Speeches
-
Oct. 3, 2014, 02:00
Sustainability of medical abortion services in the Caucasian region
Tamar Tsereteli Gynuity Health Projects, Tbilisi, Georgia - ttsereteli@gynuity.org
Caucasian women, as residents of former Soviet republics, have had widespread access to legal abortion for almost one hundred years. Abortion rates are high, and many women rely on abortion as their primary means of fertility regulation. Current laws provide for abortions up to 12 weeks’ gestation without restrictions, and up to 22 weeks’ gestation for broad medical and selected socioeconomic grounds. Until recently, surgical abortion was the only option available to women in Caucasian countries. Very few doctors were trained in medical abortion provision, most women did not know what medical abortion was or had an incorrect understanding of the procedure and there were no recommended national protocols doctors could consult if they were interested in providing the service. In addition, mifepristone was not always available: if registered at all, it often was unavailable outside of the capital cities. In 2006, Gynuity Health Projects launched a series of collaborative activities in Armenia, Azerbaijan and Georgia with the goal of increasing the availability of safe abortion services and access to medical abortion. Activities included training for doctors and nurses on medical abortion, clinical research studies, dissemination meetings to present study findings, development of Information, Education and Communication (IEC) materials for women and assistance in developing national protocols. In some cases data generated from the clinical studies supported mifepristone registration and informed national protocols. Between December 2011 and June 2013, Gynuity conducted studies in Armenia and Georgia to assess ongoing provision of medical abortion services and evaluate the quality of care provided at former research sites. This presentation will describe how programme components have contributed to sustainability of medical abortion in the Caucasian region.
-
Oct. 15, 2016, 11:00
CS08.3
The Telabourtion Study: Evaluation of a Direct-to-Patient Telemedicine Abortion Service
Erica Chong, Elizabeth Raymond, Philicia Castillo, Beverly Winikoff
Gynuity Health Projects, New York, NY, USAObjectives: Given the difficulties women face in obtaining clinic-based abortion in many parts of the US, provision of medical abortion by telemedicine to women in their homes could be highly beneficial for increasing access. We developed a pilot study to obtain preliminary data on the safety, acceptability and feasibility of direct-to-patient telemedicine abortion.
Methods: This case-series study of 50 women is being conducted in selected US states with no legal restrictions on telemedicine abortion. Women may learn about the study from staff at the collabourating study sites, from referring providers or from the study website. Each woman who is interested in the study will consult with a study investigator by videoconference and then will obtain screening tests at local facilities. If the results indicate that she is eligible, the investigator will send the abortion medications to her by mail. The participant will obtain tests at local facilities to confirm abortion completion and will have a follow-up consultation with the investigator by phone or videoconference. Data will be collected about interest in, and satisfaction with, the service, abortion complications and difficulties encountered by patients and providers in completing the protocol requirements.
Results: We will review key legal issues that impact this model and challenges in designing the service to conform to expected standards of care for clinic-based abortion. We will also present data obtained in the project to date.
Conclusions: In states with no legal restrictions, direct-to-consumer telemedicine abortion has great potential to increase women's access to abortion care in a safe and acceptable manner. -
Sept. 15, 2018, 09:00
Today many women are reluctant to use any of the existing contraceptive methods due to side effects or fear of experiencing such effects. Unsafe abortion is a major contributor to maternal mortality. Therefore effective methods for contraception and safe and acceptable methods for termination of unwanted pregnancies are prerequisites for reproductive health, for gender equality and for the empowerment of women. New methods for contraception are also needed including improved methods for emergency contraception and new mechanisms of action as well as mode of delivery. Additional health benefits of contraceptive methods such as protection against various cancers, and a wide range of other benefits need to be better recognized. Based on their mechanisms of action Progesterone receptor modulators (PRMs) can be used for emergency contraception as well as regular contraception by various modes of delivery. Progesterone receptor modulators have been shown to be effective when used on demand post coital, as daily pills, once-weekly or once-a-month and is a well establish method for medical first and second trimester abortion. The use of progesterone receptor modulators for contraception and positive health benefits such as the possible protection against breast cancer as well as prevention of uterine leiomyomas and endometriosis deserves to be further explored. Progesterone receptor modulators have also been studied for “late emergency contraception” and for menstrual induction. Very early medical abortion (VEMA) before an intrauterine pregnancy can be visualized by ultrasound has been shown to be acceptable, safe and effective. Medical abortion is also highly effective later in the first trimester and can be self administered by women. Thus PRMs such as mifepristone if offered in a suitable dosage provides a model for a woman centred contraceptive continuum with added health benefits and increased autonomy for women.
-
Oct. 15, 2016, 01:00
FC20
Why have abortions decreased in the USA?
Philip Darney
University of California, San Francisco, USABackground: The rate and number of abortions in the USA increased rapidly after legalisation in 1973 to nearly 1.5 million by 1990. But by 2009 the total was less than 1 million. What accounted for a 50% decline in less than 20 years? Those opposed to abortion rights argue that various restrictive laws in more than half the states have encouraged women to give birth rather than abort. Advocates of family planning assert that increased use of effective contraceptives has decreased the need for abortion in the USA.
