Speeches
-
Oct. 15, 2016, 04:00
PS05.1
Integrating abortion training in sexual and reproductive health care
Johannes Bitzer
University Hospital Basel, Basel, SwitzerlandPreventing unwanted pregnancies is a main objective of sexual and reproductive health care. This is achieved by women and men-friendly contraceptive services including patient centred counselling, availability of all methods, shared decision making, follow-up care etc. In reality, women are still very often confronted with unwanted pregnancies which they experience as a threat to their global health. These women need a high standard of abortion care including easy and rapid access to abortion services; non discriminative, empathic care; shared decision making about the available methods; safe and professional procedures by well trained professionals; qualified and appropriate follow up including postabortion contraception.
These qualities should be provided by recognised abortion training for health care professionals in the field of sexual and reproductive health
Abortion training: The training has to be based on 3 elements:a) Knowledge:
- Knowledge about epidemiological data, early and late pregnancy development, endocrine and non endocrine factors involved in pregnancy development, diagnostic procedures to determine the pregnancy week, diagnosis of missed and threatened abortion
- Knowledge about medical and non medical abortion techniques (dosages, timing, procedure) efficacy, risks, side effects, Standard operating procedures
- Knowledge about postabortion contraceptionb) Skills:
- Case for medical abortion. Exact procedure
- Technique of surgical abortion (simulation) assisting, performing under supervision, performing alone
- IUD and implant insertionc) Attitudes:
Group discussion about ethical and psychosocial, sociocultural aspects of abortion and critical incident reporting -
Oct. 2, 2014, 12:00
Integrating abortion within a community sexual and reproductive health service: a qualitative study of the experiences of women and health professionals
Carrie Purcell1, Sharon Cameron1 ,2, Anna Glasier1, Julia Lawton1, Jeni Harden1 1University of Edinburgh, Edinburgh, UK, 2NHS Lothian, Edinburgh, UK - carrie.purcell@ed.ac.uk
Background: Abortion in Scotland has historically been provided in a hospital setting. The availability of early medical abortion (EMA), and the possibility for women at early gestations choosing to go home to pass the pregnancy (soon after receiving misoprostol form the abortion service), have enabled the provision of abortion from an integrated community sexual and reproductive health (SRH) service. However, little is known about the impact of the clinical setting on the experiences of staff involved in the EMA service. This paper presents findings from the staff experience arm of a qualitative evaluation of EMA provision in both SRH and hospital settings. Objectives: - To examine the experience of nurses, nursing aides, doctors and sonographers involved in EMA provision. - To explore whether, and in what ways, the clinical setting shapes this experience - To highlight areas for good practice/ improvement Method: Qualitative interviews (N=35) were conducted with staff involved in EMA provision at one SRH-based and two hospital-based abortion services in central Scotland, between October 2013 and April 2014. Interviews were coded using NVivo 10 software and analysed thematically. Results: Staff in both settings emphasised the importance of team working and cited the quality of care offered as a success of the EMA service. They also described experiencing challenges, including: boundaries between roles, training, resource constraints, adjustment to change, and the perceived marginalisation of abortion services. Relative differences were identified between clinical settings, for example: nursing staff in the SRH setting described greater involvement with post-abortion contraceptive uptake; nursing aides in the SRH context expressed more negative views on their work role. Conclusions: There are many similarities of experience across staff groups and between clinical settings. Differences between the settings reflect the benefits and the challenges of the new SRH service.
-
Oct. 13, 2006, 02:00
Is ultrasound necessary
Danielle Hassoun, MD, Paris, France
The question remains whether Ultrasound (US) is a mandatory requirement for performing
medical abortion. In fact, it is very useful in diagnosing early pregnancy, in allowing early
diagnosis of ectopic pregnancy and finally in confirming success or failure of the method.
However, not having access to US technology should not be considered as a barrier to
introducing medical abortion.
To diagnose very early pregnancy requires very good equipment and highly trained
providers. Without a vaginal probe, the diagnosis of a pregnancy less than 6 weeks
remains nearly impossible.
At the follow up visit, the use of US can confirm the success or failure of the method and
especially the reassurance there is no on going pregnancy but it can also be responsible
for unnecessary interventions because of faulty interpretations of the images.
In high resource settings, where the equipment is readily available and the providers are
highly trained, the possible risk is that US may be used as a replacement for clinical exam,
resulting in a potential loss of clinical skills.
In low resource settings, where the equipment is possibly inadequate and providers not
sufficiently trained to use it, relying on their very good clinical skill
can make them good medical abortion providers.
Lessons learned after almost 20 years of experience in this field show that US is not a
requirement when clinical exam and BHCG (when accessible) are concordant with the
condition that the providers maintain a good level of clinical skill. -
Oct. 25, 2008, 02:00
IUD after medical abortion: Should it remain underused?
Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)
University Hospital of Marseille, France
pascaleroblin@yahoo.fr
Objective. Immediate post-abortum IUD insertion remains an underused option in daily practice. We evaluated the safety and acceptability of IUD insertion shortly after medical abortion at the office.
