Speeches
-
Oct. 25, 2008, 11:00
Economic discrepancies for contraception in Europe
Ines Thonke (Germany)
Pro Familia Bundesverband, Germany
ines.thonke@arcor.de
Implementation. A survey was carried out among IPPF Europe (International Planned Parenthood Federation) member organisations. It was carried out 17 sovereign nations of Europe with the emphasis on the situation in the European Union concerning costs and access of contraception. The evaluation of contraceptive costs undertaken here focuses also on the situation in Germany.
Results. This comparison of contraceptive costs and access in Europe demonstrates the great divergence in absolute price. Prices tend to be aligned with the economic situation in the respective countries; however they highlight the arbitrariness in price-setting, particularly as a number of the richest countries even supply contraceptives free of charge.
Germany always takes second place and for hormonal IUDs is the most expensive of the countries in the survey, while the country in first place is different every time.
In terms of relative prices, shown here as a percentage of income per head, no universal tendencies whatsoever can be identified
Free access to contraceptives for all or for specific groups is offered almost exclusively by countries with high income per head rates and most comprehensively in France and the UK, for example, but all – even the poorest countries in the survey – provide all their citizens free access to medical consultation – which only in Germany is no longer the case.
The fact that Germany is expensive is primarily due to the recently introduction of medical consultancy fees. It is in this respect a new finding, as this last reform catapulted Germany out of the middle ground. The special provision for under-18s and under-20s should also be noted At the same time however it must be pointed out that cancelling free provision of contraceptives to those on social welfare benefits has reduced their access to contraceptives significantly in Germany compared to price levels in the rest of Europe.
Conclusion. It has been shown that it is useful to compile a comparison of contraceptive costs in Europe. Only by making specific comparisons does the particular situation in individual countries (here, the German situation is outlined in greater detail) become comprehensible. It has been substantiated that in the case of Germany the price for contraceptives is in the upper range in terms of an absolute as well as a relative comparison and that the introduction of the Gesundheitsmodernisierungsgesetz (GMG or Healthcare Modernisation Act) in 2003 has created a huge financial burden for clients when compared to the rest of Europe.
The survey should be made available to all European member organisations in the form of a useful and up-to-date factual report on the situation.
Proposals for subsequent work will be worked out.
-
Oct. 25, 2008, 02:00
Effectiveness of intracardiac potassium chloride for feticide prior to termination of pregnancy between 20 and 24 weeks
Emeka Oloto (Great Britain)
emeka.oloto@btinternet.com
Background.There is a rising trend in the number of abortions carried out for England and Wales residents and the total was 193737 in 20061. Only 1.5% (2948) of these was carried out at 20 weeks and over of which 34% (1002) were reported as involving feticide. In United Kingdom, termination of pregnancy (TOP) can only be carried out in a National Health Service (NHS) hospital or in a place approved for the purpose by the Secretary of State for Health (non-NHS setting). In 2006, 75328 (39%) of all abortions were performed in the NHS hospitals of which 679 (<1%) were at gestations of 20 weeks and above. The distribution of the feticide procedures between the two settings was not obvious from the published data1.
Objective. This study was conducted to assess the effectiveness and safety of intracardiac Potassium Chloride administration in inducing fetal demise prior to second trimester pregnancy termination in a non-NHS setting.
Patients and Methods.Data regarding the age, parity, gestation, dose of KCl required to achieve asystole, presence or absence of cardiac activity at delivery or immediately before surgery, duration of procedure (from entering to leaving the theatre) and complications were prospectively collected in an excel spreadsheet from February 2007 till date. The feticide was carried out in theatre under general anaesthesia, aseptic conditions and continuous ultrasound guidance. A 16 cm 17-G Chiba needle (Cook Ob/Gyn, Spencer, Indiana, USA) was inserted into the fetal heart and a concentrated KCl (15% , 20mM/10ml ; B-Braun Melsungen AG, Germany) was injected 1 ml at a time until fetal asystole was achieved. A minimum of 5 mls of KCl was given in each case but the dose required to achieve asystole was recorded. Fetal cardiac activity was then observed for about 1-2 minutes to confirm that asystole persisted, but scan was not repeated thereafter. Anti-D immunoglobulin (500 iu) prophylaxis was given to all RhD-negative women. Following feticide, labour was induced for those undergoing medical TOP and surgery the following day for the rest.
