Speeches
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Oct. 14, 2016, 02:00
FC04
Safety and effectiveness of medical abortion outside the formal healthcare setting: do women seek timely care for potential complications?
Abigail Aiken1 ,2, Rebecca Gomperts3, James Trussell1
1Princeton University, Princeton, NJ, USA, 2University of Texas at Austin, Austin, TX, USA, 3Women on Web, Amsterdam, The NetherlandsObjectives: Medical abortion provided outside the formal healthcare setting is an important option for women in countries where abortion is illegal or highly restricted. Yet very little is known about its safety and effectiveness. We address this important knowledge gap using high-quality data from a setting where women commonly rely on this pathway to abortion.
Methods: We examine outcomes and complications among 1,234 women in Northern Ireland (representing 79% follow-up) who conducted medical abortion through Women on Web between March 30th 2009 and December 31st 2012. Women used a regimen of 200mg oral mifepristone and 1200mcg buccal misoprostol (with additional misoprostol provided if required).
Results: At the time of consultation, 77% reported gestational age under seven weeks, and 23% between seven and nine weeks. Abortions typically occurred between five and 21 days later (women were strongly discouraged from performing abortion after 12 weeks gestation). Virtually all women (99.0%) were able to end their pregnancies and 95.1% were able to do so without surgical intervention. Three women (0.2%) required a blood/blood product transfusion and 23 (1.9%) were given antibiotics. Nine percent of women reported bleeding lasting more than two hours soaking more than two maxi pads per hour; fever >39C or purulent discharge; or pain persisting several days postabortion. Among women reporting these possible symptoms of serious complications, 97% sought timely medical care (the other 3% suffered no harm). Among women not reporting a potentially serious complication none received treatment for one.
Conclusions: Despite a variety of gestational ages (including some beyond nine weeks) and the likely possibility that some providers performed surgical intervention and prescribed antibiotics unnecessarily, findings show that medical abortion provided outside the formal healthcare setting is highly effective and safe. Crucially, women are able to self-identify potentially serious complications and seek appropriate and timely medical assistance. -
Sept. 15, 2018, 02:00
Background: Unsafe abortion causes an estimated 43 000 maternal deaths each year. Telemedicine abortion services today abridge the lack of access to safe abortion in many countries. We aimed to evaluate the safety and acceptability of abortion through telemedicine at above nine gestational weeks (gw).
Methods: A retrospective cohort study comparing self-reported adverse outcomes among women in Poland at ≤ and > 9 gw who requested abortion through the telemedical service Women on Web between June 1st and December 31st 2016, confirmed intake and provided follow-up (n=615).
Results: Among women ≤ and > 9 gw respectively, 3.3% vs 11.7% went to hospital within 0-1 days of the abortion for complaints related to the procedure (AOR 3.82, 95% CI 1.90-7.69). In a stratified analysis the corresponding rate in the highest gestational age group, 11w0d-14w2d, was 22.5% (AOR 9.20, 95% CI 3.58-23.60). Among women ≤ and > 9 gw respectively, the rate of surgical evacuation post-abortion was 12.5% vs 22.6% (AOR 2.04, 95% CI 1.18-3.32), the rate of overall medical interventions post-abortion was 18.3% vs 29.0% (AOR 1.84, 95% CI 1.13-3.00), the rate of heavy bleeding was 6.8% vs 10.1% (AOR 1.65, 95% CI 0.90-3.04), the rate of low satisfaction was 2.4% vs 1.6% (AOR 0.69, 95% CI 0.14-3.36), the rate of bleeding more than expected was 45.6% vs 57.8% (AOR 1.26, 95% CI 0.78-2.02), and the rate of pain more than expected was 35.6% vs 38.8% (AOR 1.11, 95% CI 0.71-1.71).
Interpretation: Medical abortion through telemedicine above nine gw is associated with a higher rate of hospital visits for complaints in the days following the abortion compared to abortion at or below nine gw but not with a higher risk of heavy bleeding. It is associated with an increased risk of post-abortion treatment and intervention but not with a lower rate of satisfaction or met expectations.
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Sept. 14, 2018, 02:00
Objective: To analyze long-term satisfaction to intrauterine contraception after medical induced abortion.