Patients and Methods. In a prospective series of 300 women who underwent medical abortion in a private office before 49 days, we observed the incidents that occurred among the 104 patients (34,6%) that opted for an insertion of IUD shortly after abortion. Uterine vacuity had been controlled by ultrasound between the 8th and 12th days post abortum. IUD were inserted between the 8th an 30th day following abortion. None of the patients had received prophylactic antibiotics. 62 (60%) patients had hormonal IUD and 42 (40%) had Copper IUD.
Results. Women’s mean age was 31 years, 26% were nulliparous and 37% had already had previous abortions. None of the patients had long term reversible contraceptions before requesting an abortion and only 5 (1,6%) had used emergency hormonal contraception. 72% of IUD were inserted at the control visit on the 8th day. When uterine vacuity seemed incomplete, IUD insertion was postponed but for 90% of our patients insertion was possible before day 30. No mechanical (expulsion or perforation) and no infectious complications were registered. At insertion, the mean pain score on an analogical visual scale was 2/10. Mean duration of bleeding following IUD insertion was 6.5 days. With a follow up of 24 months in our database, 8 patients (7,7%) requested IUD removal : in 2 cases because of pelvic pain but no evidence of pelvic inflammatory disease, in 2 cases for excessive bleeding and in 4 cases for desire of pregnancy.
Conclusion. Our preliminary findings suggest that IUD may be offered shortly after an induced medical abortion before 49 days. When such method is chosen by the patients, safety and continuation rates seem high. Proposing an IUD immediately after a first trimester abortion at the office may help reduce repeat abortions.
-
Sept. 15, 2018, 11:00
Outcomes of various medical abortion research have been difficult to compare. Outcomes such as “effective”, “successful”, “complete” are defined differently in various studies or sometimes not defined. “Adverse events” similarly may not be reported or reported without clear definition.
The goal of Medical Abortion Reporting of Efficacy (MARE) guidelines is to standardize early medical abortion efficacy reporting to facilitate comparison of outcomes between studies and to enhance data synthesis from different studies. This brief presentation will discuss the MARE guidelines for research methods.
Eligibility: the eligibility criteria for participants should be clearly stated, including the range of gestational age, the methods used to determine gestational age, and the conditions for ineligibility.
Interventions: the study should state the medications used, including dose(s) and route(s) of administration. The planned time interval (in hours) between medications should be stated.
Outcomes: researchers should define primary and secondary outcome measures, including how and when they were assessed.- Define successful medical abortion: MARE guidelines propose that “successful” medical abortion should be defined as successful expulsion of the intrauterine pregnancy without need for surgical intervention.
- There are several categories of medical abortion failure:
- Ongoing pregnancy. Continuing pregnancy should be defined as a viable pregnancy following treatment (differentiated from a retained gestational sac)
- Incomplete abortion
Heavy or problematic bleeding
Assessment: Describe follow-up assessment used to determine outcome, for example, combination of ultrasound and physical exam, any pregnancy tests, symptoms checklist, etc. State the length of time planned to follow participants to determine outcomes. Reporting outcomes in a standardized manner will enhance data synthesis to produce evidence-based guidelines. -
Oct. 23, 2010, 11:00
Medabon introduced by Concept Foundation
Peter Hall, Chief Executive Officer, Concept Foundation, Bangkok, Thailand and Geneva, Switzerland
In order to make medical abortion more widely available, Concept Foundation, a not-for-profit organization based in Bangkok, Thailand, has been working to get a product available of assured quality at an affordable cost. It has been responsible, though a public-private partnership between WHO, Concept Foundation and industry, for the development of Medabon®, a co-packaged product containing 200mg mifepristone and 800µg misoprostol. The issue of abortion is often highly controversial, sensitive, emotive and with significant socio-cultural and moral dynamics and thus the introduction and use of products for medical abortion products requires careful planning. It is necessary to develop and implement an appropriately designed introductory process, which takes a systematic and incremental approach; ensures coordination and collaboration between the public health system and all key stakeholders; and utilizes a supportive health system. This has been undertaken with Medabon® in Cambodia, Nepal and Zambia.
-
Oct. 23, 2010, 02:00
Medical abortion: analysis of three marketing websites selling misoprostol
Deyanira González de León, A., Universidad Autónoma Metropolitana Xochimilco, Mexico City, Mexico
Co-authors: Erika Troncoso, María Elena Collado, Raffaela Schiavon (Ipas Mexico)
The use of Internet has increased considerably and has become a common tool to search for information on issues like abortion, especially among young people. Internet is an important source of information about the use of misoprostol as abortifacient and currently there are websites selling the drug (commercially distributed as Cytotec). In this paper we present the results of a study aimed to explore the information about medical abortion (MA) offered through websites selling Cytotec, as well as the most common questions from its users. The final purpose of this study was to obtain evidence that could be used to improve information strategies on the use of misoprostol as abortifacient.