Results.Till date241 feticide procedures have been carried out for women between 20 and 24 weeks gestation (mean gestational age of 22 weeks) of which 2 (0.8%) failed to achieve fetal demise. Fifty women (21%) had medical TOP while the rest had surgery. The average age of the patients was 22 years (range 13 – 42 years) and the average parity was 1 (range 0 – 5). 48% of the women were teenagers. The average duration of procedure was 12 minutes (range 5 – 40 minutes) and the average dose of KCl required to achieve asystole was 3 mls (range 1 – 15 mls). No live birth occurred and no maternal complication. The two cases where feticide failed were for planned surgery which was carried out successfully.
Discussion.The Royal College of Obstetrician and Gynaecologists (RCOG) recommended that the method chosen for all terminations at gestational age of more than 21 weeks and 6 days should ensure that the fetus is burn dead. Feticide prior to TOP at late gestation is necessary to avoid resuscitation dilemma for patients, nurses and doctors2; to avoid medico-legal and economic consequences of live birth that survives3; to shorten the mean ‘initiation-expulsion interval4; to reduce the prostaglandin requirement for mid-trimester medical abortion5; and to soften fetal cortical bones which aids surgery and minimises risk to the patients4. Of the available methods for feticide6, intracardiac injection of potassium Chloride (KCl) appears to be the most effective. The average dose of KCl required in this study (3mls) is similar to that reported recently7, but much less than the amount reported by Bhide et al.8
Conclusion.This is, to my knowledge, the first report of the experience of using intracardiac KCl for feticide prior to mid-trimester abortion in non-NHS setting in United Kingdom. It is an effective and safe procedure in non-NHS settings with appropriately trained team and should not be limited to tertiary fetal medicine unit as suggested by Pasquini et al.7
References.
1. Department of Health Abortion Statistics, England and Wales: 2006, Statistical Bulletin 2007/xx. London: Department of Health 2007.
2. Royal College of Obstetricians and Gynaecologists. Further Issues Relating to Late Abortion, Fetal Viability and Registration of Births and Deaths. RCOG Statement London; RCOG Press; 2001.
3. Clark et al. An Infant who survived Abortion and Neonatal Intensive Care. Blumenthal PD et al. Abortion by Labour Induction. A Clinician’s guide to Medical and Surgical Abortion.
5. Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstet Gynecol 1999;94:139-41.
6. National Abortion Federation – Clinical Practice Bulletin: Digoxin Administration. May 2, 2007.
7. Pasquini L, Pontello V, Kumar S. Intracardiac injection of potassium chloride as Method for feticide: experience from a single UK tertiary centre. BJOG 2008;115(4):528-531.
8. Bhide A, Sairam S, Hollis B et al. Comparison of feticide carried out by cordocentesis versus cardiac puncture. Ulrasound Obstet Gyncol 2002;20:230-2.
-
Oct. 19, 2012, 02:00
Results: Two prospective cohort studies (n = 3821) and two
randomised controlled trials (RCTs) (n = 3821) were included.
Three thousand seven hundred and forty-nine women underwent
a procedure administered by an MLP and 3893 women underwent
a physician-administered procedure. Three studies used surgical
TOP with maximum gestational ages ranging from 12 to 16+
weeks; a medical TOP study had maximum gestational ages up to
9 weeks.
There was no difference in incomplete/failed TOP for
procedures performed by MLPs compared to doctors in RCTs of
surgical (OR: 2.00; 95% CI: 0.85, 4.68) and medical TOP (OR:
0.69; 95% CI: 0.34, 1.37). One prospective cohort study showed
increased odds of incomplete/failed TOP among MLPs versus
physician groups (OR: 4.03; 95% CI 1.07–15.28).
None of the included studies found a difference in the odds of
overall complications between provider groups.