Minimizing delay from medical abortion procedure to insertion of intrauterine contraception is a new approach to increase intrauterine contraception uptake and reduce subsequent unplanned pregnancies. Effect of this immediate insertion on womens satisfaction and quality of life is unknown. Materials and methods: Subanalysis of a randomized controlled trial. Total of 267 women were randomized to receive levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena, Bayer, Turku, Finland) immediately (?3 days) or later (2-4 weeks) after medical induced abortion during January, 2013 December, 2014 in Helsinki University Hospital, Finland. Selected demographic factors were collected. Women answered questionnaires concerning satisfaction and quality of life at follow-up visits three months and one year after LNG-IUS insertion. Results: Following three post-randomization exclusions, there were 264 participants. Of the immediate-insertion group 98/133 (73.7%) and the delayed-insertion group 78/131 (59.5%) women returned to the 3-month follow-up, and 89 (66.9%) and 63 (48.1%) to the 1-year follow-up. Median age was 27.8 (IQR 23.033.1) vs. 27.3 years (22.532.1), p=0.54. At 3-month visit the immediate-insertion group was more often satisfied or very satisfied with their contraception compared to the delayed-insertion group (89 [89.9%] vs. 61 [79.2], p=0.048). We found no difference at 1-year (71 [79.8%] vs. 47 [74.6%], p=0.45). Womens experienced health, as measured by visual analogical scale (0100 mm), at 3-month visit was 84 mm (median, IQR 77 91) vs. 87 mm (7795), p=0.19, and at 1-year visit 85 mm (7493) vs. 86 mm (7492), p=0.75. Conclusion: Immediate LNG-IUS insertion following medical abortion did not have a long-term effect on womens satisfaction with intrauterine contraception or experienced health. Loss-to-follow-up rate was high and may have produced a selection bias. However, these results endorse the feasibility of immediate initiation of intrauterine contraception following medial abortion. -
Sept. 15, 2018, 02:00
Objectives: In October 2017, The Scottish Government approved a patient’s place of residence as a place where treatment for abortion can occur. Women up to 9+6 weeks gestation, can be administered mifepristone in a medical facility and given misoprostol to take home and self-administer 24-48 hours later. The option of early medical abortion at home (EMAH) has been available in our service since April 2018. Following ultrasound assessment of gestation, women who are under 9 weeks are offered the options of EMAH, medical abortion in hospital or surgical abortion. We aim to identify any demographic characteristics which may determine if a woman is more likely to choose EMAH, as opposed to hospital management.
Methods: A prospective review of the records of all women who attend over 4 months from April to July, who are 9 weeks or less and choose medical abortion. To be eligible for EMAH they must live in Scotland, be 16 years or over, have an adult with them on the day of abortion, not require an interpreter and have no significant medical conditions. We will analyse demographic data for those who choose EMAH and those who have medical abortion in hospital.
Results: In the first four weeks of offering EMAH to eligible patients, 184 women have been less than 9 weeks gestation and chosen medical abortion. 92 of them were booked to have medical abortion in hospital, and 92 EMAH. Upon completion of data analysis for the first 4 months, we will present the proportion of women who wished medical abortion that were eligible for EMAH, the proportion who chose EMAH and any demographic differences that exist between those choosing home and hospital management.
Conclusions: We will determine if any demographic differences exist between women who opt for home or hospital management of medical abortion. -
Oct. 14, 2016, 02:00
FC06
Seeking clandestine abortion safely: Unwanted pregnancy and medical abortion among young women in Dar es Salaam
Ingrid H. Solheim1 ,2, Catherine Kalabuka3, Karen-Marie Moland1 ,2, Andrea B. Pembe4, Astrid Blystad1 ,2
1Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway, 2Centre for International Health, University of Bergen, Bergen, Norway, 3CSK Research Solutions, Dar es Salaam, Tanzania, 4Muhimbili University of Health and Associated Sciences, Dar es Salaam, TanzaniaObjective: The aim of this project was to enhance knowledge about the challenges faced by young women with unwanted pregnancies living in an urban, low-income settings where abortion is criminalised but assumed to be performed clandestinely with increasing off-label use of the recently registered drug misoprostol.
