Speeches
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Sept. 11, 2004, 02:00
Psychological aspects of second trimester abortions for medical indications
Chantal Birman (F)
The Midwife’s Role in Helping Parents Through a Termination of Pregnancy
Before dealing with the subject proper, I feel I should describe briefly the situation in France.
Ultrasound was introduced in 1974. Early in the eighties the complete system for prenatal diagnosis was put in place. Over the same period, we learned how to extend the term of pathological pregnancies. Concurrently, progress in the management of prematurity helped these neonates to survive.
Currently, fewer than 20% of terminations are performed under the provisions of the 1975 Act that allows such procedures where the mother’s health is at risk. Some 80% are carried out for foetal indications. Indications for terminations on medical grounds involve 1% of all births. The number of such terminations due to foetal abnormalities went from 1 in 400 births en 1981/83 to 1% in 1989/90. Down’s syndrome represents 50% of all anomalies found and 90% of these pregnancies are terminated. However, 30% of abnormalities escape antepartum detection (references: « Faire vivre et laisser mourir » by Dominique Memmi who recompiled data taken from the degree in social anthropology done by M. Piejus).
The reason I have given these figures is to show that we midwives, whose role is to see mothers through their confinement, are confronted regularly, though not daily, with terminations of pregnancies for medical reasons.
Over one year, these terminations involve few tours of duty and, for me, seldom number more than 5. At the Maternité des Lilas, where I work, two midwives are on duty and I always volunteer unless my colleague has managed the woman before I begin my shift. The terminations are performed in the delivery room, between normal births.
It has been my experience that the vast majority of these procedures are done in the second three months of the pregnancy, rarely in the last three months.
In France, we induce labour by the well-known Mifegine/Misoprostol[2] protocol. Analgesia is induced in two phases:
1° Fentanyl perfusion with the flow rate adjusted to the requirement of the woman;
2° epidural analgesia when required.
It should be noted that conversely to the appeals of their partners and the opinions of the medical team, most women (of course not all of them) are less inclined to ask for immediate pain relief. For some of them, pain is a physical support for their intangible – because incomprehensible –torment caused by the anomaly.
We midwives also are reminded by the painful contractions that this child, just like those of the other women giving birth, has become incarnate within this body and will soon be born dead or alive.
While French legislation allows terminations on medical grounds, it outlaws infanticide. Application varies from one facility to another.
The couple will not get the child of their dreams.
The couple give birth to a dead baby.
But the thing is that this child is abnormal; that is, a monster. Remember that monster derives from the Latin [from Old French monstre, from Latin monstrum (portent), from mon‘re (to warn)] and the term conveys at once the idea of foreboding and demonstrating or showing. Indeed the anomaly is only realised once it is revealed by the scrutiny of the ultrasonographer or the geneticist.
The parents break both their lineages of normal children and register forever the anomaly in both families. Through this deed, for which they are not responsible, they actualise their monstrous parenthood and can bestow affection on the child they have borne.
The voice of the midwife points out that the woman giving birth in the next room to a normal baby cannot be blamed for that normality. The voids between us are made of all these unanswered questions, and the unwinnable revolt against utterly unjust circumstance.
Right then, the parents also want to vanish with their baby; yet they already know full well that the time afterwards is to come, that in it they will be survivors, and that life goes on.
You have to be mad to go through pregnancy terminations however much - or little - involved you may be. For my part, I feel that the most fragile, because at once the most vulnerable, without being able to incorporate his grief is the father. It takes modesty to help him through. Often, I try to come to their aid through their wives, explaining to the women what is about to happen. In fact, the women have an inkling of what is to come; but not the men. Such indirect assistance helps the father realise that there are limits and that the madness in which he is entangled will come to an end.
Strangely, the process of cervical dilation mimics the abnormality. Instead of being steady and predictable, as with the delivery of a normal child, the cervix remains hard, almost entirely effaced, only just patent, with a presentation bulging behind it. Suddenly, and quite unpredictably, the cervix opens and the foetus proceeds into the vagina, or is even expelled.
Often, to shield the woman from the sounds of neighbouring births, her transfer to the delivery room is delayed. Hence, so that they will know what to expect, the couple must be informed that the birth may occur in the patient’s room. Quiet, cool-headed efficiency of the team appears to be the prime requirement to ensure the smooth progress, both technical and psychological, of these births.
If necessary, once the foetus is born there is time to take the woman to the delivery room, for the placental birth and a uterine exploration. However, expulsion of the foetus on the stretcher is always upsetting to both parents and care providers.