Conclusions: Based on this evidence, there is no indication that
procedures performed by MLPs are less effective or safe than
those provided by physicians.Conclusion: Women undergoing a TOP who wish to avoid
another unintended pregnancy should consider immediate
initiation of either intrauterine contraception or the progestogen-
only implant. Service providers should be trained and supported
to provide these methods to women at the time of TOP. -
Oct. 22, 2010, 08:00
Efficacy and Acceptability of Home-Based Medical Abortion: A Systematic Review
Thoai D. Ngo, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Research and Metrics Team, Health System Department, Marie Stopes International,
London, UK
Background: Home-use of misoprostol can reduce the number of clinic visits required and improve access to medical abortion. We conducted a systematic review to assess the efficacy, safety, and acceptability of medical abortion administered at home versus at clinic.
Methods: The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Popline were searched for randomized and non-randomized prospective studies of medical abortion at home versus clinic. The main outcomes of interest were failure to achieve complete abortion, side effects, and acceptability. We calculated relative risks (95% CIs), and pooled estimates using a random-effects model.
Findings: Nine studies met the inclusion criteria (n=4,522 participants). All studies used a mifepristone-misoprostol combination for medical abortion. The proportion of women who had a complete abortion in home-based groups (n=3,478) ranged from 86% in India to 97% in Albania, with average success of 89.7%. Complete abortion in clinic-based groups (n=1,044) ranged from 80% in Turkey to 99% in France, with average success of 93.1%. Pooled analyses indicate that there is no difference in complete abortion between home-based (n=3,215) and clinic-based (n=593) intervention groups (OR=1.11; 95% CI: 0.65, 1.91). Serious complications of abortion were rare. Acceptability data indicate that women using self-administered medical abortion at home were more likely to be satisfied, to choose the method again, and to recommend medical abortion to a friend than women who opted for medical abortion at the clinic.
Interpretations: Evidence from prospective cohort studies suggests that the option of home-use of misoprostol for medical abortion is efficacious, safe, and acceptable to women living in both resource-limited and resource-rich settings. This option allows women greater flexibility and privacy in the abortion process, and could increase access to and acceptability of medical abortion.
-
Sept. 10, 2004, 09:15
Ethics and abortion
Lotti Helström, MD, Karolinska University Hospital , Stockholm
This lecture discusses attitudes towards induced abortion, held by members of medical staff involved. Most people have a morally and ethically defined opinion about induced abortions. Women in general, often regard induced abortions as something that other women may have. Should they, themselves consider induced abortion, it would be as an exception. Members of medical staff often express that induced abortions are requested by a special and “careless” kind of woman. Among members of medical staff, the free choice of induced abortions is often defended only by alternative dangerous, unsafe abortions, that women otherwise would expose themselves to. Such an attitude may reflect an attempt to avoid confrontation with the fact that induced abortions actually involve that the foetus is killed. The attitude helps the medical staff not to confront the eventual “moral advantage” of the anti-abortionists, who claim that they defend life. Members of medical staff need to carefully reflect on their own attitudes towards killing a foetus and also towards women who request abortions. It must be appreciated that the women who chose induced abortion, in fact are the same kind of woman as those who decide to carry out their pregnancies. With a reflective view, medical staff also has the best tool to help and advise a woman to avoid future abortions.
-
Oct. 22, 2010, 09:00
EU networking in sexual reproductive health and rights
Åsa Regnér, Secretary General RFSU, Sweden
Working with gender equality issues and SRHR at the international level is a constant battle, not only to advance the agenda but also to defend progress that has already been made. The International Conference on Population and Development (ICPD) in Cairo in 1994 was a breakthrough. This was the first time an international document, agreed within the UN, pointed to unsafe abortions as a major contributor to maternal mortality. The ICPD affirmed that regardless of national legislation, women must have access to quality services for the management of complications arising from abortion. Access to post abortion care is an issue that is still being debated at the UN.
In 1995 the Forth Conference on Women in Beijing sparked a renewed global commitment to the empowerment of women and to gender equality. This time countries around the world agreed to ìconsider reviewing laws which punish women for having illegal abortionsî. When the same language was put forward by the US this year at the UN Commission for Population and Development - some countries did not agree and therefore it couldnít be accepted.
In the European Union we have also seen a development during the last five or six years which points to an increasingly worrying political situation when it comes to SRHR. In 2004, when the ICPD Plan of Action celebrated its 10 anniversary, the EU issued strong and rights based Council Conclusion on the theme. Last year, at ICPDís 15th anniversary, nor the Czech or Swedish presidency dared suggesting the subsequent council conclusions on the agenda in fear of political set-back or conflict.