Methods: The study was explorative, involving the use of in-depth interviews with women ≤ 25 years having performed medical abortion (n = 15), postabortion care providers (n = 16) and pharmacy workers (n = 10) and informative interviews with different stakeholders (n = 15). Focus group discussions (FGDs) were performed with women from low-income areas and students ≤ 25 years (n of FGDs = 10).
Results: To induce abortion is viewed as a common practice by young women in Dar es Salaam. While hospitals are often considered the safest providers of abortion, misoprostol is viewed by many as the best method. Misoprostol is perceived to be more accessible, simple to use, private, cheap and less dangerous compared to surgical hospital procedures. Many health workers experience fewer and more manageable complications among their postabortion care patients related to misoprostol use for abortion. However, girls often view the procedure as a ‘matter of chancing'. Low drug doses are typically used, and there is little follow-up and lack of information from vendors concerning potential complications. Finally, even though ‘miso' is commonly known among young women, traditional methods are still the cheapest and therefore the only option for some.
Conclusion: In Dar es Salaam misoprostol can be accessed clandestinely for pregnancy termination through drug stores or health facilities offering different levels of safety and costs. For many young women this is the preferred abortion method but use, and especially safe use, is limited to those who can afford it. -
Oct. 14, 2016, 02:00
FC07
Efficacy of very early medical abortion
Isabella Bizjak1, Christian Fiala2, Helena Kopp Kallner1, Ingrid Sääv1, Kristina Gemzell-Danielsson1
1WHO CCR, Department of Women´s and Children´s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Stockholm, Sweden, 2GynMed Clinic, Vienna, AustriaBackground: In countries which have introduced medical abortion an increasing number of women present very early for their abortion. However due to limited data and fear of an adverse effect on a possible ectopic pregnancy many health care providers are reluctant to initiate the abortion treatment before an intrauterine pregnancy can be visualised and therefore tend to delay the treatment. This study was conducted to assess the effectiveness and safety of medical abortion in women with very early pregnancy (VEMA) and no confirmed intrauterine gestation (IUG).
Methods: Register based multicentree cohort study comparing women undergoing very early medical abortion (gestations ≤49 days) with or without a confirmed intrauterine pregnancy (i.e. yolk sac or foetal structure) at the initiation of the abortion treatment. 435 women without confirmed IUG were identified and compared with 870 controls with confirmed IUG, matched with regard to age, parity and date of initiation of abortion treatment.
Results: Women with no confirmed IUG were not more likely to experience VEMA failure (i.e. ongoing pregnancy or incomplete abortion) than those with gestations ≤49 days and confirmed IUG. Ectopic pregnancies (n=3) were diagnosed and treated without any serious adverse events.
Conclusion: VEMA failure is not more likely in women with very early pregnancy and no confirmed IUG on ultrasound than those with gestations ≤49 days and confirmed IUG. Hence our findings support that VEMA is both effective and safe for terminating pregnancies in women with no confirmed IUG. Women should, therefore, not be subject to unnecessary delay but should be offered medical abortion accordingly. -
Sept. 15, 2018, 02:00
Much attention is given to the alleged right of healthcare professionals to refuse treatment under the guise of “conscientious objection,” especially abortion. But what about those who conscientiously commit to providing this life-saving care despite stigma, obstacles, and legal risks? The organization Women Help Women believes in the ethical value of conscientious commitment to provide abortion care as a way to break the taboo around provision regardless of legal settings. WHW does this by equipping local activists and health workers to guide women through self-managed abortion in countries where abortion is illegal.
This presentation will share aspects of WHW’s unique partnership model, which is based on collaborative, participatory, feminist efforts to advance access and knowledge. WHW works horizontally, promotes local ownership of joint initiatives, and strengthens and develops capacities of local and regional movements. One example is WHW’s “Mobilizing Activists for Medical Abortion” network (MAMA), which operates in at least eight African countries.