Methods: State and US National data are reviewed in light of legislative changes to examine the relationships among contraceptive prevalence, method mix, age specific fertility, employment, unintended pregnancy and abortion rates. Specific states, eg, California and Texas, are compared and contrasted.
Results: Several factors explain the steep decrease in abortion rates and numbers in the USA, but legislative restrictions and declining numbers of providers account for only a small proportion of state-specific variance. Changes in age-specific fertility rates, particularly a rapid decline in teen pregnancies, increased use of more effective contraceptives and rising employment rates among women provide, along with other demographic factors, powerful explanations for fewer abortions.
Implications: Fewer abortions require fewer providers which could further decrease access to family planning for poor women living in medically underserved areas. Less access in already impoverished regions, where restrictive abortion laws are most likely, increases teen and premature births, poverty rates and local health care costs leading to a cycle of declining reproductive health services and increasing poverty and social disruption. -
Oct. 15, 2016, 11:00
FC12
Analysis of cervical resistance during continuous controllable balloon dilatation
Petar Arsenijevic, Slobodan Arsenijevic, Aleksandar Zivanovic, Slavica Djukic Dejanovic
Faculty of medical sciences, Kragujevac, SerbiaBackground: Hydraulic dilatation is a novel method of cervical dilatation that is based on continuous and controllable dilatation by the pumping of fluid into the balloon extension of the system for continuous and controllable balloon dilatation (CCBD). The main advantage of this procedure is that it allows control and insight into the process of cervical dilatation.
Methods: For the purposes of our research, we created a new and upgraded system for continuous and controllable balloon dilatation (CCBD), which consists of a programmed hydrostatic pump connected to a balloon extension. With regards to our aim to precisely measure and determine the location of the cervical resistance, we placed two pressure-measuring films on the top and on the bottom of the balloon extension. This study included 42 women in whom cervical resistance was measured prior to the suction curettage.
Results: Cervical dilatation and measurement of cervical resistance were successful in all women. The analysis of the pressure-measuring films showed that the points of highest resistance are located in the zone of the internal cervical os and that these values are much higher than those in the zone of the external cervical os (0.402 versus 0.264 MPa at the upper pressure-sensitive film; 0.387 versus 0.243 MPa at the lower pressure-sensitive film). This study also showed that an increase in cervical resistance in the zone of the internal cervical os was followed by an increase in cervical resistance in the zone of the external cervical os.
Conclusion: During continuous controllable balloon dilatation, the internal cervical os is the centre of cervical resistance, and the values do not decline with the number of miscarriages or the number of previous births. -
Oct. 3, 2014, 12:45
Comprehensive pain management in medical abortion
Christian Fiala
Gynmed Clinic, Vienna, Austria - christian.fiala@aon.at
Management of pain during medical abortion has been given insufficient attention in clinical practice as well as in research. For example neither pain nor its treatment are systematically reported in clinical trials: a literature research on Pubmed revealed 1 459 publications on medical abortion from 1988 until 2011, but only 18 trials reported pain when comparing different treatment regimens using mifepristone and misoprostol in first trimester. This shortcoming reflects a neglect of the individual pain perception, yet pain remains a decisive factor for women in the decision making process of abortion. Comprehensive pain management in medical abortion should be based on the principles of general pain management:
Avoidance of pain
As a first step, measures should be taken to avoid pain as far as possible:
* Unrestricted access to abortion would enable women to come as early as possible. Studies show that women’s experience of pain increases with gestational age. Reducing restrictions in access are therefore an important pain reduction measure.
* Induction of contractions should be limited as far as possible. Therefore the lowest effective dosage of the prostaglandin should be given.
* Free choice of the method is important because women report less pain when the choice of early medical abortion has been their own decision.
* Full and accurate information should be given on what to expect and what to do in case of pain.
* Women should feel relaxed and safe. Taking misoprostol at home is a pain reducing measure for many women.
Non-medical pain treatment
Classical hot water bottle, choosing the preferred body position and activity are effective aspect.
Medical pain treatment
* NSAIDs such as ibuprofen or diclofenac should be an integral part of pain management. They do not interfere with medical abortion treatment.
* Codein or tramadol should be available as backup.
Medication should be started as early as possible or even be given as prophylaxis before intake of misoprostol. (absorption of misoprostol is very fast and the first contractions can occur already within 15 minutes.) Providers should also make sure that patients have analgesics at home.
Reference: Pain during medical abortion, the impact of the regimen: A neglected issue? A review.
Fiala C, Cameron S, Bombas T, Parachini M, Saya L, Gemzell-Danielsson K.
Eur J Contracept Reprod Health Care. 2014 Sep 2:1-17.
-
Oct. 4, 2014, 09:00
Contraception: why it fails
James Trussell1,2 1Princeton University, Princeton NJ, USA, 2The Hull York Medical School, Hull, UK - trussell@princeton.edu
In this presentation, I discuss the difference between contraceptive failure rates during perfect use and during typical use. I examine the logical error that many investigators make when computing failure rates during perfect use. I then highlight the impact of simultaneous use of two methods. I next explore the reasons for observed differences in correctly computed failure rates during perfect use and during typical use. Next I discuss reasons for the “creeping Pearl” (Pearl indexes for oral contraceptives approved by the FDA have increased over time). Finally, I report on the results of clinical trials of two new contraceptive patches and the stark implications for pharma and regulatory agencies.
