Speeches
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Sept. 15, 2018, 02:00
Australia is a prosperous country which endeavours to provide equitable access to high-quality healthcare. Yet this is not the case for abortion.
With the introduction of government-subsidised medical abortion in 2013 it was envisaged that women would be able to access affordable abortions, medical or surgical, across the country. Unfortunately, this promise has not been met, especially for those who are financially disadvantaged or who live in rural and remote areas.
Australia has a complex patchwork of abortion laws across its 8 states and territories, ranging from legal abortion available on request up to 24-weeks with potential supply of early medical abortion drugs by nurses in Victoria, to abortion provision still residing in the Crimes Act of 1900 in the most populous state of New South Wales. While decriminalisation has not always led to improved access, the risk of prosecution serves as a barrier to service provision, particularly in the public setting. Publically-funded hospital services, except for fetal abnormality, are difficult to access or non-existent in most states and territories and costs for private medical and surgical abortion services vary widely and can be substantial and unaffordable. While General Practitioners are potentially able to provide low cost medical abortion to their patients only a very small number do so due to perceived stigma, poor remuneration and concerns about managing complications in the absence of clear referral pathways into local hospitals. Australia’s innovative telemedicine service has the potential to overcome barriers to access but reports of obstruction and psychological abuse of women by health care providers providing radiology and other necessary support services highlights that abortion is far from stigma-free in Australia. Despite these challenges key steps are being taken by professional colleges and other leading health organisations to integrate abortion care within their training pathways and in calling for policy reform focussing on reducing costs and enhancing early access. -
Oct. 4, 2014, 02:00
Alternative schemes for follow-up, including use of a semi-quantitative pregnancy test
Wendy Sheldon Gynuity Health Projects, New York, USA - wsheldon@gynuity.org
Semi-quantitative urine pregnancy tests are a recent innovation with the potential to revolutionize abortion care worldwide. Sequential use of such tests enables women to monitor the success of their abortion procedures in the privacy of their own homes and can be an effective replacement for serum hCG and/or transvaginal ultrasound, thus reducing overall abortion-related costs and, for many women, the need to return for clinic-based follow-up. This presentation will summarize data from multiple studies conducted in the United States, Mexico, Tunisia and Vietnam using a semi-quantitative test with five bracketed hCG ranges (25-99, 100-499, 500-1,999, 2000-9,999, and 10,000 mIU/ml). The studies explore the effectiveness, feasibility and acceptability of using a semi-quantitative pregnancy test for at-home medical abortion follow-up at various points in time up until 14 days after initiation of the abortion procedure.
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Oct. 15, 2016, 02:00
FC26
Analysis of induced abortion-related complications admitted to referral based medical facilities in Kinshasa, Democratic Republic of the Congo.
Daniel Ishoso Katuashi1, Antoinette Tshefu Kitoto2, Yves Coppierters3
1Kinshasa School of Public Health, Lemba, Kinshasa, The Democratic Congo, 2Kinshasa School of Public Health, Lemba, Kinshasa, The Democratic Congo, 3Université libre de Bruxelles, Bruxelles, BelgiumObjectives: This study aims to analyse the extent of induced abortion-related complications at referral health facilities in Kinshasa and their characteristics, the length of hospitalisation, the proportion of deaths and their characteristics, as well as deaths that occurred after two days of hospitalisation.
Methods: The cross-sectional study focused on 1541 gynaecological patients admitted as emergencies at 7 referral health facilities in Kinshasa, from 1 January to 31 December 2014, facilities that were selected representatively from the 5 types of districts of Kinshasa. Information was collected by reviewing patient files/records and analysed with SPSS20 and Epi-Info3.5.4.
Results: There were 12.8% (11.2% to 14.6%) cases of induced abortion-related complications with a correlation to adolescence, celibacy, nulliparity, residence in semi-rural districts of Kinshasa and history of one or more abortions; 4.0% of deaths, including more than one third (1.8% to 4.0%) that are related to induced abortion-related complications, with a mortality of 13.6% and a significant increase in risk of death in the presence of a post abortive, pelvic peritonitis type complication. Half of these deaths occurred after two days of hospitalisation. Finally, the median length of hospitalisation was 10 days, higher in post abortive, pelvic peritonitis compared with patients with pelvic peritonitis due to Caesarean section/hysterectomy.
