Speeches
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Oct. 14, 2016, 02:00
FC04
Safety and effectiveness of medical abortion outside the formal healthcare setting: do women seek timely care for potential complications?
Abigail Aiken1 ,2, Rebecca Gomperts3, James Trussell1
1Princeton University, Princeton, NJ, USA, 2University of Texas at Austin, Austin, TX, USA, 3Women on Web, Amsterdam, The NetherlandsObjectives: Medical abortion provided outside the formal healthcare setting is an important option for women in countries where abortion is illegal or highly restricted. Yet very little is known about its safety and effectiveness. We address this important knowledge gap using high-quality data from a setting where women commonly rely on this pathway to abortion.
Methods: We examine outcomes and complications among 1,234 women in Northern Ireland (representing 79% follow-up) who conducted medical abortion through Women on Web between March 30th 2009 and December 31st 2012. Women used a regimen of 200mg oral mifepristone and 1200mcg buccal misoprostol (with additional misoprostol provided if required).
Results: At the time of consultation, 77% reported gestational age under seven weeks, and 23% between seven and nine weeks. Abortions typically occurred between five and 21 days later (women were strongly discouraged from performing abortion after 12 weeks gestation). Virtually all women (99.0%) were able to end their pregnancies and 95.1% were able to do so without surgical intervention. Three women (0.2%) required a blood/blood product transfusion and 23 (1.9%) were given antibiotics. Nine percent of women reported bleeding lasting more than two hours soaking more than two maxi pads per hour; fever >39C or purulent discharge; or pain persisting several days postabortion. Among women reporting these possible symptoms of serious complications, 97% sought timely medical care (the other 3% suffered no harm). Among women not reporting a potentially serious complication none received treatment for one.
Conclusions: Despite a variety of gestational ages (including some beyond nine weeks) and the likely possibility that some providers performed surgical intervention and prescribed antibiotics unnecessarily, findings show that medical abortion provided outside the formal healthcare setting is highly effective and safe. Crucially, women are able to self-identify potentially serious complications and seek appropriate and timely medical assistance. -
Oct. 15, 2016, 02:00
FC29
Contraception before and after abortion: what do women seek? – experience of an abortion referral centrecentre in Lisboa, Portugal.
Catarina Reis Carvalho, Joaquim Neves, Raquel Gonçalves, Carlos Calhaz-Jorge
Hospital Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, PortugalIntrodution: Abortion by women’s request is one of the most commonly performed procedures in the world. The objective of this study was therefore to assess the choice of contraceptive method after abortion and the factors that may determine this choice.
Methods: This was a retrospective cohort study based on a medical record review at one hospital in Portugal. We included 613 women who had an abortion in January 2015- March 2016. We conducted associations between age, number of previous abortions, educational status and receipt of contraception at the time of abortion.
Results: Among the women included, the average age was 28 years (13-47), 47.3% nulliparous and 10.2% unemployed. Concerning obstetric history, 41.4% had a previous, voluntary abortion (1-8) with18.6% within the last five years. Previous to the abortion, 20.1 % had no contraception, 1.8% used natural methods, 22.2% barrier methods and 36.4% oral contraceptives. When asked, 76% knew why the previous method failed, identifying the main cause as forgetfulness in taking oral contraceptives followed by voluntary suspension of the method. After the abortion, 19.2 % had no review consultation or refused counselling, without getting contraception or adopting their previous method, 14.9% preferred oral contraceptives and the majority (51%) chose long-acting reversible contraceptives (LARC). Women with a previous history of abortions seem to adhere less to later contraception and prefer oral contraceptives while the others prefer LARC (p=0.003). We found no association between age and educational status and contraceptive choice (p=1.12, p=0,67).
Conclusions: Despite high access to contraceptive services, subsequent voluntary abortions are a reality. Education on contraception is an essential element of high-quality abortion care. Choosing LARC was popular for these women. A major limitation of this study is the short follow-up of the women. More studies are needed. -
Oct. 14, 2016, 02:00
FC05
Disparities in access to first trimester legal abortion in the public sector in Mexico City: Who presents past the gestational age limit?
Blair G. Darney1 ,2, Biani Saavedra-Avendano1, Patricio Sanhueza4, Raffaela Schiavon3
1National Institute of Public Health, Cuernavaca, Morelos, Mexico, 2Oregon Health & Science University, Portland, OR, USA, 3International Pregnancy Advisory Services, Mexico City, Mexico, 4Mexico City Ministry of Health, Mexico City, MexicoObjective: First trimester abortion was decriminalised in Mexico City in 2007; laws in Mexico’s other 31 states remain restrictive. Women who present for care past 12 weeks are not able to receive services. The objective of this study was to identify factors associated with presenting for public abortion services past the gestational limit.
