Speeches
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Oct. 14, 2016, 09:30
PS01.3
Improving women´s journey through abortion in Portugal
Lisa Vicente
Directorate of General of Health, Lisbon, PortugalAbortion, according to the Portuguese penal code, is considered a crime against intrauterine life. Over the years Portuguese law has incorporated reasons that preclude the illicit use of abortion.
Serious maternal illness, foetal malformation and rape constitute grounds for termination of pregnancy. These motives are accepted for 32 years in Portuguese health care.
It was just in 2007, after a national referendum, that the practice of abortion at women´s request up to10 weeks gestation was recognised. Since then it has been performed within the National Health Service (NHS) or in officially recognised, private clinics.
The implementation of abortion services was made possible within the NHS through a national network, along with the availability of mifepristone and misoprostol, the publication of national guidelines and the creation of a national online registry, mandatory for all health care units.
Nowadays 67% of all the abortions are performed in the NHS, where 95-97% of interventions are medical abortions. In private units the majority of the interventions are still performed using the surgical method (98%).
It is unknown what was the absolute number of illegal abortions before 2007, although 20 000 was the estimated number. We only have data on the complications caused by these abortions because women came to health services looking for treatment. Serious complications included deaths, uterine perforations and sepsis. Many women travelled abroad to seek a safe abortion – a number never known.
National reports show a significant decrease in the number and seriousness of complications caused by illegal abortions since 2008. With legal abortions complications remain low but in 2010 there was one fatal case of Clostridium Sordellii associated with medical abortion. -
Oct. 15, 2016, 02:00
CS15.3
Identifying and managing on-going pregnancy after medical abortion
Patricia Lohr
British Pregnancy Advisory Service, Stratford Upon Avon, UKThe incidence of on-going pregnancy after early medical abortion with mifepristone and misoprostol is about 1%. Early detection is important so that further management can occur within the skill-set of the provider and any country-specific gestational age limits for abortion. A common method of identifying the success or failure of medical abortion is to undertake an ultrasound scan during an in-clinic visit. However increasing evidence supports the effectiveness and acceptability of remote methods of follow-up, typically using a single or multi-level urine pregnancy test and a symptom checklist.
This talk will review how on-going pregnancy after early medical abortion may be detected, surgical and medical management of failure and the risk of continuing a pregnancy that has been exposed to mifepristone and misoprostol. -
Oct. 15, 2016, 02:00
CS14.3
MSF: Addressing challenges to providing safe abortion in humanitarian emergencies
Catrin Schulte-Hillen
Medecins Sans Frontieres, Geneva, SwitzerlandMSF responds to needs for the termination of pregnancy, including on request (TPR); it is part of the organisation's work aimed at reducing maternal mortality and preventing unsafe abortions in the countries where we work. The presentation shares insights into MSF's experience over the past few years. A policy decision on safe abortion care was taken in 2004 - the fact that care did not expand rapidly came as a surprise. It also took time to recognise that specific efforts are required to understand and address key challenges that present barriers to the provision of safe abortion care.
With policy, guidance, tools and training in place, humble progress has been made and some key lessons have emerged: the importance of making patient needs a priority over other considerations; acting accordingly requires organisation of services and other measures to mitigate potential risk for the patients and staff. There are undeniably strong social norms regarding abortion and they must be considered. An important knowledge gap remains, even among MSF staff. An open dialogue with staff, relevant medical actors and at community level is essential to address this and result in a change in attitude. -
Oct. 3, 2014, 11:15
Abortion in Spain: recent developments
Alberto Stolzenburg ACAI, Spain
The current 2010 Law on Sexual and Reproductive Health and Voluntary Termination of Pregnancy recognizes for the first time abortion as a fundamental women's right. It clearly sets the health dimension of this right and provides legal certainty as well. Women have access for free to abortion on demand up to 14 weeks, in case of maternal and fetal pathology up to 22 weeks and beyond 22 weeks for very severe and incurable diseases. When the majority of Spanish society has gone in the last years through democratic values regarding abortion, the Government strives to change the current law even though 80% of the population reject the draft law and 68% of their own voters believe that women should decide themselves. Meanwhile the abortion rate in Spain keeps stable and is similar to other countries of Western Europe. The preliminary draft of Justice Minister Gallardón specifies these and other realities and seeks to placate the most reactionary wing of the Spanish right. In this way, abortion will be allowed only under two conditions: rape and serious maternal diseases, eliminating fetal deformations as a reason. At the same time, it establishes a medical and legal journey of such magnitude, that in practice it makes abortion impossible even for the legal reasons mentioned. In addition, this law penalizes severely health professionals, deepening the stigma and the legal uncertainty that have marked them. The draft law is pending approval by the Council of Ministers. An approval that has been awaited by the strong social and political opposition and internal contestation among the Executive and the ranks of the Popular Party. If finally the Parliament approves the draft this year, Spain would have in 2015 the most restrictive law of the democratic era.
