Speeches
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Oct. 24, 2008, 11:15
Physiological and reproductive outcomes
Michel Tournaire, Sophie Gaudu, Philippe Faucher (France)
Paris, France
m.tournaire@svp.aphp.fr
Surgical abortion. The influence of surgical abortion on subsequent reproductive outcome, reported for several decades in the literature can be summarized with seven criteria.
- Fertility. Four studies did not find an increased infertility after surgical abortion and one retrospective study showed a slight increase.
- Uterus. Synechiae have been diagnosed by hysteroscopy in 17 to 30% of the cases after curetage and 7.7% after suction.
- Miscarriage. In five studies from 1986 to 1998 the incidence of miscarriage after surgical abortion was not significantly increased. In a large series published in 2000 the risk of miscarriage was increased if the interval between abortion and the following pregnancy was lower than three months.
- Ectopic pregnancy. In seven studies no association was found between past history of surgical abortion and ectopic pregnancy, but two studies found such an association.
- Placental abnormalities. In nine studies there was an inceased risk of placenta praevia (OR 1.7 in a metaanalysis) after curetage but not after suction. The frequency of placenta accreta was not higher in two studies.
- Prematurity. In a metaanalysis published in 2003 twelve studies found a higher riskof prematurity (OR 1.3 to 2). In seven studies the risk increased with the number of previous surgical abortions. Eight found an increased risk for severe prematurity (<32w). However in the two most recent studies there was no augmentation of prematurity.
- Preeclampsia. In a majority of studies the ratio of pre eclampsia after induced abortion was reduced but only with women conceiving again with the same partner.
Medical abortion. Despite the increasing proportion of abortion by means of medication, limited information is available regarding the effects of this procedure on subsequent pregnancies.
A recent (2008) metaanalysis including eight studies on reproductive outcome compared the influence of medical and surgical abortion. The incidence of miscarriage and post partum hemorrage was significantly lower for the pregnancy immediatly following a medical abortion. No other significant difference was found.
For the outcome of the future pregnancies, medical abortion may thus be safer than the surgical option.
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Oct. 22, 2010, 08:00
Pilot project: potential for midwives to manage medical abortions independently
Anneli Pehrsson and Pia Karlsson, Licensed Midwives; Karolinska University Hospital, Sweden
Background: According to rules issued by Sweden’s National Board of Health and Welfare, Advice on Abortions 2004: Section 4; Chapter 2, when a woman has made the decision to have an abortion it should be carried out at the earliest possible time.
Our previous routines could not adequately address the waiting times for the required ultrasound examination by physicians. Not every woman who had contacted the clinic <9 weeks gestation could be offered medical abortion. Hence, a project was initiated to train two midwives in transvaginal ultrasonography.
In 2007, the National Board of Health and Welfare decided to make the regulatory changes necessary to broaden the authority of midwives in this context.
Aims: - To train and certify midwives to independently manage medical abortions, perform dating scans by transvaginal ultrasonography, and prescribe mifepristone and misoprostol.
- To provide women with rapid and effective care.
- To be able to offer a medical abortion to any healthy woman <9 weeks gestation.
- To ensure continuity, i.e. the woman meets one and the same person during the entire abortion process.
Methods: - Auscultation/training in transvaginal ultrasonography, at IVF clinic.
- Individual training and supervision in ultrasonography, Center for Fetal Medicine.
- Individual training and supervision in transvaginal ultrasonography, by Prof. Seth Granberg.
- Transvaginal ultrasonography with the department’s gynecologists. Images were reviewed, commented on, and approved by Prof. Seth Granberg. Accompanied by theoretical studies.
- Ten cases of abortion counseling with ultrasound examinations, supervised by C. Rasmussen (Section Chief at the time).
Results: - For the past 2 years we have performed transvaginal ultrasonography in healthy women early in pregnancy. We have been delegated authority to prescribe mifepristone and misoprostol, to prescribe contraceptives, and to deliver patient care encompassing the abortion itself and follow-up visits.
- We have shortened the waiting times at the clinic; freed time for physician appointments; increased the number of medical abortions; and reduced the demand on surgical time and recovery unit beds.
- We can offer medical abortion to all healthy women who request it, and most can begin the abortion with the first visit.
Conclusions: - Midwives with adequate education have the capability to independently manage healthy women requesting an abortion early in pregnancy. Usually the problems are more of a psychosocial than medical nature. The abortion is not the problem, but often the solution to the woman’s problem.