Within the EU the polarization between on the one side countries like Sweden, which prioritizes these
issues, the Netherlands and Denmark and on the other side Poland, Ireland and Malta has increased in the last decade. This inability to agree has lead to a split in EUís positions at the UN, resulting in member states negotiating as separate countries and not as the EU on issues on SRHRadmin. This is an obvious failure for the EU as an global actor.
One reason for the development within EU and globally is an unfortunate mixture of religion and politics.
Luckily, I think this last year there has been an awakening regarding the slow progress on reducing maternal mortality in the world. The UN Secretary General is particularly concerned about this and has therefore recently launched a Global Strategy and Joint Action Plan on women and childrenís health. In the strategy, the Secretary General points out life-saving interventions such as family planning services and making childbirth safe He underlines that in order to reach MDG 5 on maternal health women need to have access to comprehensive and integrated health services that include skilled care during childbirth at appropriate facilities, HIV prevention and also to safe abortion services (when abortion is not prohibited by law).
I recently attended the Millenium Development Goal Summit in New York. During the negotiations on the Outcome document the EU was able to take a strong approach on human rights and defended and pushed for wording on for example human rights and gender equality. This resulted in a better document than was first anticipated. However, because of this political division the EU could not push for wordings on reproductive rights or even state the linkages between unsafe abortion and maternal health. Still, we know unsafe abortion is the third biggest reason for maternal deaths. As a result the document doesn´t even mention access to post-abortion care, something that I as mentioned was already agreed upon in Cairo 1994.
The EU must do better. The EU, including the Commission and all member states, is the worldís largest donor of development aid. The EU is committed to reach the MDGs. This summer the Commission adopted a paper on a twelve point Action plan to reach the MDGs. One important point in the document is to focus on the MDGs most off-track, one of them being MDG5 on maternal health. Progressive and brave policies on issues on SRHR are therefore vital.
One formal obstacle when advocating for better SRHR policies within the EU is that the EU has no mandate to legislate on SRHR issues like abortion, sexual or reproductive health or sexuality education. Those are political decisions that fall under the so called principle of subsidiary, which means that member states decides on their own.
There are however some openings to include SRHR in EU politics:
1. The most obvious being that all member states have committed to implement the ICPD Programme of Action and the Beijing Action Plan and the MDG. In June the Development Committee in EP adopted a report on implementation of MDG in which it clearly states that EU member states and the commission should support policies on safe abortion.
2. There are also several important areas of EU-competence that touches upon issues of sexual and reproductive health and rights. Trafficking for the purpose of sexual exploitation is one example. Gender equality is another very important area. The EU also has some competence in the area of public health.
Experiences show that it has been easier to talk about sexual and reproductive rights in the area of HIV and AIDS. Recently (June 2010) the European parliament adopted a resolution on a rights based approach to the EUís respons to HIV and AIDS. The EP calls on the Commission and Member States to ensure the promotion, protection and observance of the human rights, including the sexual and reproductive rights, of people living with HIV and AIDS and other key population. The High Representative / Vice-President, Catherine Ashton, made a very supportive statement in front of the Parliament, committing to fully implementing this resolution.
3. EU claims to be a protector and promoter of human rights. EU:s inability to push for sexual and reproductive rights is not worthy an institution that is built on the fundament of human rights and democracy.
Lately we have seen a positive development on a human rights perspective on maternal mortality. It was a major breakthrough in June 2009 when the Human Rights Council of the UN adopted a resolution (resolution 11/8) stating that preventable maternal mortality and morbidity should be seen as a human rights issue. The human rights argument should be used towards the EU, now more than ever. The adoption of the Lisbon Treaty has strengthened the protection of human rights and hopefully also sexual and reproductive rights. For example:
The Charter of Fundamental Rights of the European Union (CFR-EU), 2000, can also be utilised to advance SRHR. Since December 2009, with the adoption of the EU Lisbon Treaty, member countries are bound to follow the Charter's provisions.
Since the adoption of the Treaty the European Union, as an institution, is also in process to accede to the European Convention for the Protection of Human Rights and Fundamental Freedoms Convention. The process of accession is expected to be finished in 2011.