Methods: We conducted a retrospective cohort study using clinical data from the public abortion programme in 2011 and 2012. Our primary outcome was receipt of abortion services. We compared characteristics of women who did not receive abortion services with those who received either medical or aspiration abortion. We used multivariable logistic regression to identify associations between client characteristics and our primary outcome, controlling for socio-demographic and clinical confounders.
Results: Our sample included 22,945 women, 73.1% of whom had a medical, and 18.3% an aspiration abortion; 8.6% of the sample (n=1935) did not receive abortion services due to presenting past the gestational age limit. Adolescents (aged <18) made up 14.2% of the total sample and 32.7% of women came from outside Mexico City. In multivariable analyses women who travelled from the nearby State of Mexico (aOR=0.89; 95%CI=0.79–0.98) or from another state (aOR=0.83; 95%CI=0.67-0.99) both had lower odds of receiving services, compared with women living in Mexico City. Adolescents had lower odds of receiving services compared with adults (aOR=0.67; 95%CI=0.58-0.77). Women with basic educational levels (aOR=0.71 and 0.72 for primary and secondary versus high school or higher), or who had not experienced a previous pregnancy (aOR=0.79; 95%CI=0.69-0.90) had lower odds of receiving services.
Conclusions: Factors associated with delay in seeking abortion services in Mexico City’s public abortion programme include distance travelled, younger age, nulliparity and low education level. Our results can be used to support efforts to promote earlier recognition of pregnancy and timely assistance to access services. -
Sept. 14, 2018, 02:00
Aim: To explore women’s experiences of returning for subsequent abortions and the experiences of staff who provide abortions.
Background: While overall abortion rates are decreasing in the UK, the percentage of women undergoing more than one abortion has increased. Between 2006-2016 there was a 6% increase in the number of women requesting repeat abortions, rising from 32% to 38% despite historical improvements in medical interventions for contraceptive technology. Previous quantitative research has focussed on what is different about women who request multiple abortions and how to get them to uptake and adhere to long acting reversible contraception. Rather than their personal experiences.
Methodology: Qualitative semi structured interviews with 10 women who have had multiple abortions and 12 semi structured interviews with staff who work in an abortion service. All interviews were transcribed verbatim. Interviews were analysed using thematic analysis.
Results: Four overarching themes emerged which were guilt, shame, coping and perfect contraception. Women experience guilt at multiple levels from the legal framework, to service and individual level; whereas staff struggle with their own guilt regarding provision of services. Stigma is expressed in the language used, by both women and staff, surrounding abortion and by the issue of woman returning for multiple procedures. Coping describes the different ways that women coped with their abortions and how they coped differently with each one, examining how patterns of behaviour may emerge. Accounts evidence a sense of deep shame around returning for abortions which links closely with guilt where both women and staff apportion and internalise blame.
Conclusions: Abortion is a stigmatised medical procedure for both women and the staff who provide them. Women and staff use a variety of mechanisms to reduce that stigma some of which may fail to address ongoing problems with contraception. However, women who return for multiple abortions are diverse and so are their experiences, procedural and service issues may need to re-examine implicit attitudes to abortion. -
Sept. 15, 2018, 02:00
Background: Unsafe abortion causes an estimated 43 000 maternal deaths each year. Telemedicine abortion services today abridge the lack of access to safe abortion in many countries. We aimed to evaluate the safety and acceptability of abortion through telemedicine at above nine gestational weeks (gw).
Methods: A retrospective cohort study comparing self-reported adverse outcomes among women in Poland at ≤ and > 9 gw who requested abortion through the telemedical service Women on Web between June 1st and December 31st 2016, confirmed intake and provided follow-up (n=615).
Results: Among women ≤ and > 9 gw respectively, 3.3% vs 11.7% went to hospital within 0-1 days of the abortion for complaints related to the procedure (AOR 3.82, 95% CI 1.90-7.69). In a stratified analysis the corresponding rate in the highest gestational age group, 11w0d-14w2d, was 22.5% (AOR 9.20, 95% CI 3.58-23.60). Among women ≤ and > 9 gw respectively, the rate of surgical evacuation post-abortion was 12.5% vs 22.6% (AOR 2.04, 95% CI 1.18-3.32), the rate of overall medical interventions post-abortion was 18.3% vs 29.0% (AOR 1.84, 95% CI 1.13-3.00), the rate of heavy bleeding was 6.8% vs 10.1% (AOR 1.65, 95% CI 0.90-3.04), the rate of low satisfaction was 2.4% vs 1.6% (AOR 0.69, 95% CI 0.14-3.36), the rate of bleeding more than expected was 45.6% vs 57.8% (AOR 1.26, 95% CI 0.78-2.02), and the rate of pain more than expected was 35.6% vs 38.8% (AOR 1.11, 95% CI 0.71-1.71).