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Oct. 3, 2014, 04:00
Pain management
Nathalie Kapp HRA Pharma, Paris, France - n.kapp@hra-pharma.com Background: Pain is a predictable feature of induced abortion in both the first and the second trimester, but pain control regimens available to women vary considerably.
Methods: We searched the PubMed and Cochrane databases for publications of trials comparing methods of pain control during induced abortion.
Results: Few rigorously conducted studies of pain control regimens for medical abortion have been conducted. Five studies conducted in women with pregnancies <9 weeks' gestation found that prophylactic analgesia did not reduce medical abortion pain, including the most recent rigorous trial where prophylactic ibuprofen was administered and dosing was repeated through the abortion process. In second-trimester medical abortion, one study found more pain relief with higher doses of fentanyl delivered through PCA than lower doses; the only adjuvant therapy shown to be associated with decreased opioid use has been diclofenac. During first trimester surgical abortion, more than 40 randomized controlled trials are available. Paracervical block, conscious sedation, general anesthesia and non-pharmacologic interventions decreased procedural and postoperative pain during first trimester abortion. Second trimester surgical procedures generally use conscious sedation or general anesthesia which have not been the subject of comparative trials. The severity of pain experienced by a woman varies considerably, but appears to be influenced by the age of the woman, parity, history of dysmenorrhea, and fearfulness/ anxiety. Prior vaginal delivery and a shorter procedure time are associated with lower levels of pain.
Conclusion: As pain associated with the process of abortion should be expected, medication for pain management should always be offered to women who desire it, and may be combined with non-pharmacologic techniques. Further research is needed to determine the optimal analgesia regimens for first-trimester and second-trimester medical termination of pregnancy. To facilitate comparability of data, researchers should use contemporary medical abortion regimens, outcomes and study instruments to measure pain.
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Oct. 4, 2014, 02:00
Using mobile phones to strengthen medical abortion provision: opportunities and dangers identified from the South African experience.
Deborah Constant1, Katherine de Tolly2, Marijke Alblas3,4 1University of Cape Town, Cape Town, South Africa, 2Cell-Life, Cape Town, South Africa, 3Association des sages femmes, Douala, Cameroon, 4CSU/CNRS, Paris, France - deborah.constant@uct.ac.za
Objective: To report the South African experience using text systems on mobile phones to provide support and a self-assessment of completion of their procedure to women undergoing medical abortion. Methods: A randomized controlled trial during 2011-2012 recruited 469 women seeking medical abortion at clinics in South Africa. All women received standard abortion care with mifepristone and home administration of misoprostol and were asked to return to the clinic to assess completion 14 - 21 days later. Consenting women were randomized to standard-of-care or intervention groups. The intervention group received timed SMSs over the period between their clinic visits, with reminders on what to expect, alerts to complications and encouragement to complete the self-assessment. They were also prompted to access a contraception mobisite. Interviews were conducted at both clinic visits and one month later by telephone. Results: Most found the SMSs helped them manage the abortion symptoms and would recommend them to a friend; however 20% of recipients had concerns around phone privacy. The intervention group were significantly better prepared (p<0.05) for the pain, bleeding and side effects of the abortion. Of the 5471 messages sent, there was only a 5% failure rate. Seventy-eight percent completed the self-assessment and of these, 93% found it easy to do, however the questions did not predict all cases requiring further surgical management or additional misoprostol. More in the intervention group chose long-acting reversible contraception at their follow-up clinic visit. Conclusions: Support SMSs were effective in assisting women manage their abortion symptoms between clinic visits. Most could conduct a self-assessment of abortion completion on their mobile phones and promotion of contraception can succeed using mobile text systems. The self-assessment showed promise but was not sufficiently accurate; problems with privacy can be of concern for some women and a mechanism for stopping the SMSs is required.