The Treaty also gives EU citizens' a ìright of initiativeî. It means that a million citizens may sign a petition inviting the Commission to submit a proposal on any area of EU competence.
In addition the parliamentary assembly of Council of Europe ((PACE) has adopted a resolution in 2009 on ICPD +15 in which they call on the members states review, update and compare members statesí national and international SRHR policies and strategies and, in the context of reducing maternal deaths, reduce the numbers of unsafe abortions. Already one year earlier the assembly adopted a resolution on "Access to safe and legal abortion in Europe" in which they invite member states to guarantee womenís effective exercise of their right of access to a safe and legal abortion and decriminalize abortion.
4. The EUs role as international actor, for instance within the UN and through it´s development aid, which I described before.
There is much need for cooperation between actors who are determined to fight for a woman´s right to decide over her body, to reduce maternal mortality rates, to safeguard access to safe and legal abortions Global politics is not looking too good in this field right now, but some governments are determined to work in a progressive way. I believe it´s important that civil society, human right´s advocates, medical experts and politicians from many countries work strategically together and I am happy to be able to speak about these injustices in front of such a knowledgeable audience. I am convinced, although it sometimes looks difficult, that joint efforts will change the world to the better for women.
-
Oct. 20, 2012, 02:00
Examples from Italy
ABSTRACT TEXT
The Italian law no.194 approved in 1978, is often considered one of the most advanced inWestern Europe. An abortion may only be carried out in a public hospital and there are no special abortion clinics inItaly. The conscience clause is partially responsible for many of the difficulties in availability of services. The Article 9 provides for the non-participation of staff of any level who work in hospitals and do not want to participate in abortions for reasons of conscience. The objectors are freed from activity specifically directed to the interruption of pregnancy but not from assistance before or after the abortion. It is the responsibility of the hospital to ensure the procedure is efficient and the Region is responsible for the to the provision of the services. This brings to remarkable differences from one region of the country to another. For example the Region of Emilia Romagna, where social and medical facilities are easily available, offers better services with access to medical abortion. Conscientious objection is a major limiting factor in the implementation of the law. According to the Secretary for Health’s last report, at a national level nearly 71 % of the gynaecologists are conscientious objectors and in some regions this percentage reaches 80-85%. Medical abortion has been approved since 2009, but only within 49 days of amenorrhea, in spite of the European mutual recognition procedure. In all cases, with only two regional exceptions , a compulsory hospitalization is requested. So far the medical procedure is not readily accessible in all localities. Restrictions in access to abortion and lack of having the choice between a medical or a surgical procedure are currently the major problems.
-
Oct. 23, 2010, 09:00
Experiences of decriminalising abortion in Victoria
Dr Leslie Cannold, author, medical ethicist and the President of Reproductive Choice Australia and Pro-
Choice Victoria, grass-roots community groups that have played key roles in reforming Australian laws
In Australia, abortion is regulated by the states, most of which maintain abortion in the criminal code. In 2008, after a brutal political battle within and outside the Parliament, the Government’s Abortion Law Bill 2008 was passed into law without amendment. The new law removes abortion from the Crimes Act. Up to 24 weeks gestation, it is now regulated like all other medical procedures. After 24 weeks, doctors maintain control of the decision, two of whom must judge it as “appropriate in all the circumstances.” Subsequent efforts to reform laws similar to Victoria’s in NSW and Queensland, where a young woman is currently being prosecuted for the crime of procuring her own abortion, have so far been unsuccessful. Based on my involvement in successful law reform efforts nationally (in removing restrictions to the i mportation of RU486) and in Victoria, NSW and Queensland (in attempts to reform state abortion laws), I will identify factors vital to successful law reform efforts.
-
Oct. 24, 2008, 02:00
Experiences of health care professionals
André Seidenberg (Switzerland)
Zürich, Switzerland
andre.seidenberg@hin.ch
Not only by the general public but also by health professionals induced abortion is regarded as something special. Emotional, ethical, and psychological considerations were inevitable and a matter of course. We conducted a little survey on opinions and measures in the region of Zurich, Switzerland. Medical directors of gynaecological clinics take precautions for their staff, who is involved in induced abortion treatment.