Conclusion: This study demonstrates that induced abortion-related complications were a significant public health problem, because of their frequency in cases admitted as gynaecological emergencies at referral medical facilities in Kinshasa and their weight on hospital maternal deaths, and, furthermore, that supportive care in hospitals poses a serious problem. Accordingly, there is a need to understand the reason for the problem of hospital care in order to fulfil and provide a set of services that is appropriate for those medical facilities. -
Oct. 14, 2016, 12:45
LS01.3
A tailored pregnancy test offers new possibilities to women for follow-up after medical abortion
Kristina Gemzell Danielsson
Karolinska Institutet, Stockholm, SwedenOne reason for limited access to medical abortion is that women are required to make multiple visits to the clinic. The purpose of a follow-up visit after medical abortion has been to ensure that pregnancy has successfully terminated, to detect complications and to start contraceptives. However, in case of complications women should not wait until a routine follow-up visit and, importantly, to help women start contraception after the abortion contraceptive counselling and provision should be done at the first visit to the abortion clinic and should not be postponed to the follow-up. Hence the main purpose of a routine follow-up visit after medical abortion is to detect an on-going pregnancy. Most service delivery guidelines recommend that women return at 2-3 weeks for a follow-up visit. However, an increasing number of women choose not to return for follow-up after their medical abortion.
Recently, studies have assessed alternative methods of follow-up after medical abortion, such as using a low-sensitivity urine pregnancy test, semi-quantitative urine pregnancy test or a high sensitivity pregnancy test followed by a telephone follow-up or through text message or online. A few studies have also investigated women’s experiences and perceptions of self-assessment and safety and effectiveness of self-assessment in low resource settings, including women who reside in rural areas, have low literacy levels and limited access to telephone and transport facilities.
Overall there is no increased risk of complications in women who self-assessed their treatment outcome compared with women who attend clinical follow-up. Self-assessment of treatment success after early medical abortion has a resource-saving potential. Women need to be counselled about the risk of continuing pregnancy and any strategy for self-assessment will need to be carefully assessed for test and user performance before introduction.
A simple, reliable test for self assessment allows a one-stop clinic for medical abortion. -
Oct. 15, 2016, 02:00
CS12.3
Refusal to treat is not ‘Conscientious Objection’
Christian Fiala
Gynmed Clinic, Vienna, AustriaHealth Care Professional’s (HCP) refusal to treat or serve patients in Reproductive Health based on personal or religious reasons is frequently and misleadingly called ‘Conscientious Objection’ (‘CO’). In many countries ‘CO’ is lawful but almost always unregulated. HCP invoking ‘CO’ are misusing their position of power and trust but expecting to keep their job and salary, even if they deceive their patients and refuse to comply with part of their professional duty. ‘CO’ is mainly a phenomenon in public health services because private institutions rarely engage, pay and keep employees who do not fulfil all their professional duties. Consequently ‘CO’ is abuse of the public service and taxpayers money. The significant negative impact on women’s basic healthcare and human rights is well known and has been published repeatedly. The impact is strong especially in those countries where abortion and contraception are mainly provided by public institutions, whereas it is negligible in countries:
- with a predominantly private health care
- where the law obliges all hospitals to provide abortion or
- where ‘CO’ is not tolerated (Sweden, Finland, Iceland).
The debate around ‘CO’ is characterized by
- one side defending an eminence based position with faith based arguments giving HCP the right to refuse patients versus
- the other side arguing for an evidence based position with arguments based on facts and in favour of giving patients the right to a legal treatment for which they pay either directly or indirectly via a health care insurance.