Interpretation: Medical abortion through telemedicine above nine gw is associated with a higher rate of hospital visits for complaints in the days following the abortion compared to abortion at or below nine gw but not with a higher risk of heavy bleeding. It is associated with an increased risk of post-abortion treatment and intervention but not with a lower rate of satisfaction or met expectations.
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Oct. 15, 2016, 11:00
FC15
Access to abortion in Australia: insights from health care professionals
Angela Dawson1, Deborah Bateson2, Rachel Nicholls1, Anna Doab1, Jane Estoesta2, Elizabeth Sullivan1, Ann Brassil2
1Faculty of Health, University of Technology Sydney, Sydney NSW, Australia, 2Family Planning New South Wales, Sydney NSW, AustraliaObjectives: Recent changes in Australia's national policy with the approval of mifepristone and misoprostol for medical termination of pregnancy (MTOP) have led to increased choices for Australian women. In New South Wales (NSW), the largest and most populous state, there is no statewide data on abortion and incomplete information on MTOP. Further, there is limited research concerning the practices of trained and credentialled abortion service providers. We undertook a qualitative research study to investigate health professional views, perceptions and practices concerning MTOP.
Method: Eighty-one general practitioners (GPs), surgeons, gynaecologists, nurses and Aboriginal health workers in urban, rural and remote locations who do and do not provide abortion were interviewed. A deductive content analysis methodology was employed to analyse transcripts based upon a framework we developed to examine access to early abortion.
Results: Private clinic abortion providers noted that they were busy and were mainly involved in surgical procedures with MTOP accounting for half of their work. Gynaecologists viewed abortion at the fringes of the speciality. GP and gynaecologist non-providers thought of abortion as stigmatised work that ‘others' do in private clinics and referred accordingly. Abortion was not seen as a priority for the public system and only provided at the will of interested doctors. MTOP provision was regarded by GPs as difficult due to the follow up required and most were not interested in provision. GP MTOP providers felt isolated and reported demand was low as was women's awareness. Nurses and Aboriginal health workers play an advocacy and facilitation role for mostly disadvantaged women.
Conclusions: This study provides insight into access to abortion in the public sector and the low interest in provision from GPs who are at the forefront of primary care provision. Leadership from professional associations as well as the involvement of nurses may increase access for women. -
Sept. 14, 2018, 02:00
Objective: To analyze long-term satisfaction to intrauterine contraception after medical induced abortion.
Minimizing delay from medical abortion procedure to insertion of intrauterine contraception is a new approach to increase intrauterine contraception uptake and reduce subsequent unplanned pregnancies. Effect of this immediate insertion on womens satisfaction and quality of life is unknown. Materials and methods: Subanalysis of a randomized controlled trial. Total of 267 women were randomized to receive levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena, Bayer, Turku, Finland) immediately (?3 days) or later (2-4 weeks) after medical induced abortion during January, 2013 December, 2014 in Helsinki University Hospital, Finland. Selected demographic factors were collected. Women answered questionnaires concerning satisfaction and quality of life at follow-up visits three months and one year after LNG-IUS insertion. Results: Following three post-randomization exclusions, there were 264 participants. Of the immediate-insertion group 98/133 (73.7%) and the delayed-insertion group 78/131 (59.5%) women returned to the 3-month follow-up, and 89 (66.9%) and 63 (48.1%) to the 1-year follow-up. Median age was 27.8 (IQR 23.033.1) vs. 27.3 years (22.532.1), p=0.54. At 3-month visit the immediate-insertion group was more often satisfied or very satisfied with their contraception compared to the delayed-insertion group (89 [89.9%] vs. 61 [79.2], p=0.048). We found no difference at 1-year (71 [79.8%] vs. 47 [74.6%], p=0.45). Womens experienced health, as measured by visual analogical scale (0100 mm), at 3-month visit was 84 mm (median, IQR 77 91) vs. 87 mm (7795), p=0.19, and at 1-year visit 85 mm (7493) vs. 86 mm (7492), p=0.75. Conclusion: Immediate LNG-IUS insertion following medical abortion did not have a long-term effect on womens satisfaction with intrauterine contraception or experienced health. Loss-to-follow-up rate was high and may have produced a selection bias. However, these results endorse the feasibility of immediate initiation of intrauterine contraception following medial abortion. -
Sept. 15, 2018, 11:00
After accessing safe abortion and post-abortion care (SA/PAC), clients often have an unmet need for family planning. We used routine programme data to assess post-abortion family planning (PAFP) uptake and PAFP contraceptive methods in Kenya.
Methods: We analysed routine programme data for women who visited Marie Stopes centres for SA/PAC services in Kenya from 1 Jan 2015 to 31 Oct 2017. The proportion of women who chose PAFP (contraception on same day or within 14 days of SA/PAC) and uptake of contraceptive methods were examined by type of SA/PAC service (medical or surgical). Data were analysed in Stata version 11, using chi-square tests to assess differences in proportions.
