Speeches
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Oct. 4, 2014, 11:00
Medical abortion provided by nurse-midwives or physicians: a cost-effectiveness analysis
Susanne Sjöström1, Helena Kopp Kallner1, Emilia Simeonova2, Andreas Madestam3, Kristina Gemzell-Danielsson1 1Karolinska Institutet, Stockholm, Sweden, 2John Hopkins University, Baltimore, USA, 3Stockholm University, Stockholm, Sweden - susanne.sjostrom@ki.se
Objective: To make a cost-benefit analysis of medical abortion provided by nurse-midwives and physicians. Study Design: A cost-effectiveness analysis is conducted based on a previously performed randomized controlled equivalence trial comparing efficacy, safety and acceptability of medical abortion performed by nurse-midwives or physicians in a high-resource setting. Materials and methods: Direct and indirect costs associated with the standard and intervention treatment have been calculated and an incremental cost-effectiveness analysis is performed. Equivalence in effectiveness was established for the primary and secondary outcomes in the original study, the outcome measures were complete abortion, and safety in terms of hospitalization, blood transfusion and acceptability. Direct costs include salaries including general payroll tax, rent, training of providers and costs for consultation (second opinions). Since the patients received the same treatment there was no difference in costs of disposables, ultrasound or medication. Indirect costs include women’s loss of salary and alternative cost for consultants (second opinions). Benefits emerging from increased prescription of long-acting contraceptives (LARCs) and also possible utility such as decreased waiting time for abortion seeking women from first contact to consultation/ treatment will be considered. All costs were taken from Karolinska University hospital where the parent study was conducted. Results: Preliminary results are that medical abortion provided by nurse-midwifes alone is more cost-effective than the standard treatment involving both nurse-midwives and physicians. The savings are mainly derived from lower salary costs for nurse-midwives but also from less total time for the visit.
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Oct. 4, 2014, 11:00
Medical abortion with mifepristone + misoprostol at 13 – 22 weeks: how long between the mifepristone and the misoprostol?
Dina Abbas1, Nguyen thi Nhu Ngoc2, Jennifer Blum1, Nguyen thi Bach Nga3, Huynh Kim Chi4, Roxanne Martin1, Beverly Winikoff1 1Gynuity Health Projects, New York, NY, United States Minor Outlying Islands, 2Center for Research and Collaboration in Reproductive Health, Ho Chi Minh City, Viet Nam, 3Hung Vuong Hospital, Ho Chi Minh City, Viet Nam, 4Huynh Kim Chi, Binh Duong Hospital in Obstetrics and Newborn, Binh duong Province, Viet Nam - dabbas@gynuity.org
Objective: To compare a regimen that initiates misoprostol dosing at the same time as mifepristone to a regimen where misoprostol is started 24 hours after mifepristone for termination of pregnancy of 13 – 22 weeks. Method: Double blinded randomized placebo controlled trial where participants received mifepristone either 24 hours before, or at the same time as, misoprostol (repeat doses of 400 mcg buccal every three hours). If abortion was not completed within 48 hours after induction with misoprostol the participant received standard care. Results: 504 women were enrolled in Vietnam. 87.1% of women who received the two drugs simultaneously experienced complete uterine evacuation within 24 hours after induction with misoprostol, compared to 95.1% of women who received misoprostol 24 hours after mifepristone. At 48 hours, this increased to 96% in both study arms. The mean misoprostol treatment duration and total misoprostol doses received was significantly lower in the group that received the misoprostol 24 hours later 9.13 vs. 14.66 (p=.000) and 3.47 vs. 5.44 (p=.000) respectively. Mean duration of the process, defined as receipt of mifepristone to complete abortion, was significantly shorter for women who received the drugs simultaneously 14.66 vs. 33.37 (p< 0.0001). In both groups the side effect profile was similar and overall satisfaction was high (>98%). Results will be presented by gestational age group (13 – 16; 17 – 22 weeks). Conclusion: Preliminary findings suggest that taking mifepristone and misoprostol simultaneously significantly lowers clinical efficacy at 24 hours; results in a longer mean misoprostol treatment duration; and requires more misoprostol doses. However there may be trade-offs as the simultaneous regimen significantly shortens the total time of the overall process and may require fewer clinic visits in some settings. The study provides evidence that allows providers and women to choose among two viable second trimester medical abortion regimens.