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Oct. 14, 2016, 02:00
CS04.3
Quickstarting implants after medical abortion
Helena Kopp Kallner
Karolinska Institutet, Stockholm, SwedenGiven the choice, the majority of women in the first trimester choose medical rather than surgical abortion. In Europe, and globally, a significant proportion of women having an abortion have had one or more previous abortions. Long acting reversible contraception reduces subsequent abortions in women. In studies, women resumed sexual intercourse quickly and are thus at risk for unintended pregnancy if effective contraception is not provided. Immediate postabortion initiation of long acting reversible contraception is therefore desirable and recommended by guidelines.
Implants are the only long acting contraception which can be provided at the same time as the initial abortion medication. However, theoretically treatment with a progestin could affect the binding of mifepristone to the progesterone receptor.
Several pilot studies have reported implant insertion at the time of mifepristone in medical abortion. In addition, there is one randomised study performed in Mexico and the United States and one randomised study performed in Sweden and Scotland. Women were randomised to implant insertion at the time of mifepristone ingestion or at follow up. These studies show that implant insertion at the time of the mifepristone is safe and acceptable for women. In addition, the efficacy of the medical abortion is not affected. In the study from Mexico and the United States insertion rates differed between countries and no difference could be shown in unintended pregnancy at the 6 month follow up. The study from Sweden and Scotland had similar insertion rates to women recruited in the United States. There was a significant difference in unintended pregnancy at the 6 month follow up between the immediate and delayed insertion group.
Thus, immediate insertion of implants is safe and acceptable and may prevent subsequent abortions as early as 6 months postabortion. -
Oct. 15, 2016, 09:00
PS04.3
Strengthening autonomy: Mobile technology and self-assessment for medical abortion
Deborah Constant1, Jane Harries1, Caitlin Gertz2
1University of Cape Town, Cape Town, South Africa, 2Ibis Reproductive Health, San Francisco, USAShortages of providers of surgical abortion methods are a significant barrier to safe abortion care across diverse settings where abortion is legal. Early medical abortion using mifepristone and misoprostol requires less provider involvement, is highly effective and can largely be managed by women themselves. Medical methods are highly acceptable to women and can increase women’s autonomy.
Self-determination of gestational age eligibility, self-administration of misoprostol and management of abortion symptoms, self-assessment of abortion outcome and selection of postabortion contraception can be strengthened using mobile phone technology (mhealth). Reliable networks, adequate connectivity, phone ownership and phone privacy are necessary for mhealth to effectively facilitate safe abortion care. These conditions exist in developed but also in many developing countries.
In South Africa studies have shown most women with gestations within 70 days can recall their last menstrual period with sufficient accuracy and use an online gestational age calculator to determine eligibility for medical abortion. Supportive text messages including reminders and information on complications over 14 days following mifepristone significantly improved preparedness and provided effective emotional support during the abortion. Self-assessment using a text questionnaire was feasible, but not accurate, and a low sensitivity pregnancy test was necessary to better detect ongoing pregnancies. Twenty-three percent of women correctly recalled information from the messages on contraceptive methods 4-6 weeks after they had received them. In Colombia a low sensitivity pregnancy test together with text questions for self-assessment was a safe and feasible alternative to in-facility care.
Mhealth, using text messages, shows promise for strengthening women's roles and control with respect to medical abortion. Other approaches include telemedicine consultations, automated text checklists on incomplete abortion symptoms, digital images to verify pregnancy test results and online resources with contraceptive advice. The increasing familiarity with digital technology provides a powerful opportunity to strengthen women’s reproductive autonomy. -
Oct. 4, 2014, 04:00
Methods of surgical abortion in the second trimester
Patricia Lohr British Pregnancy Advisory Service (BPAS), Stratford Upon Avon, UK - patricia.lohr@bpas.org
Vacuum aspiration, hysterotomy, hysterectomy, dilatation and evacuation (D&E), and a variant of D&E called intact dilatation and extraction (D&X) are all procedures used for second trimester surgical abortion. Vacuum aspiration is effective up to 16 weeks' gestation, but forceps are often required to remove larger fetal parts. Hysterotomy and hysterectomy are reserved for cases where neither a medical induction nor a trans-cervical surgical approach is feasible. Dilatation and evacuation remains the most commonly performed method of surgical abortion in the second trimester, with D&X often utilized when preservation of fetal anatomy is desired. This talk will briefly review the safety and prevalence of second trimester surgical abortion and then will focus on pre-operative assessment, cervical preparation, surgical technique and post-operative care.