of IUC expulsion six months after IUC insertion. Secondary outcomes were rate of insertion, use at 6 and 12 months, and adverse events.
Results: A total of 129 women were randomised and 116 women had a successful IUC insertion. There was no difference in expulsion rate between the groups (p=0.65) with 6 expulsions in the early insertion group (9.7%) compared to 4 in the late insertion group (7.4%). Significantly more women returned for insertion in the intervention group (p=0.03) and more women (41%) had unprotected intercourse prior to insertion in the delayed group (p=0.015). Adverse events were rare in both groups.
At the follow ups no differences could be found in regard to bleeding patterns, menstrual pain or compliance with the IUC.
Conclusions: Early insertion of IUC after medical abortion is safe and well tolerated with no increased incidence for expulsions or complications. Women are more likely to return for the IUC insertion if scheduled early after the abortion and less likely to have had an unprotected intercourse prior to insertion. Early insertion should be offered as a routine for women undergoing first trimester medical abortion.
Key words: IUC, medical abortion, insertion, intrauterine contraception -
Oct. 3, 2014, 09:45
Non-physician providers’ roles in access to safe abortion care: an overview of evidence
Bela Ganatra WHO, Geneva, Switzerland - ganatrab@who.int
Unsafe abortion continues to constitute a major mortality and morbidity burden especially in the developing world (21.6 million unsafe abortions; 13% of maternal deaths). Access to safe abortion is limited by numerous barriers but one of the most critical is the lack of trained providers. Many countries limit abortion service provision to specialist doctors. However, most developing country regions suffer from a critical short supply of OBGYNs , generalist doctors and even midwives. Areas with a critical shortage of health service providers also have the highest burden of unsafe abortion-related deaths. Expanding the provider base to include a range of other health workers is a recognized strategy to expand access to health services and scale up implementation of interventions of public health significance including for safe abortion care. Medical abortion as an effective and recommended technology has made it even more relevant to expand health workers' roles in provision of safe abortion care and to look at self-assessment as ways of reducing the need for health worker time and resources. There is a growing body of research evidence on the issue. Additionally, in several countries use of some cadres of non-physician providers is already part of practice (though often not of policy). The Department of Reproductive Health and Research at the WHO is currently reviewing and synthesizing evidence related to task shifting and task sharing in the provision of safe abortion and postabortion care with the aim of developing specific recommendations on the issue. The evidence base includes comparative studies, qualitative data and country case studies to synthesize programmatic experience form countries where non-physician providers have already been providing such care. The presentation will give a broad overview of the evidence on this topic and the process of the guidelines development.
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Oct. 15, 2016, 11:00
CS08.2
Multi-level pregnancy test for medical abortion follow-up: what do we know so far?
Elizabeth Raymond, Tara Shochet, Jennifer Blum, Wendy Sheldon, Beverly Winikoff
Gynuity Health Projects, New York, NY, USAObjectives: To summarise data on the effectiveness and feasibility of a strategy involving serial use of an urine multi-level pregnancy test (MLPT) for at-home follow-up after early medical abortion.
Methods: We included data from five published studies involving a total of 1,848 women who received treatment at ≤63 days of gestation. In all five studies, an MLPT with five hCG ranges was used for assessing medical abortion outcomes. A baseline test was administered just prior to mifepristone and a follow-up test was administered 1-2 weeks later. Declining hCG concentrations in successive tests were interpreted as indication of abortion success, while stable or increasing hCG concentrations were interpreted as indication of possible continuing pregnancy. The MLPT results were then compared with results from standard clinical assessment.
Result: A total of 93.8% (1487/1585) of those with successful abortion outcomes (no ongoing pregnancy) observed declining hCG concentrations in successive tests. All those with continuing pregnancies (21/21) observed stable or increasing hCG concentrations. The predictive value of the MLPT strategy for identifying continuing pregnancy was thus 100%. In addition, 94.0% (1496/1591) of women reported that the MLPT was either very easy or easy to use.
Conclusions: The MLPT strategy is highly successful at identifying continuing pregnancies as well as absence of continuing pregnancy. Use of this strategy is both feasible and effective and would reduce the need for clinic follow-up after medical abortion for the majority of women. -
Oct. 4, 2014, 02:00
Outpatient medical abortion in the later first trimester: is it possible? desirable?
Ilana G. Dzuba Gynuity Health Projects, New York, USA - idzuba@gynuity.org
First trimester medical abortion is typically provided through 63 days gestational age as an outpatient service. Nonetheless, many women with pregnancies more advanced than 63 days wish to avoid a surgical procedure and would opt for medical management if offered. But can women with 64 day gestations or 72 day gestations or 80 day gestations avoid facility-based management with multiple repeat doses of misoprostol and, therefore, heightened side-effects? Recent studies explored the use of an outpatient approach with more advanced first trimester pregnancies to establish efficacy, side-effect profile, acceptability to women and to determine any change in outcomes compared with medical abortions in the previous gestational week. Results support the use of outpatient regimens through 77 days of gestation and suggest new counselling considerations. Successful medical abortion appears to decrease in the 12th gestational week. Expanding provision of medical abortion for additional weeks of pregnancy would increase access, including for those women for whom suction curettage is not feasible.