No country has regulated ‘CO’ in a way that would satisfy women and their need for basic medical care as well as HCP’s personal or religious beliefs. What is misleadingly called ‘CO’ is a remnant of a patriarchal social model and incompatible with evidence based medicine as well as current human rights standards.
www.conscientious-objection.info -
Oct. 15, 2016, 11:00
FC11
Evaluation of two low sensitivity urine pregnancy tests (1000 IU) used for self assessment following early medical abortion
Sarah Millar, Sharon Cameron
Chalmers Centre, Edinburgh, UKIntroduction: The majority of women who have early medical abortion (EMA) at our service choose to confirm the success of the procedure by “self assessment” (a self-performed low sensitivity urinary pregnancy (LSUP) test at home two weeks after EMA). Women contact the abortion service if they have an invalid or positive result or symptoms of ongoing pregnancy. In 2014 we changed from a double cassette LSUP (Babyduo) to a single window LSUP (Check4) (both Quadratech diagnostics, UK). We predicted the Check4 test would be easier for women to use and interpret.
Aims: To determine if the Check4 test improves the detection of ongoing pregnancies when compared with Babyduo and if there are any differences in reported invalid or positive results between the two tests.
Methods: A retrospective database review identified women who had EMA “self assessment” in the 10 months before and 10 months after the introduction of the Check4 test. Fishers exact test and descriptive statistics were used for data analysis.
Results: 1047 women were identified (n=492 Babyduo group and n=555 Check4 group). There were 2 ongoing pregnancies in the Babyduo group and 3 in the Check4 group. Significantly more invalid tests were reported in the Babyduo (n=18, 3.6%) than the Check4 group (n=6, 1.1%) (p=0.0064). Significantly more positive tests tests were reported in the Check4 (n=19, 3.4%) than the Babyduo group (6, 1.2%) (p=0.0244).
Conclusion: The introduction of the Check4 LSUP has not altered the detection rates, or time to detection, of ongoing pregnancies. It has, however, been associated with fewer attendances for ‘invalid’ results and more for positive results. These findings may reflect that the single window Check4 test gives less margin for error in interpretation than the former double window test. We will continue to use the Check4 LSUP for EMA “self assessment” for this reason. -
Sept. 15, 2018, 11:00
Objectives: To determine whether prophylactic administration of ibuprofen and metoclopramide or tramadol alone provides superior pain relief compared to analgesia when pain begins with mifepristone and misoprostol medical abortion through 63 days gestation. Methods: We conducted a multi-center randomized, placebo-controlled trial in Nepal, South Africa and Vietnam. Participants were randomized 1:1:1 to: (1) ibuprofen 400 mg and metoclopramide 10 mg ; (2) tramadol 50 mg and a placebo; or (3) two placebo, taken immediately before misoprostol and repeated four hours later. All women had supplementary analgesia to use as needed. Our primary outcome was maximum pain within 8 h of misoprostol administration. Secondary outcomes included maximum pain within 24 h, additional analgesia use, and medical abortion effectiveness. 86 women were required in each arm for 90% power to detect a 1.5 point reduction in maximal pain score using an 11-point visual analogue scale (VAS) compared to placebo; the sample size doubled to examine the effect of parity on the primary outcome. Results: 563 women (nulliparous n=275; parous n= 288) were randomized between June 2016 and October 2017. Women in both treatment arms reported lower pain scores compared to placebo (1: 6.43 (95% CI 6.10, 6.75); 2: 6.78 (95% CI 6.10, 6.75); 3: 7.42 (95% CI 7.10, 7.74). Ibuprofen and metoclopramide reduced scores more than tramadol compared to placebo (D mean 1: -0.99 (95% CI -1.45, -0.54); 2: -0.64 (95% CI -1.09, - 0.18); similar results were noted within 24 hours. Nulliparous women reported higher overall pain scores compared to parous women; but, treatment effect was similar. Women receiving prophylactic treatment generally used less additional analgesia. There was no difference in medical abortion effectiveness. Conclusion: Prophylactic ibuprofen and metoclopramide or tramadol reduced pain with medical abortion compared to placebo; ibuprofen and metoclopramide appears to offer better pain control compared to tramadol.