-
Oct. 2, 2014, 08:00
Dilatation and evacuation (D&E) is one of the World Health Organization's recommend methods for abortion in the second trimester. In addition to its safety and effectiveness, advantages of D&E are that the procedure can be scheduled as a day case and operating times are short (about 10-15 minutes), as opposed to the unpredictable duration of a medical abortion (MA), which may require hospitalisation. The efficiency and predictability of D&E is also beneficial where women require an abortion for maternal medical conditions or complications of pregnancy which could deteriorate during the course of a lengthy labour induction. Lastly, D&E is an important back-up for failed second trimester MA. In many parts of the world multiple barriers prevent access to D&E. One important barrier is a lack of trained providers. Using a mixture of didactic and adult learning methods, this day long workshop will cover the practical requirements of D&E including pre-operative assessment and planning, instruments, cervical preparation, pain control, procedural steps, immediate post-abortion care, and identification and management of complications. We will also cover the next steps in developing a D&E service such as preparation of clinical teams, training, waste management, and infrastructure requirements.
-
Oct. 15, 2016, 02:00
FC27
European transnational survey related to medical abortion in the first trimester of pregnancy
Filipa Mendes Coutinho1, Teresa Bombas1 ,2, Paulo Moura1
1Serviço de Obstetrícia A, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 2On behalf of Expert Group on abortion, European Society of Contraception and Reproductive Health (ESC), Coimbra, PortugalBackground: Currently most European countries allow abortion upon women's request in the early weeks of pregnancy. Despite WHO's recommendations, the definitions and methods used in clinical practice are not well established. The knowledge of the different attitudes regarding abortion would be beneficial.
Methods: We conducted a survey via mail involving 20 centres from 19 countries in which abortion is legal, to understand the differences in clinical practice regarding medical abortion. We performed a statistical analysis assessing a number of variables, including: number of abortions per year; rate of medical abortion; availability of national guidelines; methods of follow-up; among others.
Results: Nineteen centres responded (95%) and most of these (84%) perform medical abortion. A large number do not use it as a first-line method. Thus, from an estimated 21,925 abortions registered in the past year, only 39% were performed by medical protocol. In spite of the lack of guidelines all the institutions use a combination of mifepristone and misoprostol to terminate pregnancy. The differences lie in the dosage used as well as the route of administration. Concerning follow-up, 52% of the institutions agree on a two week interval and almost 65% perform an hCG blood level as well as an ultrasound scan after this period. Similar percentages (63%) repeat medical treatment in case of ongoing pregnancy after a first cycle of medication and 68% in case of incomplete abortion. When asked if having more precise definitions for success of medical/surgical abortion would be beneficial, nearly 77% responded affirmatively.
Conclusions: In late years we have witnessed an increase in the number of medical abortions performed in European countries. Despite the WHO recommendations the access to abortion methods are quite different. The majority of the surveyed institutions agree this would be an important step towards improving management of the procedure. -
Oct. 4, 2014, 02:00
How do women manage antibiotic pills after medical abortion?
Laura Frye, Erica Chong, Beverly Winikoff Gynuity Health Projects, New York, USA - bwinikoff@gynuity.org
Is it time to move away from routinely giving doxycycline to medical abortion patients? Objectives: Routine provision of antibiotics following medical abortion is common, yet practitioners and professional societies differ on the utility of this practice. Our study compares the side-effects experienced by women who were prescribed doxycycline following medical abortion to those who were not and assesses the adherence to one regimen. Methods: 581 women seeking medical abortion were enrolled in this prospective, observational study in nine study sites. They were recruited from 1) clinics that routinely prescribe a seven-day course of doxycycline (Doxy Arm) and 2) clinics that do not routinely prescribe any antibiotics (No Doxy Arm). Seven to fourteen days following the administration of mifepristone, women were asked to self-administer a computer-based survey. The survey asked about side effects experienced (both arms) and adherence to the regimen (Doxy Arm only). Results: Self-reported adherence to the doxycycline regimen was moderate: 44% reported missing at least one dose and 34% stopped taking the doxycycline before 7 days. There was a trend toward increased nausea in the Doxy Arm (48% vs. 41%; p=.06) and a statistically significant difference in vomiting (25% vs. 19%; p=.03). A small but noteworthy number of women were confused about various aspects of the different medicines they received or were prescribed, including misunderstanding the purpose of a medicine, claiming to not have received a drug despite medical chart confirmation and noting costs of filling prescriptions that were not received. Implications: In the absence of robust evidence that prescribing 7 days of doxycycline following medical abortion is effective at reducing serious infections, these data can assist in deciding whether routine provision is the most appropriate strategy. Given the limits of any patients' ability to follow multiple and varied instructions, it is worth considering the impact of adding doxycycline, especially when it is frequently advised to be taken with an anti-emetic.