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Sept. 15, 2018, 04:30
All restrictions to access abortion services, legal logistic financial, creates social inequality. Women with access to financial means and information will always be able to access safe abortion services and women without the financial resources are most affected by these obstacles. abortion laws. Women on Waves and Women on Web use new technology (drones, robots, internet, apps) and research, to break the taboo around abortions and change policies and laws and in the same time make sure women have access to contraceptives and safe medical abortions. This presentation will highlight some of the work, achievements and challenges in the past years.
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Oct. 15, 2016, 02:00
CS15.2
Practical management of midtrimester abortion
Linda Hunt
Royal Infirmary, Edinburgh, UKThis presentation will cover the practical aspects of managing mid trimester medical abortion as conducted by a nurse midwife.
It will draw upon experience from a Scottish hospital setting in Edinburgh where all mid trimester abortions have been performed medically using mifepristone and misoprostol for more than 25 years (approximately 120 per year). The presentation will cover management of complicated cases including the scarred uterus and twin pregnancy. It will also give practical advice for how to manage pain relief and how long to wait before intervention for retained placenta. -
Oct. 15, 2016, 11:00
CS10.2
RCOG Leading Safe Choices: Training abortion providers in South Africa
Alison Fiander3, Judith Kluge1 ,2
1University of Stellenbosch, Western Cape Province, South Africa, 2Tygerberg Hospital, Western Cape Province, South Africa, 3Royal College of Obstetricians and Gynaecologists, London, UKThe Choice-on-Termination-of-Pregnancy ACT of 1996 changed laws in South Africa from highly restrictive to more liberal laws for abortion provision. It legalised abortion-on-demand for women in the first trimester and allowed abortion provision for socio-economic reasons, amongst others, up to 20 weeks gestation. The law also allowed trained registered nurses to provide both surgical and medical abortions in the first trimester. In the ensuing years, non-governmental organisations such as Marie Stopes and IPAS assisted the Department of Health with training of nursing staff. Following withdrawal from South Africa by some NGO's a void was left in comprehensive abortion care training. Additionally, other ongoing challenges to ensuring designated TOP facilities had trained staff to provide abortion services continued. In 2011 only 57% of designated abortion facilities were providing abortion services. A persistent high proportion of abortions are performed in the second trimester. Forty present of women who had a second trimester abortion had initially presented to a health facility in the first trimester but had the procedure delayed at the facility or by a requirement to refer to other health facilities. Women still have unsafe abortions, accessing illegal abortion providers. Unsafe abortions also occur in legal facilities due to lack of training and services failing to meet minimum standards.
The RCOG Leading Safe Choices initiative aims to improve the competence and standing of abortion care providers. It has recently been implemented in Western Cape Province, South Africa with the training of master trainers in December 2015. Subsequent Comprehensive Abortion Care training was initiated in March 2016. The Best Practice paper on Comprehensive Abortion Care was included in the Western Cape Province Department of Health Abortion Policy in 2016. Progress regarding this initiative in South Africa will be presented. -
Oct. 15, 2016, 11:00
CS11.2
Reasons for the use of medical versus surgical abortion in Europe
Alberto Stolzenburg
Clínica Ginecentre, Málaga, SpainAlthough most countries in Europe have similar abortion laws and belong to the most advanced category in the world, the implementing regulations can in practice facilitate or hinder access to abortion care. In the same way, since the legalisation of Mifepristone in France in 1988, the use of specific drugs in the abortion practice has spread in Europe unevenly but there are still significant differences from one country to another.
We classify the countries as follows:
- Countries with high prevalence of medical abortion
- Countries with prevalence of medical over surgical abortion
- Countries where both methods are used with similar frequency
- Countries with a predominance of surgical over medical abortion
- Countries with high prevalence of surgical abortion
The main reasons affecting the use of medical versus surgical abortion are:
- Legislation, administrative and health regulations
- Legalisation of Mifepristone
- Legal and off-label use of prostaglandins (Misoprostol)
- Where (type of health care facility, inpatient and outpatient care)
- Public or private institution
- Who performs abortions (gynaecologists, general practitioners, nurses, midwives)
- Conscientious objection
- Preference for usual practice ("culture") by health professionals and also the women
- Access to continuing vocational training, dissemination of knowledge (medical guidelines: WHO, RCOG, IPPF, NAF etc.)
- Scientific research, especially use of drugs in abortion care
- Political factors (conservative or liberal governments)
- Economic factors
- Cultural and religious factors
This paper reviews the impact of these factors in different European countries and regions.
Proposals are presented to improve the availability of the most appropiate method for each woman, according to their special circumstances.
Our top priorities: medical safety and free method choice for the women