- In the past 2 years we have become proficient in performing and assessing ultrasonography and detecting anomalies, whereupon we contact the attending physician.
It is important for midwives and physicians to collaborate in the care of these women. It must not become a matter of prestige.
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Oct. 22, 2010, 02:00
Post-abortal infection - prevention strategics
Dr. Sharon Cameron, United Kingdom
The reported incidence of post -abortal infection (in countries where abortion is legal ranges from 1% to10%, depending on the population, diagnostic criteria used to define infection, use of peri-abortal antibiotics and the method used. Prospective comparative studies have suggested that medical abortion may be associated with an overall lower risk of infection, possibly because it is less invasive procedure. The presence of chlamydia, gonorrhoea or bacterial vaginosis in the lower genital tract at the time of abortion has been shown to be associated with an increased risk of post-abortal infection. Strategies for preventing post- abortal infection include (i) a screen-and-treat policy (ii) universal antibiotic prophylaxis or (iii) a combined approach, of both screening and prophylaxis. Meta-analysis of randomised trials have shown that antibiotic prophylaxis at the time of abortion is associated with a reduction in the risk of subsequent infection of around 50%. Furthermore, antibiotic prophylaxis has been shown to benefit women who have negative pre abortion genital swabs and is less costly than the other strategies. However, failure to test for sexually transmitted infections pre-abortion and to identify infected women, perpetuates the risk of re-infection by an infected partner. This is important since it is believed that re-infection with chlamydia may increase the likelihood of complications such as tubal infertility.
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Oct. 23, 2010, 11:00
Post-abortion contraception
Gabriele Susanne Merki-Feld, MD, PhD, Universtiy Hospital, Zürich, Switzerland
Contraceptive counseling is an important part of postabortion care and should include accurate and comprehensive information about different contraceptive options. Surprisingly not all studies provide evidence for a higher acceptance and lower rate of repeat abortions in women after extensive postabortion counseling. Other studies investigate preabortion counseling in comparison to postabortion counseling.
Today most abortions are performed with medical procedures. Use of combined contraceptive pills is recommended to start already on day 3 of abortion ( day of misoprostol administration). After abortion 80% of all women ovulate before the first menstrual period and many of them ovulate within 22 days. Thus providing the pill before leaving the hospital is of importance. Immediate IUD insertion after surgical abortion is effective and safe, even if some studies suggest a slightly increased rate of partial or complete expulsions. Since medical abortion takes longer than surgical abortion, IUD insertion is recommended during the first menstrual cycle after medical abortion. This procedure is of course associated with a small risk for another pregnancy. Progestagen-only methods can be started immediately after medical abortion. The implant in an important alternative for women with desire for longterm contraception.
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Oct. 19, 2012, 11:30
Post-abortion contraception:
start immediately
Contraceptive failure - unprotected sex or failure
in use of the chosen contraceptive method or use
of an ineffective method - leads to unintended
pregnancy. Most women choose abortion in this
situation. Avoiding the same incident in future, that is
reducing the risk of repeat abortion, is in the interest
of the woman and also the society both medically,
psychologically, socially and economically. Including
contraceptive counselling in post-abortion care is
important and emphasized also in recent guidelines
(WHO, RCOG). However, counselling itself has not
been shown to have a beneficial long-term effect on
contraceptive use and risk of repeat abortion.
Recovery of ovarian function after abortion is
rapid, ovulation occurs within the first month after
abortion in most women. Thus contraception
should be started as early as possible after
abortion. Immediate start of both hormonal
(pill, patch, ring) and also long-acting reversible
(LARC) methods (implant, injection, intrauterine
contraception) is recommended in the above
mentioned guidelines. After medical abortion
LARC using implants, injections can be started on
the day of abortion, intrauterine contraception as
soon as an on-going pregnancy is excluded. There
is evidence that if after abortion a LARC method
is chosen, the risk of repeat abortion is reduced.
Well-functioning, easy-access contraceptive
services are important in the follow-up. -
Sept. 10, 2004, 09:00
Christian Fiala (A)
Easy access to safe and effective contraception as well as to legal and safe abortion – both free of charge for those in financial need: no other intervention in human history has had a similarly strong effect in improving women’s health and survival. But it is not women alone who profit from this cultural achievement: men too feel the positive impact of a better health of their mother, sister, partner or daughter. Not to talk about children who need their mother. And even society as a whole is benefiting from improved health status of women. It is safe to say that we would never have reached the high standard of living we currently enjoy, if half of the population would still be at serious risk of health and even life.