In conclusion, to help people through a termination of pregnancy is to weave mortality with monstrosity. This takes us to the borderline of humanity. You don’t know whether you come through it a better person or a destroyed one. One thing is sure: afterwards, it’s my skin (organ delineating the inside from the outside) that I determinedly scrub under the shower. I have long kept quiet about this cleansing, that I believed private; but my colleagues also feel this need. Now I know why that ablution belongs in traditional and religious rituals surrounding death.
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Sept. 10, 2004, 11:30
Psychosocial background factors and mental health-consequences of
induced abortion in Austrian women[1]
Erika Baldaszti and Beate Wimmer-Puchinger
Ludwig Boltzmann Institute for Women’s Health Research, Vienna, Austria
Objective:The aim of this study was to gain knowledge about the role of psychosocial conditions, contraceptive use, partnership and sexuality in the decision-making process about unplanned pregnancies of Austrian women seeking abortion. Furthermore aspects of choosing medical or surgical abortion and the prevalence of post-abortion depression are addressed.
Materials and methods:350 women who underwent surgical abortion and 227 women choosing medical abortion answered a questionnaire after abortion; as controls 400 women continuing pregnancy answered after week 12 of gestation. A follow-up questionnaire was administered three months after abortion.
Results:Women who decided to terminate pregnancy were found to have more often instable partnerships. At the time of conception 40% of women undergoing an abortion had not used any contraceptive method, of those who did, 50% had used condoms; dissatisfaction with contraception was high. Comparing the medical to the surgical method of abortion satisfaction of women with both procedures is high. Depression score assessed by means of HAD Depression Scale was not increased at time of abortion or three months after. At time of abortion half the participants felt sure about their decision for termination of pregancy, three months after abortion two thirds of the women had the feeling that the decision for abortion was right.
Conclusions:Once more our results indicate that prevention of abortions is a matter of making contraceptives more accepted and easily obtainable for all groups in society. All women surveyed in this study decided to terminate pregnancy after a thoroughly reflexion about the basic conditions of their life. This can be seen as the main reason that mental health consequences after abortion like feelings of guilt, fear or depression were within a normal range.
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Nov. 25, 2000, 04:00
The law on abortion has been deleted in 1988. Since, there is no law governing
abortion. The procedure is therefore subject to an agreement between the women and her doctor, as with any other medical treatment. The availability of
terminations depends on the good will of the doctors. There are 30,000
terminations in Quebec; 125.000 for the whole of Canada. -
Oct. 14, 2006, 11:00
Recent developments
Kristina Gemzell MD, PhD, Professor
Dept. of OB/Gyn, Karolinska University Hospital/Institutet, Stockholm, Sweden
Medical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined
with a prostaglandin has been available in Europe since 1988 for termination of pregnancy
up to 49 days of amenorrhea. In the UK (1991), Sweden (1992) and later on Norway the
method is approved up to 63 days of amenorrhea. Further development of the method will
be discussed in the workshop and include reduced doses of mifepristone, research on the
optimal type, dose and route of administration of the prostaglandin analogue and reduced
treatment intervals. Furthermore home-use of misoprostol allows women more flexibility,
privacy and control in their abortions. More recently medical abortion has also become
increasingly used in the interval 9 to 13 weeks as well as for midtrimester terminations with
an increased need to optimise pain management.
Anti-D immune globulin is given in most places after early abortion, although evidence is
lacking for the need of this intervention. As a result of the lack of evidence-based data, a
high number of women are receiving foreign immune globulins based on a questionable
indication. Furthermore this practice increases the costs of induced abortion. The need for
studies to clarify the indication of RH-prophylaxis is obvious especially when it comes to
medical abortion.
The generally accepted obligation in medicine to offer every patient the best evidence
based care should also apply to women with an unwanted pregnancy. An increasing
number of women in Europe now opt for medical instead of surgical abortion. A shift which
is expected to continue during the next year’s world-wide.