MAMA expands community access to information and provides reproductive health training about misoprostol use and self-induction. In 2017, MAMA member organizations reached over 19,000 women with information and services.In Latin America, WHW collaborates with activists throughout the region, with a focus on Central America, Brazil, and Chile. The group helps local collectives launch and maintain new safe abortion hotlines, trains activists in counseling skills and medical abortion, and supports access to safe abortion via locally-led campaigns and awareness actions. For example, in Chile, the “Misoprostol for All” campaign used radio spots and street actions to promote information about the local safe abortion hotline and the use of misoprostol.
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Oct. 15, 2016, 11:00
FC16
Safety of medical abortion up to 10 weeks at home
Iolanda Ferreira, Filipa Coutinho, Manuel Fonseca, Elsa Vasco, Teresa Bombas, Maria Céu Almeida, Paulo Moura
Obstetrics Service A and B of Centro Hospitalar e Universitário de Coimbra, Coimbra, PortugalIntroduction: In Portugal, abortion by women's request is legal until 76 days of pregnancy. The rate of medical abortion is nearly 96% in the National Health System.
Objectives: Evaluate the safety of medical abortion at home before and after 9 weeks of pregnancy.
Methods: Retrospective evaluation of 6735 women (Group1-before 9 weeks; Group2-after 9 weeks), who attended our department between January 2007 and December 2015. For abortion the protocol used was mifepristone 200 mg and vaginal misoprostol 800 mcg after 48 hours. Statistical analysis was made using Independent T-test; Chi-Square and Mann-Whitney U test in SPSS 20.0.
Results: Medical abortion was an option in 98.8% (n= 6650) of cases; 56 (0.8%) at hospital and 6594 (99.2%) at home. Regarding abortion at home, the mean age was higher in group 1 (28.9 vs 28.3; p= 0.05).
According to national guidelines, an abortion is complete when there is no need for additional medical or surgical intervention. There was no difference in efficacy between groups (Group 1: 97.4% vs Group 2; 96.5%; p= 0.3). The most common side effect was pain, which was moderate (Group1: 34.3% vs Group2: 30.9%) intense (32.3% vs 38.2%) and maximal (11.6% vs 18.2%). Pain scores were significantly higher after 9 weeks of gestation (p= 0.04).
There were no differences between groups regarding complication rate (Group1: 7.9% vs Group 9.9%; p= 0.2). The most common complication was retained abortion (6.1% vs 6.5%); method failure (1.2% vs 1.6%); endometritis (0.2% vs 0.8%) and severe blood loss (1% vs 1%). The rate of admission to hospital due to complications did not differ between groups (3.7% vs 4.4%; p= 0.5).
Conclusion: Medical abortion is equally effective and was proven to be safe at home in both groups. The most common side effect was pain and it was significantly more intense after 9 weeks of gestation. -
Sept. 15, 2018, 11:00
Introduction: Increasing proportions of womenwho access abortion services in Europe choose to have an early medical abortion (EMA) (<= 9 weeks). Provision of quality information on EMA(medications, process, confirmation of success of the procedure and signs/symptoms after the procedurethatnecessitate medical review) is important. However, the quality of information provided to women on EMA may be variable and provider dependent. There is some evidence that audiovisual information (e.g. film or animation) can be an effective way of providing information about abortion. Objective To evaluate an audiovisual animation as a method of information provision on EMA for women seeking EMA in four European countries.
Method: We developed a short animation (3 mins) about EMA that summarises the key steps in theEMA process but is also adapted to reflect subtle differences in EMA practice and law in Scotland, France, Portugal and Sweden. Fifty women choosing EMA in each country (total 200 participants)will be randomisedto information provision on EMA delivered by the animation(n=35) versus a face-to-face consultation with a provider (n=15). Outcomes include information recall on EMA and womens acceptability of provision of information on EMA by the animation.
Results: The study is ongoing. Preliminary data (one country) indicate high levels of acceptability and utility of the animation and comparable levels of information recall to face to face consultations. Free text responses from women indicate that they feel positive about the diversity of female characters depicted in the animation.
Conclusion: Provisional data suggests that even a short audiovisual animation might adequately and acceptably deliver key information about EMA. If shown to be acceptable in the other countries, then this intervention could be used routinely to provide standardised and high quality information to women seeking EMA throughout Europe.