We have succeeded in making most of Europe a safe place for women. But there is still a lot to do. A few countries still have no legal access to voluntary abortion: Ireland, Nothern Ireland, Portugal, Malta and Poland. But even in those countries which have a provision for legal access, an unacceptable number of various obstacles do exist resulting in an unnecessary delay in access to abortion. And there is even a high number of women in Europe who have no access to medical abortion, 15 years after it’s first marketing in France.
Looking beyond Europe, most parts of the world still stick to medieval European laws on reproductive health. These laws had been introduced by the former colonial powers and have not been changed so far. Consequently women in their daily life run a high risk for the terrible consequences of illegal abortion, including death.
It is in this context that the association of FIAPAC has been founded, following the congress “Abortion Matters” in Amsterdam in 1995. During this congress it became obvious how much there is to do to overcome the prevailing barriers in access to contraception and abortion and to guarantee a standard of care in “reproductive health”. A few professionals working in the field, recognised the urgent need for regular meetings on this topic. The association was founded thanks to their engagement. Since, 5 congresses have been organised with an increasing number of participants.
This conference would not have been possible without the engagement and support of many dedicated individuals. The FIAPAC board which has already organised 5 other conferences, has planned since two years. Very important, the team of our clinic which has calmly managed the additional workload while continuing to run the clinic and being dedicated to every single patient. These are mainly Barbara Laschalt, Leila Akinyemi and Margot Schaschl. Some of you may remember being in contact with Florian Hahn who has done all the registrations with admirable patience. Finally I would like to thank the friendly staff of the technical University.
Nobody is perfect although all of us have tried to come as close as possible. But some mistakes may have occurred during the preparation of the congress and some are probably going to occur during these 2 days. May I kindly ask you for you to forgive us and please let us know or note them on the evaluation form.
My special thanks go to the pharmaceutical companies who understand that our patients need a reliable and safe contraception after the abortion. It is my hope that more contraceptive producers will be present at the next congress.
There are some special events I would like to briefly mention:
We are working very hard to open a museum of contraception and abortion. It will be located very centrally in Vienna. Furthermore all items will be displayed on the website, together with old books. Unfortunately we did not succeed to open the museum until this congress. But we brought 4 panels displaying a small part of what the museum will be. You may have a look in the entrance hall.
I would like to take the opportunity to kindly ask you to donate or let us any historic objects or publication.
There is a list of films dealing with abortion, which will be displayed during these days. They cover a long range of time from 1929 to a new one about the impact of the policy by President Bush. The films are very touching and make clear why we engage in this field. Please find the films on the separate program. It has not been easy to bring together all these films together. Therefore a website abortionfilms.org will soon be online with a list of different films dealing with abortion. Please let us know in case you know of any other important film on abortion.
There is the training model for vaginal ultrasound during early pregnancy and medical abortion. We have worked hard to finalise in time and you may be able to try it during the congress for a small fee. This is a new device allowing training without a patient. This system is routinely used in Germany since some time, but it can be used for training for medical abortion and early pregnancy. Tomorrow there is also a presentation about this device.
Concerning the program, one small mistake has made it in the final version. Please note that tomorrow we will start at 14 00 and not at 14 30 as stated in the printed program.
Before giving the word to the next speaker I would like to make a short remark on the role of men in this debate.
As we all know, men cannot become pregnant nor can they have an abortion. Preserving the reproductive health of women is nevertheless in our very own interest and we directly feel the consequences.
It is therefore our duty to ensure a legal framework and easy access to standard of care abortion services so that women, who after all got pregnant by us, can terminate an unwanted pregnancy without unnecessary delay and suffering.
To further improve women’s health has been the motivation for all of us to come together. We are looking forward to exchange experiences, listen to each other, learn from each other and find ways to further improve the standard of care of our patients or clients. The success of the congress depends mainly on your engagement. We have been careful in the planning to let enough time for “networking” between the presentations. I hope we will use this opportunity and make these two days an occasion worth to remember.