The need for more research to further improve the procedure, reduce side effects and
facilitate access is obvious. -
Oct. 2, 2014, 12:00
Regarding medical abortions at the Gynaecological Clinic in Majorna
Monika Axelsson Närhälsan Västra Götaland, Gothenburg, Sweden - monika.axelsson@vgregion.se
We started the office with the idea of facilitating so-called early medical abortions that are terminated at home. After contact with and visits from the The National Board of Health and Welfare, in addition to hard work on routines and quality as well as medical safety, we finally managed to get the permit to open our doors. To summarize the results from the survey, the information given corresponds with the patients´ expectations. The patient receives sufficient analgesics to take home which is crucial. Measuring the level of pain is difficult but I have used a scale without numbers that goes from no pain to severe pain and most fall in the middle of the scale. 37% have chosen the lower end of the scale, meaning less pain, while 42% have chosen the higher end of the scale. 17% chose the middle of the scale. 82% thought they had received enough analgesics. 7% asked for emergency care during 4 weeks following the procedure due to bleeding, dizziness, pain, and so on. An interesting finding was the choice of contraception, where most patients have chosen combined birth control pills (32%) or no protection (22%). The conclusion is that we offer a good service at the gynaecology clinic in Majorna to women that wish to carry out an abortion. What could be explored further, and should be discussed, is the fact that such a high percentage of the women chose to use no contraception after abortion. One solution could be to offer an additional follow-up visit later on. However, important is to be able to offer abortions that are as good and safe as possible.
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Oct. 20, 2012, 02:00
Regional differences in surgical intervention
following medical termination of pregnancy
provided by telemedicine
Gomperts, R1,2; Jelinska, K1,2; Sabine, S1,2;
Gemzell-Danielsson, K1,2; Kleiverda, G1,2
1 Women on Waves; 2 Department of Obstetrics and Gynaecology,
Karolinska Institutet, Stockholm, Sweden
Objective: Analysis of factors influencing surgical intervention
rate after home medical termination of pregnancy (TOP) by
women in countries without access to safe services using the
telemedical service ‘Women on Web’.
Design: Cohort study.
Setting: Women with an unwanted pregnancy <9 weeks pregnant
who used the telemedicine service of Women on Web between
February 2007 and September 2008 and provided follow-up
information.
Sample: Women who used medical TOP with a known follow up.
Methods: Information from the online consultation, follow-up
form and emails was used to analyse the outcome of the TOP.
Main Outcome Measures: Ongoing pregnancy, reason for surgical
intervention, perceived complications and satisfaction.
Results: Of the 2323 women who did the medical TOP and had
no ongoing pregnancy, 289 (12.4%) received a surgical
intervention. High rates were found in Eastern Europe (14.8%),
Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in
Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%;
P = 0.000). More interventions occurred with longer gestational
age (P = 0.000). Women without a surgical intervention more
frequently reported satisfaction with the treatment (P = 0.000).
Conclusions: The large regional differences in the rates of
reported surgical interventions after medical TOP provided by
telemedicine cannot be explained by demographic factors or
differences in gestational length. It is likely that these differences
reflect different clinical practice and local guidelines on
(incomplete) abortion rather than complications that genuinely
needed surgical intervention. Surgical interventions significantly
influenced womens’ views on the acceptability of the TOP. -
Sept. 15, 2018, 01:00
Majority of research about the protective and risk factors of repeated teenage pregnancy has been carried out in the US. Worldwide, there is more information available about subsequent adolescent deliveries than abortions. The main reason here is that the availability and quality of abortion statistics vary largely in countries. In many countries with restrictive laws abortion statistics hardly exist. Estonia is considered to be a country with liberal legislation and complete abortion data since 1992. From the same period, after regaining independence from Soviet occupation in 1991, Estonia has undergone major socio-economic changes including profound educational and health care reforms. According to the World Bank Analytical Classification of countries Estonia has turned from upper/lower income country in 1990-ies to high-income country since 2006.
The objective of this presentation is to analyze trends in adolescent pregnancies in Estonia from 1992 until 2017 and the proportion of repeated pregnancies from 1996 until 2017.
Methods. Data on abortions were obtained from the Estonian Medical Statistical Bureau (1992–1995) and the Estonian Abortion Registry (EAR, 1996–2017).
The completion and return of an anonymous record card to the EAR for each abortion is obligatory for every institution licensed to perform pregnancy terminations. Data about births were obtained from the Estonian Medical Birth Registry, which was established in 1992. The number of women in the 15–19-year age group was obtained from the Statistical Office of Estonia.
Results. The percentage of teenage mothers from all parturients was 14.6% in 1992 and 2.0% in 2017, the proportion of adolescents from all women terminating pregnancy was 11.4% in 1992 and 7.2% in 2017. During the same period teenage abortion and fertility rates have decreased 81.7% and 79.8% respectively. In 1996–2017 the average proportion of teenage abortion patients with repeat abortion has been 18%, over the years no clear increasing or decreasing trend can be observed (lowest 15.8% in 2005 and highest 22.3% in 1996), the same is true concerning delivery before the index abortion (average 16.1%, lowest 13.0% in 2015 and highest 20.4% in 1996). In average, 8.4% of teenagers were multipara during 1996–2017 (lowest proportion - 6.0% - in 2005 and highest in 2015 - 11.8%).
