Speeches
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Sept. 15, 2018, 11:00
Objectives: The objectives of this study are to describe the health sector's role in establishing or expanding abortion services following legal or policy reform, and to compare strategies used in order to generate practice-based options for the implementation of abortion services. Method: This is a comparative case study of six countries that recently changed abortion laws: Colombia, Uruguay, Portugal, Ghana, Ethiopia, and South Africa. For each, we completed a desk review of published and unpublished data, and conducted in-depth, semi-structured interviews with key stakeholders involved in the implementation of abortion services. Interview guides were tailored to each country, and stakeholders identified through a network of in-country partners.
Results: We conducted 58 interviews with healthcare providers, public health officials, academics, and members of advocacy groups. We found that specifics of the laws did not predict their successful implementation. Ministry of Health involvement was key. Collaborations with UN agencies and international NGOs helped establish clinical and training protocols. Integration of abortion into existing public facilities led to more rapid and broader access. Key strategic decisions included a focus on medical rather than surgical abortion; the expansion of midlevel providers' role; and integration of contraception into abortion care.
Conclusions: We observed a range of approaches to the implementation of abortion services in response to varying legal and policy frameworks.
Public sector commitment and early involvement was key to the successful establishment of services, and thoughtful adaptations to local contexts can significantly reduce logistical and financial barriers to the equitable provision of services. -
Sept. 15, 2018, 02:00
Introduction: In 2015, mifepristone was approved in Canada, making it the 61st country to do so. Prior to mifepristone, there were only 60 physicians providing medical abortion in Canada. In anticipation of the commercial availability of mifepristone in 2017, clinicians prepared clinical practice guidelines and an online medical abortion training course. Health Canada mandated training prior to prescribing or dispensing mifepristone, however, in late 2017, the regulation was relaxed from “mandatory” to “recommended”.
Methods: We present participant data on the first 16 months of medical abortion training to provide an estimate of clinicians who are currently eligible and/or likely to provide mifepristone medical abortion across Canada.
Results: Overall, 167 Obstetrician/Gynaecologists, and 408 Family Physicians (which make up the majority of abortion providers in Canada) have completed the Medical Abortion Training Course. 1346 pharmacists have completed the course and are eligible to dispense the medication. 173 nurses (of which 112 are nurse practitioners with prescribing privileges), 6 midwives, and 151 medical students and residents also have been trained in medical abortion. There is a physician trained in every province and territory, however there is no pharmacist trained in Nunavut, a northern territory.
Conclusion: There is widespread interest and uptake of mifepristone medical abortion in Canada. Within the first year of availability of mifepristone, over 2000 medical professionals have completed the medical abortion training course. In contrast to pre-mifepristone, where very few physicians provided methotrexate-based medical abortion, there are at least 575 physicians currently eligible to prescribe, and 1346 pharmacists eligible to dispense mifepristone. -
Oct. 3, 2014, 12:45
Self-assessment of urine hCG – a novel option in the follow-up after induced abortion?
Oskari Heikinheimo
Helsinki University Central Hospital and University of Helsinki, Department of Obstetrics and Gynecology, Helsinki, Finland - oskari.heikinheimo@helsinki.fi
There is controversy concerning the need for routine follow-up after an uncomplicated abortion. This is also reflected in the various guidelines on induced abortion. The WHO guideline states that following safe, induced abortion, post abortion care may not require follow-up visit, whereas according the Royal College of Obstetricians & Gynaecologists guideline there is no need for routine follow-up after surgical or medical abortion if successful abortion has been confirmed at the time of the procedure. The Finnish guideline states that ‘the follow-up is important’. This controversy is also reflected in women’s compliance with a follow-up: in research studies, up to 50% of the women do not attend the scheduled follow-up visit. Ideally, during follow-up, completeness of the abortion can be verified, possible complications excluded and the use of post-abortion contraception encouraged. In addition, counseling and psychological support could be provided. The completeness of the abortion can be ascertained in several ways. The value of pelvic examination or ultrasonography have been questioned, whereas the use of serum or urine hCG to exclude ongoing pregnancy has been advocated. Recent studies have focused on development of semi-quantitative urine hCG tests as possible self-assessment tools to verify the completeness of an abortion. We have recently completed a randomized multicenter study to compare self-assessment at home using a two-step urinary hCG tests vs. assessment at the clinic following early medical abortion (Oppegaard et al., accepted for publication). The results show that the rate of complete abortion (94% vs. 95%) or the need for surgical evacuation of the uterus did not differ between the groups. Nine in ten of the women found the urine hCG test easy to use, and significantly higher proportion of the women (82% vs. 59%) would prefer the self-assessment should they undergo an other abortion. It is concluded that self-assessment by means of urinary hCG test performed at home might be an important option for many women to verify the completeness of an induced abortion.
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Oct. 15, 2016, 04:00
PS05.2
How can a Fellowship in Family Planning be established in Europe?
Uta Landy
Fellowship in Family Planning and Ryan Residency Training Programme, San Francisco, CA, USASubspecialisation has expanded with the growth of evidence-based practice and complexity in medical care in the US. There are now 127 accredited subspecialties across all medical disciplines with four in Obstetrics and Gynecology: Reproductive Endocrinology and Infertility, Maternal Foetal Medicine, Oncology and, most recent, Female Pelvic and Reconstructive Surgery. The Family Planning Fellowship is exploring potential accreditation and certification.
Why did we create a subspecialty in family planning? Historically, US medical schools gave clinical care, training, research and advocacy in abortion and contraception little attention. Since the demand for pregnancy termination was mostly met by freestanding clinics, few teaching hospitals offered or taught abortion or complex contraception.
In response, we launched two national initiatives. The first, the Fellowship in Family Planning, was started at UCSF in 1990 and now counts 31 sites in leading academic ob-gyn departments. It has produced a new generation of leaders in the field who have advanced abortion and contraceptive research, clinical training, and advocacy. Our 300 graduates have helped launch 90 new academic training programmes through a parallel initiative, the Ryan Residency Training Programme.
While the results of our model may serve as an inspiration to our European colleagues, our approach may not be replicable in the European context. There are certain steps required to ensure fellowship success. Leaders in the field must be motivated to serve as champions of the effort, and professional organisations, e.g. ESC, must lend their official support. The service delivery system must allow for clinical training and sources of research funding must be identified. Advocacy for reproductive justice should become part of training. Finally, the structure and settings, clinical care, teaching and research of the family planning fellowship must be substantial enough for academic centres and the service delivery community to recognise it as an essential component of reproductive health. -
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. -
Sept. 15, 2018, 11:00
The health system modernization law in 2016 allows the practice of instrumental TOP without general anesthesia in primary care centers subject to partnership agreement with a hospital. The aim is to diversify the care offer and facilitate abortion access for women : proximity, rapidity, and real ability for women to choose the method. The Regional Heath Agency (Ile de France) has commissioned REVHO to assess the feasibility and to assist primary care centers in this practice. We have developed tools and training for medical practitioners and for the staff. Five pilot primary care centers were interested and eligible. Two years have been necessary for implementing the law providing for reimbursement of such practice by French social security (February 2018) and administrative constraints have delayed the beginning of this new practice outside the hospital. Last June, the first three surgical abortions were performed in Aubervilliers with great success and women’s satisfaction. As for any new practice, it will take several years before a generalized implementation with possible extension to other structures and other professionals
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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.