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Oct. 4, 2014, 11:00
Feasibility of a self-performed urinary test for the follow-up of medical abortion: the Betina study
Danielle Hassoun1, Ines Perin2 1Private Practice Office, Paris, France, 2Gynaecology Department, Delafontaine Hospital, Saint Denis, France - sbarbeau@gecem.com
Background: Medical Termination of Pregnancy (MToP) implies a follow-up visit (14 to 21 days after mifepristone intake) to verify the effectiveness of the abortion procedure and the absence of any complication. Studies have shown that a level of hCG in the serum less than 1000 IU, two weeks after the intake of the mifepristone means the success of the method in 90% of the case. Objectives and method: We set up an observational study among French specialized centres either private practice offices, academic hospital centres or family planning facilities. The objectives were to assess the benefit of a self-performed urinary semi-quantitative test in the follow-up of MToP, assessing the feasibility, acceptability and user-friendliness of the test as well as the women’s capacity to interpret it correctly. Concordance between qualitative results from the test and quantitative values from the blood hCG measurement was also assessed. Results: 322 women were included by 17 centres (47% private practice, 35% hospital practice, 18% family planning centers) from May to October 2013. The mean age was 28.1 ± 6.4 years. 82% (N=264) of patients attended the follow-up visit and 13% (N=42) of patients were lost to follow-up. 69% (N=183) patients had performed the two tests on the same day ± 1 day. Concordance between urinary test and hCG blood measurement was 94.5% [90.2%; 97.4%]. A large majority of women (90%, N=198)) read the urinary test correctly whatever the levels of hCG. Performing the test at home was found reassuring for 40% (N=71) of them, and satisfactory for 26% (N=46) of them but 3% (N=5) considered it to be alarming and 12% (N=46) unsettling. Conclusion: The semi-quantitative urinary test shows good concordance with plasma level. Proposing a urinary test for the women to control the success of the procedure appears to be relevant, efficient and safe.
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Oct. 4, 2014, 02:00
Improved access to safe abortion in Ukraine: Comprehensive Care for Unwanted Pregnancies project results, 2009-2013
Anastasiya Dumcheva1, Galina Maistruk2 1World Health Organization, Kyiv, Ukraine, 2Charitable Foundation "Women Health and Family Planning", Kyiv, Ukraine - ada@euro.who.int
Introduction: Before 2009, most of the pregnancy terminations in Ukraine were unsafe, which contributed from 8.5% to 16.0% to the maternal mortality in Ukraine over the period from 2003 to 2009. To address this issue, Comprehensive Care for Unwanted Pregnancies (CCUP) project was introduced in 2009 in partnership with Swiss Agency for Development and Cooperation, MoH Ukraine, NGO "Women Health and Family Planning", and WHO. Objective: The project goal was to improve availability, accessibility and quality of safe abortion in Ukraine. Methods: The project included activities at the national - improving legislation, monitoring and evaluation system, and regional levels - strengthening capacity of health care professionals, improving quality of abortion services and enhancing communication in five pilot regions of Ukraine. Results: Over the period from 2009 to 2012, the contribution of unsafe abortions into overall maternal mortality in Ukraine has steadily decreased from 9.2% (12 cases) to 4.6% (3 cases). The main reason for the overall decrease was the development and endorsement of new national legislation documents - organizational and clinical protocols, which adapted WHO recommendations on safe abortion. The percentage of women undergoing safe abortion methods in the first trimester (medical abortion, manual or electrical vacuum aspiration) vs unsafe (dilatation and curettage) has increased in pilot regions from 25-32% in 2011 to 53-75% in 2013 (variability is due to the regional context and time of project start in the region). The percentage of women who received local vs general anaesthesia has increased from 11% in 2011 to 29-37% in 2013. By the end of 2013, most of the women received pre- and post-abortion counselling sessions (82-95% compared 59-62% in 2011). Conclusion: The project interventions contributed to the overall decrease of abortion-related maternal mortality in Ukraine. Interventions piloted at the regional level are acceptable for healthcare professionals and women and can be disseminated nationwide.