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Oct. 3, 2014, 02:00
Integrating abortion and contraception training into medical education: the Family Planning Fellowship and Ryan Residency Training Programs in the US
Uta Landy The Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences; University of California, San Francisco, San Francisco, CA, USA - landyu@obgyn.ucsf.edu
Although abortions were legalized in the United States in 1973, the focus was on service access, not training. As a result, the number of teaching hospitals offering abortion services and conducting research declined steadily. A training mandate was finally passed by the US professional standard setting organizations in 1995 when a lack of trained physicians was noted. The mandate has been affirmed regularly despite the increasing political interference with abortion care and teaching. The Fellowship in Family Planning was founded to ensure future generations of leaders for abortion services, research, teaching and advocacy. During the past 23 years, its graduates have ensured the integration of family planning into the curriculum of medical students and postgraduates, conducted seminal research in abortion and contraception, contributed to the family planning work of national and international governmental and non-governmental organizations and become advocates for evidence-based policies. A parallel organization, the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning, was founded in 1999 to support academic programmes in complying with the new training standards. Since its inception, it has initiated formal programmes in 78 departments of obstetrics and gynaecology to ensure the clinical competence in evidence-based approaches in family planning and abortion for future generations of OBGYNs. Systematic training is an essential aspect of ensuring that future physicians are clinically competent, understand and contribute to research, understand the medical, social and psychological aspects of uterine evacuation and contraception and become advocates for evidence-based policies.
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Oct. 3, 2014, 09:45
From hospital to community
Sharon Cameron1,2 1NHS Lothian, Edinburgh, UK, 2University of Edinburgh, Edinburgh, UK - sharon.cameron@ed.ac.uk
There is growing recognition that termination of pregnancy (TOP) services should be able to offer both high quality contraceptive advice and provide women with the most effective methods of long-acting reversible of contraception (LARC), to start immediately after the TOP. Women who choose to start LARC immediately post TOP have a significantly reduced risk of having another TOP than counterparts choosing less effective methods. In many countries, TOP services are traditionally delivered from hospital departments of obstetrics and gynaecology where staffing of the labour ward usually takes priority. Junior medical staff delegated to undertake the consultations of women requesting a TOP may be disinterested in TOP care and may lack specialist contraceptive knowledge and training to insert the most effective LARC methods. In contrast, staff working in specialist contraceptive services (family planning/ sexual and reproductive health) in the community possess the knowledge and skills to offer the most effective methods of contraception. Furthermore, early TOP can clearly be delivered from the community setting. This raises the question of whether higher LARC uptake rates and as a consequence, fewer subsequent TOPs could be achieved if more TOP care was delivered from the community specialist contraceptive setting.
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Sept. 14, 2018, 04:00
When planning post-abortal contraception it is important to note that women seeking trimester termination of pregnancy (TOP) have demonstrated their high fertility and are at risk of subsequent induced abortion. The importance of the efficacy of the post-abortal contraceptive method has been increasingly recognized during the last decade. A safe and highly effective method with minimal dependency on the user compliance, i.e. long-acting reversible method of contraception (LARC) is clearly of value. When compared to use of LARCs and especially intrauterine contraception (IUD), use of oral contraceptives or postponing initiation of contraception is associated with a significantly increased risk of subsequent TOP.
Placement of an IUD immediately at the time of first trimester surgical abortion is the standard of care and it is also recommended in international guidelines. In comparison to delayed insertion, the expulsion rate is somewhat higher (5 vs. 3 %). following immediate insertion. However, the number of IUD users during the follow-up is increased when compared to delayed insertion (92 vs. 77 %).
Increasing use of the medical TOP and home administration of misoprostol pose challenges to provision of post-abortal contraception. However, progestin implants can be safely inserted on the day of mifepristone administration. A recent RCT comparing fast-track insertion (≤3 days vs. 2-4 weeks after misoprostol administration) of the levonorgestrel-releasing intrauterine system (LNG-IUS) after first trimester TOP has shown that also rapid initiation of intrauterine contraception is feasible. Fast-track insertion is associated an increased risk of partial expulsion (12.5 vs. 2.3%).However, fast tract insertion was safe with similar rate of adverse events, and identical bleeding profile as that associated with later insertion. At one year of follow-up the user rate was higher and number of new pregnancies lower if the LNG-IUS had been inserted immediately.
Thus, an effective, quickly-started long acting contraception should be the goal of treatment regardless of the method of TOP as long as a new pregnancy is not planned. To reach this contraceptive initiation should be an integral part of comprehensive patient friendly abortion care with low threshold and easy access. This will also reduce the need of additional visits, subsequent TOP, and allows initiation of an effective contraception, with all its added health benefits.