Please let me underline how much we appreciate the support, moral and financial of the city of Vienna. Reproductive health is not an empty word in this city, as shown by the impressive engagement in this field. I am therefore very happy to announce Sybille Straubinger, member of the local parliament who is representing the city
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Sept. 14, 2018, 01:00
Progress in medical abortion in Thailand
Kamheang Chaturachinda, WHRRF, Thailand
Prior to 2002 Misoprostol was freely available over- the- counter in Thailand at a cost of US 40 cents each. In 2002 the Ministry of Health had the first ever female Minister. She was from an ultra- conservative religious right political party (Palang Dhama Party). This party viewed abortion as immoral and sinful. Misoprostol was therefore put on the restricted drug list that needed to be prescribed only in hospital by a physician. The cost of the tablet in the market rocketed from 13 Bahts (40 US cents) up to 2,500 Bahts (70 USD ) and even to 5,000 Bahts (160 USD ) per tablet. A combination of Mifepristone 200 mg and Misoprostol 800 microgram package (commercial name MEDABON) was introduced in to Thailand in 2009 by the Concept Foundation. This was first introduced in to 3 leading medical schools in Bangkok(and later in to Provincial medical schools) as a research project. The second phase research of the efficacy and effectiveness of MEDABON was launched by WHO and our Foundation (WHRRF) at Ramathibodi hospital in Bangkok in 2010. After the publication of this study, we vigorously pushed for the registration of the drugs in Thailand as well as listing in the essential drug list (EDL). Listing in EDL allows the National Health Security Office (NHSO) to obtain the drugs for use in the Women’s Reproductive Health Entitlement Package at a reduced price. Registration was successful in 2014 . And listing in EDL in 2016. Medabon is now bought by the NHSO at a reduced price for distribution and use in the Women’s Reproductive Health Entitlement Package free of charge (market price 500 B./package: NHSO price 230 B./package). Even though Medabon is registered for use to terminate pregnancy, Safe Abortion is still not universal available to women in Thailand. The main reason for inaccessibility of women in Thailand to medical termination of pregnancy is the negative attitude of the healthcare providers. WHRRF together with the Royal Thai College of Obstetricians and Gynaecologists are trying to overcome this obstacle by education and training.Progress in medical abortion in Thailand
Kamheang Chaturachinda, WHRRF, Thailand
Prior to 2002 Misoprostol was freely available over- the- counter in Thailand at a cost of US 40 cents each. In 2002 the Ministry of Health had the first ever female Minister. She was from an ultra- conservative religious right political party (Palang Dhama Party). This party viewed abortion as immoral and sinful. Misoprostol was therefore put on the restricted drug list that needed to be prescribed only in hospital by a physician. The cost of the tablet in the market rocketed from 13 Bahts (40 US cents) up to 2,500 Bahts (70 USD ) and even to 5,000 Bahts (160 USD ) per tablet. A combination of Mifepristone 200 mg and Misoprostol 800 microgram package (commercial name MEDABON) was introduced in to Thailand in 2009 by the Concept Foundation. This was first introduced in to 3 leading medical schools in Bangkok(and later in to Provincial medical schools) as a research project. The second phase research of the efficacy and effectiveness of MEDABON was launched by WHO and our Foundation (WHRRF) at Ramathibodi hospital in Bangkok in 2010. After the publication of this study, we vigorously pushed for the registration of the drugs in Thailand as well as listing in the essential drug list (EDL). Listing in EDL allows the National Health Security Office (NHSO) to obtain the drugs for use in the Women’s Reproductive Health Entitlement Package at a reduced price. Registration was successful in 2014 . And listing in EDL in 2016. Medabon is now bought by the NHSO at a reduced price for distribution and use in the Women’s Reproductive Health Entitlement Package free of charge (market price 500 B./package: NHSO price 230 B./package). Even though Medabon is registered for use to terminate pregnancy, Safe Abortion is still not universal available to women in Thailand. The main reason for inaccessibility of women in Thailand to medical termination of pregnancy is the negative attitude of the healthcare providers. WHRRF together with the Royal Thai College of Obstetricians and Gynaecologists are trying to overcome this obstacle by education and training.
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Sept. 10, 2004, 11:30
Providing safe surgical and medical abortion services in low-resource and legally restricted environments: The Latin American Abortion Provide Network
Dee Redwine, MPH, regional Director for Latin America and the Caribbean, Planned Parenthood Federation of America- International, PPFA-I
Heather Blank, associate Regional Director for Latin America and the Caribbean,PPFA-I
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In Latin America and the Caribbean, Planned Parenthood Federation of America-International (PPFA-I) focuses on establishing and strengthening safe abortion services through partnerships with women’s organizations that advance sexual and reproductive rights and health services. Many of these agencies in Latin America and the Caribbean suffer from a sense of isolation, as they provide life-saving services under severely restricted legal circumstances, in politically difficult and dangerous situations.