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Oct. 4, 2014, 02:00
Making medical abortion woman-centered and accessible in Kazakhstan: a study of 600 mcg sublingual misoprostol following 200 mg mifepristone for abortion up to 70 days’ gestation
Ingrida Platais1, Tamar Tsereteli1, Galina Grebennikova2, Beverly Winikoff1 1Gynuity Health Projects, New York, NY, USA, 2Kazakhstan Association on Sexual and Reproductive Health, Almaty, Kazakhstan - iplatais@gynuity.org
Objective: To assess whether the option to take mifepristone at home is feasible and acceptable to women with pregnancies up to 70 days' LMP seeking medical abortion in Kazakhstan. Method: Typically, medical abortion in Kazakhstan consists of four visits. This study consisted of two visits. During their initial visit, women were given the option to swallow mifepristone at the clinic or take it home, and all women were instructed to take misoprostol at home. The follow-up visit was scheduled two weeks after mifepristone. This open-label study enrolled women with pregnancies ≤70 days' LMP. The study regimen consisted of 200 mg mifepristone, followed by 600 mcg misoprostol 24-48 hours later. Results: As of April 2014, 106 women were enrolled. Ninety-eight percent of women had successful abortions. All women took mifepristone and misoprostol at the scheduled time, and no woman took mifepristone after 70 days' LMP. No serious adverse events were reported. Most women (99.0%) reported that the ability to plan when the abortion would occur was important for them. More than half of the women (61.3%) chose to take mifepristone at home, citing compatibility with home and family duties as the top reason for their choice in location of mifepristone administration. For clinic users, the presence of a provider was the most common reason for their choice. Almost all women (99%) were satisfied with the abortion procedure and most (98.1%) would choose medical abortion in the future. Most home users (90.8%) said they would choose to take mifepristone at home again if they needed another abortion, whereas only 12.2% of the clinic users would choose to take mifepristone in the clinic again. Conclusion: An outpatient medical abortion procedure up to 70 days’ gestation using mifepristone and misoprostol, taken at a place of women's choosing, is safe, effective and acceptable.
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Oct. 4, 2014, 02:00
Access to safe abortion reduces the number of complications and financial costs
Galina Dikke1, Dmitry Kochev2 1Russian Peoples Friendship University, Moscow, Russia, 2JSC "Pentkroft Pharma", Moscow, Russia - pentcroft@mail.ru
The main method of terminating unwanted pregnancies in Russia remains a D&C (62%, 2012). Medical abortion (MA) is 8% and vacuum aspiration (VA) 30%. In several regions administrative measures have been taken to implement usage of safe methods into clinical practice. Objective: To evaluate the dynamics of the numbers of early complications and financial costs. Material and methods: We choose two regions in the Ural - Sverdlovsk region (SR) and Tyumen region (TR). SR implemented VA in outpatient and inpatient hospitals up to 12 weeks of gestation (N = 2640). TR introduced the method (the combination of mifepristone/misoprostol (200 mg/400 mcg) up to 42 days of amenorrhoea (N=2758). Results: In 2013, in the SR VA was used in 99.2 % of cases (compared to 45.3% - in 2012). Ambulatory holds 35 % VA procedures, the rest - in the hospital. The number of early complications decreased by 3 times (2.0 % vs. 6.0 % respectively), mainly due to incomplete abortion and postpartum endometritis. MA in the TR was used in 97% in early pregnancy, 34.8% of all medical abortions up to 12 weeks. Numbers of early complications decreased by 3.5 times (4.0 % vs. 13.7% respectively), mainly due to bleeding, haematometra and postpartum endometritis. Costs of treatment of early complications observed were 3 times lower in both regions. Cost savings to perform an abortion is 44 % due to the lack of need for inpatient beds, operating, disinfectants, instruments, medicines, including narcotic drugs, equipment, anaesthesia, etc. Conclusions: The introduction of sound technologies and accessibility of abortion contributes to the preservation of reproductive health (reducing complications 3-3.5 times) and lower financial costs of the procedure to perform an abortion (2 times) and the treatment of early complications (3 times).
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Oct. 4, 2014, 02:00
Medical abortion in the United States and Canada: why so different?
E. Steve Lichtenberg1, Heidi Jones2, Katharine O'Connell White3, Maureen Paul4, Edith Guilbert5, Christopher Okpaleke6, Wendy Norman7 1Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA, 2CUNY School of Public Health, Hunter College, New York, New York, USA, 3Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA, 4Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA, 5Institut National de Sante Publique du Quebec, Quebec, Canada, 6University of British Columbia, Vancouver, British Columbia, Canada, 7University of British Columbia, Vancouver, British Columbia, Canada - jodotter@aol.com
Objectives: To understand differences in medical abortion provision in the United States compared to Canada. Methods: We conducted a cross-sectional survey of abortion facilities identified via publicly available resources simultaneously in the United States (n=705) and Canada (n=94) from June through December 2013, which included questions on socio-demographic characteristics and medical abortion procedures for up to 5 clinicians per facility. Results: In Canada 78 (83%) and in the US 379 (54%) of all abortion facilities participated, with respectively 60 and 348 medical abortion clinicians participating from 32 and 286 facilities providing medical abortions. In Canada all medical abortions are provided by physicians with nearly two thirds of these (59.3%) being family physicians/general practitioners compared to over three quarters of physician providers in the US (84.9%) who are specialists. In the US, 56% of providers were physicians, 26% nurse practitioners, 11% physician assistants and 6% certified nurse-midwives. In both countries, the majority of providers were female (78.7% in the US and 79.7% in Canada). Providers reported 2706 (Canada) and 135,129 (US) first trimester and respectively 322 and 1646 second trimester medical abortions. Among reported procedures in each country, medical abortion comprised 3.8 % (Canada) and 35.6 % (US) of all first trimester abortions, and 6.7% (Canada) compared to 4.3% (US) of all second trimester abortions. In the US, the majority provided medical abortions through 63 days LMP (79.1%) compared to 49 days LMP in Canada (63.3%). Providers in both countries reported practices predominantly aligned with evidence-based guidelines. Conclusion: Medical abortion is provided much less commonly in Canada where mifepristone is not an approved drug, and is more often provided by family physicians compared to the United States, where specialists or non-physicians provide most medical abortions.