MA is, alongside with manual vacuum aspiration, one of the standard methods recommended by the World Health Organization (WHO) to terminate pregnancies. The practice of MA has increased in many countries over the recent years and has substantially contributed to improving the quality of legal abortion services. The combined use of mifepristone and misoprostol is currently the most effective regimen for early MA and has been included in the complementary List of Essential Medicines of the WHO since 2005. Millions of women worldwide have used this combination of drugs and have found it to be safe and
effective.
Mifepristone is not legally available in most countries of the developing world and the use of misoprostol alone has become a safe alternative to provide early MA in places where the drug is available. An optimal regimen for the use of misoprostol alone is still under research, but clinical studies report high efficacy rates –around 85% and more- when applied vaginally or sublingually for pregnancies of 63 days’ gestation or less.Because of legal restrictions on abortion the use of misoprostol alone has gained interest and acceptability among physicians in Latin America. Besides, the drug is increasingly being self-administered by women as an alternative to other dangerous methods. In many countries, misoprostol is available at pharmacies without medical prescription, and in some, such as Brazil and Peru, its use has been associated with less complications and deaths.
In Mexico, abortion laws remain highly restrictive except for Mexico City where abortion was decriminalized in 2007 and is permitted on demand during the first 12 weeks of gestation. Since then, public health services governed by the local Department of Health provide abortions using the WHO recommended methods. In 2008, 39% of all legal pregnancy terminations were done using misoprostol alone.11 On the other hand, the use of misoprostol as abortifacient is common and increasing in Mexico, but as in other Latin American countries both women and pharmacists, and even many physicians, lack of enough information on the safest and most effective doses of the drug, or about what to expect during the process or what to do if it fails.
A search performed in 2008 found seven websites offering misoprostol, out of which three were selected for further analysis: Ayuda Cytotec, Cytotec México, and Soluciones Cytotec. Criteria used for the selection was that these websites had question/answer sections, open not only to buyers but also to all visitors. 20% of all questions and answers registered between January and June 2008 were randomly selected for each one of these websites. The search was done giving a marker to each question and then making a random selection of them using the SPSS. The analysis was performed on 215 cases, which were incorporated into an Excel database. The database included the specific website, questions, dates of questions and answers, and answers from the website. Although the database included information on sex and age of those consulting, as well as weeks of pregnancy and use of misoprostol at the time of the query, these data were not always consistent because of insufficient information at the websites.
The results show that the five most common questions asked by users referred to: how to detect if the abortion was completed (21%); information about the use of misoprostol, including efficacy, risks related to previous abortions, weeks of gestation, and confirmation of pregnancy, among others (17%); routes of administration and dosage (11%); side effects (9.7%); and post-abortion care (7.9%). In addition, 79% of questions were made by women; 41% of those consulting had 9 or less weeks of gestation; and 43% were using misoprostol at the time of the query.
A first conclusion is that the selected websites not only sell misoprostol but also represent a useful source of information about the drug (dosage, gestational limit, side effects). However, these websites do not include accurate information about the evolution of an abortion using misoprostol or what to do in case of failure. This kind of information is only available to those using the question/answer sections and answers from the websites do not always meet the needs of users. Another conclusion is that self-administration of misoprostol without all the necessary information is a common practice among women. Finally, the analysis of the questions made by users demonstrates the need to elaborate documents and other resources that give women complete, accurate and reliable information about MA.
-
Oct. 25, 2008, 11:00
Medical abortion at 7 - 9 weeks gestation: Considerations and challenges
Kristina Gemzell (Sweden)
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden
kristina.gemzell@ki.se
Medical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined with a prostaglandin has been available in Europe since 1988 for termination of pregnancy up to 49 days of amenorrhea. In the UK (1991), Sweden (1992) and later on Norway the method is approved up to 63 days of amenorrhea. Recently medical abortion up to 63 days has been approved also in the rest of Europe. With the recommended regimen the high efficacy and acceptability of the method can be maintained beyond 49days. Critical aspects to consider when medical abortion is used beyond 49days of pregnancy will be discussed in the workshop. These include the regimen of mifepristone and misoprostol, the interval between the drugs, pain medication and home-use of misoprostol. An increasing number of women in Europe opt for this choice instead of surgical abortion. A shift which is expected to continue in the next years world-wide. It is crucial that providers are familiar with the method and aware of the critical differences compared to medical abortion before 49 days of pregnancy.
-
Oct. 23, 2010, 11:00
Medical Abortion at 9-13 Weeks
Professor Allan Templeton, University of Aberdeen, United Kingdom
The formulation of the antiprogesterone drug mifepristone in the 1980s led to the development of safe and effective medical abortion as an alternative to surgery. Initially the regimens were used in the early first trimester and second trimester, and increasingly employed the prostaglandin E analogue misoprostol given by a variety of routes, including oral (swallowing), vaginal, sublingual and buccal.
About ten years ago this approach was also assessed for use in the late first trimester and as a result medical abortion is now used at all gestations, where preferred to surgery. This review will focus on 10 years experience of late first trimester medical abortion at one centre, including efficacy, side-effects and acceptability. It will also illustrate how frequent review has facilitated improvement and development of the regimens used.