Results: Over the study period there were 46,531 SA/PAC services (26,084 medical and 20,447 surgical). The proportion medical SA/PAC increased from 43.8% in 2015 to 64.5% in 2017. Almost two-thirds of clients were single (65.0%) and their age distribution was: <15 years (0.3%), 15-19 (8.9%), 20 -24 (31.4%), 25 – 34 (45.8%), ≥35 years (13.6%). Overall, 26,928 clients (59.8%) chose PAFP; this increased from 50.7% in 2015 to 66.5% in 2017; p<0.0001. PAFP uptake did not vary by age, but was greater among women who had surgical vs medical SA/PAC (71.8% and 63.5% in 2017, respectively; p<0.0001). Surgical SA/PAC clients were more likely to choose long acting or permanent methods (76.5% vs 64.2% among medical clients), with a greater proportion choosing intrauterine devices (37.3% vs 13.1% for medical clients).
Conclusions: PAFP uptake was consistently greater among women who had surgical SA/PAC, and uptake of long acting methods was higher among surgical SA/PAC clients. Women may prefer to complete the SA/PAC process before choosing a PAFP method, which may explain lower PAFP uptake among medical SA/PAC clients. Client-centred interventions are essential to ensure women receive family planning methods appropriate to their needs and preferences. -
Sept. 15, 2018, 02:00
Objectives: In October 2017, The Scottish Government approved a patient’s place of residence as a place where treatment for abortion can occur. Women up to 9+6 weeks gestation, can be administered mifepristone in a medical facility and given misoprostol to take home and self-administer 24-48 hours later. The option of early medical abortion at home (EMAH) has been available in our service since April 2018. Following ultrasound assessment of gestation, women who are under 9 weeks are offered the options of EMAH, medical abortion in hospital or surgical abortion. We aim to identify any demographic characteristics which may determine if a woman is more likely to choose EMAH, as opposed to hospital management.
Methods: A prospective review of the records of all women who attend over 4 months from April to July, who are 9 weeks or less and choose medical abortion. To be eligible for EMAH they must live in Scotland, be 16 years or over, have an adult with them on the day of abortion, not require an interpreter and have no significant medical conditions. We will analyse demographic data for those who choose EMAH and those who have medical abortion in hospital.
Results: In the first four weeks of offering EMAH to eligible patients, 184 women have been less than 9 weeks gestation and chosen medical abortion. 92 of them were booked to have medical abortion in hospital, and 92 EMAH. Upon completion of data analysis for the first 4 months, we will present the proportion of women who wished medical abortion that were eligible for EMAH, the proportion who chose EMAH and any demographic differences that exist between those choosing home and hospital management.
Conclusions: We will determine if any demographic differences exist between women who opt for home or hospital management of medical abortion. -
Oct. 14, 2016, 02:00
FC06
Seeking clandestine abortion safely: Unwanted pregnancy and medical abortion among young women in Dar es Salaam
Ingrid H. Solheim1 ,2, Catherine Kalabuka3, Karen-Marie Moland1 ,2, Andrea B. Pembe4, Astrid Blystad1 ,2
1Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway, 2Centre for International Health, University of Bergen, Bergen, Norway, 3CSK Research Solutions, Dar es Salaam, Tanzania, 4Muhimbili University of Health and Associated Sciences, Dar es Salaam, TanzaniaObjective: The aim of this project was to enhance knowledge about the challenges faced by young women with unwanted pregnancies living in an urban, low-income settings where abortion is criminalised but assumed to be performed clandestinely with increasing off-label use of the recently registered drug misoprostol.
Methods: The study was explorative, involving the use of in-depth interviews with women ≤ 25 years having performed medical abortion (n = 15), postabortion care providers (n = 16) and pharmacy workers (n = 10) and informative interviews with different stakeholders (n = 15). Focus group discussions (FGDs) were performed with women from low-income areas and students ≤ 25 years (n of FGDs = 10).
Results: To induce abortion is viewed as a common practice by young women in Dar es Salaam. While hospitals are often considered the safest providers of abortion, misoprostol is viewed by many as the best method. Misoprostol is perceived to be more accessible, simple to use, private, cheap and less dangerous compared to surgical hospital procedures. Many health workers experience fewer and more manageable complications among their postabortion care patients related to misoprostol use for abortion. However, girls often view the procedure as a ‘matter of chancing'. Low drug doses are typically used, and there is little follow-up and lack of information from vendors concerning potential complications. Finally, even though ‘miso' is commonly known among young women, traditional methods are still the cheapest and therefore the only option for some.
Conclusion: In Dar es Salaam misoprostol can be accessed clandestinely for pregnancy termination through drug stores or health facilities offering different levels of safety and costs. For many young women this is the preferred abortion method but use, and especially safe use, is limited to those who can afford it.