Unsafe abortion in Latin America and the Caribbean can be described as nothing less than a public health crisis. The correlation between access to safe, legal abortion and maternal mortality in the region is shocking: approximately 20 percent of maternal deaths in Latin America and the Caribbean are due to unsafe abortion, a higher proportion than in any other region of the world. In 1995 there were 4.2 million abortions in Latin America and the Caribbean region, 4 million of which were illegal. Except for Eastern Europe, Latin America has the highest global abortion rate (37 abortions per 1,000 women aged 15-44) and abortion ratio (27 abortions per 100 pregnancies) (AGI, 1999).
The average Latin American woman is likely to have at least one abortion in her lifetime, with women in some countries, such as Peru (AGI, 1999), having an average of nearly two abortions. Since the vast majority of these procedures are performed illegally and most likely under unsafe conditions, women are taking enormous risks to prevent unwanted childbearing. This situation results in approximately 800,000 hospitalizations per year in the region.
Access to safe abortion services is critical to preventing maternal mortality and morbidity. In developing countries, regardless of the legal status of abortion, it is poor women in rural areas and poor young women who are most at risk of undergoing unsafe abortion, and most likely to die. However, in various Latin American countries, there are a growing number of health care providers who are committed to combating this trend. In areas where women are most likely to die from an unsafe abortion, client-centered sexual and reproductive clinical services must be provided for poor and marginalized women – the very ones who are most likely to face an unwanted pregnancy, seek out an untrained provider, and most likely to suffer severe consequences.
The reproductive health provider network supported and facilitated by PPFA-International is a forum to link these providers in a mutually constructive and supportive way, in order to regularly exchange ideas and expertise. They represent 8 different Latin American countries.
All of these providers offer life-saving services under extremely difficult circumstances, in both geographic and legal terms. From the rural areas to the rapidly expanding urban slums, these providers offer high-quality health services to those most in need. The network offers a forum in which critical mutual support can be lent to those working in this harsh environment as well as an opportunity for the exchange of information and expertise.
The specific goal of the network is to strengthen and expand sexual and reproductive rights through improved and increased access to services coupled with advocacy efforts in countries where the political and social climate is very restrictive. In order to reach this goal, the network facilitates the professional support needed by local groups working to reduce restrictions on abortion and improves services where they exist, as well as increases the sense of solidarity among service providers in the region.
Furthermore, the group is working to increase access to medical abortion throughout the region through the integration of a misoprostol-only regimen of early first trimester medical abortion. This is being piloted in order to decrease the consequences of unsafe abortion, and create alternative pathways for women to access safe abortion.
Throughout Latin America, misoprostol is cheap, easily accessible, and badly mis-used. From physicians to pharmacists, off-label use of misoprostol for pregnancy termination is increasingly common. Misoprostol has been shown to have a high rate of efficacy for abortion, but it must be used with the correct dosages, within certain gestational age ranges, and with clear instructions for follow up for the woman in order to be successfully used. Even so, given the severe legal restrictions on abortion in the region, a widely disseminated protocol for misoprostol, either for clinic- or home-based use, could radically change not only how abortion is viewed, but also prevent women from resorting to other invasive, highly dangerous forms of abortion.
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Oct. 2, 2014, 12:00
Psychological adjustment following induced abortion for fetal abnormality
Lucija Pavse1, Vislava Globevnik Velikonja1, Robert Masten2, Nataša Tul-Mandić1 1University Medical Centre Ljubljana, Gynaecological clinic, Ljubljana, Slovenia, 2University of Ljubljana, Faculty of Arts, Psychology Department, Ljubljana, Slovenia - lucija.vidmar@gmail.com
The purpose of this study was to explore the ways in which bereaved women perceive and cope with induced abortion for fetal abnormality. We examined the relative impact of major variables for predicting adjustment (in terms of depression, anxiety and grief) among bereaved women. 108 bereaved women who had had an induced abortion for fetal abnormality completed standardized self-report questionnaires measuring depression (Beck Depression Inventory–Short Form; BDI-SF), anxiety (State- Trait Anxiety Inventory; STAI-X1) and grief (Munich Grief Scale; MGS). More educated women had lower levels of depression and anxiety and felt less guilty. Women with more remaining children were more anxious. Women who had induced abortion at a higher gestation of pregnancy had higher levels of sadness and anger. Women with two or more induced or spontaneous abortions had higher levels of anger. These findings increase the understanding of the impact of factors associated with bereavement outcome following induced abortion for fetal abnormality. On that basis adequate intervention strategies should be established to identify and help mothers at high risk of poor psychological adjustment following perinatal loss.