Conclusions. During the period of remarkable changes in the Estonian society and economic growth teenage fertility and abortion rates have decreased substantially and become a rather rare event. During the study period a little less than one fifth of teenage abortion patients have experienced previous delivery or abortion, around one tenth of teenage parturients are multipara. Thus the proportion of repeated pregnancies among adolescents has remained the same. -
Oct. 22, 2010, 02:00
Title: The experience of use of medical abortion for HIV-infected women at home in Ukraine
Posokhova Svitlana
ABSTRACT TEXT
Women with HIV have a right to decide about their reproductive choice. There is no reason why HIV positive women cannot use medical abortion. HIV positive women may be at higher risk of reproductive tract infections from retained products of conception, but this may occur with medical or surgical abortion.
The aim of our study was to assess the efficacy and acceptability of home administration of misoprostol for early medical abortion up to 63 days of amenorrhoea for HIV-infected women.
Methods. This case-control study included 68 cases of medical abortion in HIV-infected women who did not receive antiretroviral therapy. About 20% of women lived in the rural regions. Among of them 10 (14.7%) of women had previous cesarean sections Medical abortion was used the first time in 89.7% of women, the second time – 8.9%, the third time – 1.4%. About 2% of women came back to the hospital after misoprostol because they were worried (25% of them had previous cesarean section).
Results. The method was effective in 95.5% of cases. Three failures (4.5%) were recorded which included incomplete abortion (1.5% of cases), heavy bleeding (1.5% of cases), continuing pregnancy (1.5% of cases). In case of complications we performed vacuum-aspiration. We did not have cases of serious infections after medical abortions. The complete abortion has occurred after taken of misoprostol in the first 3 hours in 46.9% of cases, after 6-9 hours – in 49.4% of women, at the third day – in 2.6% of women and at the fifth day – in 1% of women.
Conclusion
Our study shows very high results of success and minimal complications of medical abortions in HIV-infected women at home (95.5% of cases). More than 80% of women were satisfied. Our data suggest that the use medical abortion at home is the safe effective alternative to surgical abortions for all women.
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Oct. 23, 2010, 02:00
Results from a 4-year study on 15447 medical abortions performed by privately-practicing general practitioners and gynecologists in France
Sophie Gaudu, Hôpital Cochin-Saint Vincent de Paul, Centre d’orthogénie et de planification familiale
Co-authors: Drs I. Dagousset, L. Esterle, S. Eyraud, P. Faucher, D. Hassoun, and M. Teboul
The French legislation allows women to get a medical abortion at home under the control of GPs or gynecologists in private surgeries. In 2007, these abortions represented almost 9 % of induced abortions in France and 18% of the medical abortions (DREES, Etudes et résultats, n°712, 2009). The process is strictly defined by law. The termination of pregnancy (max 49 amenorrhea days) should be carried out by doctors who have signed a contract with a referral hospital. This hospital takes the charge of treating any complication that may arise. REVHO, a network of private physicians and hospitals, has been created in Paris and suburban areas in order to train the doctors, to set-up contract-based links with hospital family planning centers and to evaluate the quality of the method as well as the users’ satisfaction.
Five years after the creation of REVHO, 20 200 abortions at home using mifepristone and misoprostol have been performed within the network. This paper presents the results of 15 447 abortions carried out in the network. Data were entered on a PC held database and analyzed using EPI INFOTM Version 6. The women were 41 days of amenorrhea on average (90 % between 35 and 49 days) and their age varied from 14 to 55 (median: 28 years).
From 2005 to 2008, 162 physicians with private practices were involved: respectively 44 % and 56 % of abortions were carried out by GPs and gynecologists. The quantity of supervised abortions varied from 1 to more than 3600 per physician on the 4-year period. Twenty-three physicians (14%) performed more than 200 medical abortions and three, more than 1500.
About 80% of the abortions were followed up two weeks later. The success rate (as defined by the absence of surgical completion) was 97.9%, which is among the highest rates reported for medical abortion. There was a statistically significant difference between GPs (success rate of 98.2 %) and gynecologists (success rate 97.5 %) which can be discussed. The global rate of continuing pregnancy was 0.7%. No serious complication was observed.
These results demonstrate that medical termination of pregnancy at home can be performed under the control of physicians in their private practices without increasing the risks of failures or complications. GPs are efficient as well as gynecologists, which could allow an increase of the number of practitioners involved and contribute to health care proximity. Five years after its creation, REVHO demonstrated its capacity to incorporate the medical abortion into primary practices, with referral hospital services available for complications or surgical completions.