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Sept. 15, 2018, 11:00
The RCOG stipulates that 'Feticide should be performed before medical abortion after 21 weeks and 6 days of gestation to ensure that there is no risk of a live birth.' Live birth is to be avoided for 'emotional, ethical, and legal reasons.' But live births happen with medical abortions at earlier gestations and can occur prior to surgical abortions in the second trimester if labour is precipitated by cervical preparation agents. Furthermore, the very same emotional and ethical matters apply to surgical termination in the second trimester, because the same questions are raised regarding how best to end both a woman's pregnancy and a fetal life. I argue that if there are compelling reasons to perform feticide prior to second trimester medical termination, the reasons are even more compelling prior to surgical termination. Both women undergoing abortion in the second trimester and their care providers should have the choice of using feticide, regardless of the method chosen.
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Oct. 22, 2010, 08:00
Final stage of early medical abortion at home : womens experiences and impact on a hospital abortion service
H.Dewart , S.T.Cameron, A.Glasier and A.Johnstone - Dean Terrace Centre, NHS Lothian, Royal Infirmary of Edinburgh, Department of Reproductive and Developmental Sciences, University of
Edinburgh, United Kingdom
Background and methodology: Research has shown that many women would prefer to be at home rather than in hospital, to pass the final stage of an early medical abortion. A pilot was therefore conducted over six months at a hospital abortion service in Edinburgh, Scotland, that allowed women up to 8 wks gestation to be discharged home soon after misoprostol administration. An anonymous questionnaire of womens’ experiences was conducted one to two weeks later. An audit of the numbers of abortions performed by each method, during the pilot and the same period the previous year, was also conducted.
Results:A total of 250 women chose to go home after misoprostol. This corresponded to 34% of the total number of women having an early medical abortion. A 24% increase in the total numbers of women having a medical method (n=142) was observed compared to the same period the previous year. A total of 100 women completed questionnaires out of 145 distributed (69%). The commonest reasons given for choosing to go home were, to have treatment sooner (53%) and to be in the privacy of one’s own home (47%). Most women stated that bleeding (81%) and pain (55%) were as, or not as bad as expected. Most would recommend this method to a friend (84%).
Discussion and Conclusions: Discharge home for the final stage of a medical abortion was highly acceptable to women. Since availability is not limited by hospital bed space, more women can be treated by medical methods
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Oct. 13, 2006, 02:00
For the counsellor
Christiane Der Andreassian, Hospital Broussais, Paris, France
To give information takes time.
Counselling doesn’t need necessary to be done by doctors.
Well trained, nurse or midwife who belongs to the team can easily do it.
Make sure that woman‘s decision to abort is firmly settled.
Listen to the woman’s motivation behind her choice of the method.
Ensure a proper understanding of the method.
Make sure that women is psychologically able to take upon herself and to comply with the
schedules of the appointments, in particular coming back for ultra sound and follow up visit
Be able to reach an emergency area, during the following 2 weeks, in case of problems.
Discuss any concerns at the follow up visit.
What the women say
Avantages of medical abortion
- Pill, no surgical intervention
- Its more natural
- No doctors touching my body
- Conscious and self experience
- Choose to come back for the misoprostol at the clinic or to stay home in their
own environment
Disadvantages of medical abortion
- Not sure when abortion will take place
- More blood loss
- Anxious about cramps, nausea, or eventually diarrhoea
CONCLUSION
Receive the patient in her request,
- With respect
- With a positive attitude,
- Listen to her in the globality of her situation.
- And of course, provide her with the advice’s most relevant to her choice.
- Giving her the relevant information fitted to her case,
- Understand that the team is available if she needs help.
- Allow her to take responsibility for her own actions with more autonomy and confidence
all along the procedure.
A patient correctly informed will be more comfortable and will improve the chances of
succes of method.