More than 15 years of experience – new developments,
Kristina Gemzell Danielsson. MD. PhD, Associate Professor in Obstetrics and Gynecology at the Karolinska Institute, Stockholm, Sweden
Senior consultant in obstetrics and gynecology at the clinic of Sexual and Reproductive Health, Department of Woman and Child Health, Division for Obstetrics and Gynecology.at the Karolinska Hospital, senior research position at the Karolinska Institute sponsored by the Swedish Research Council
Head of the WHO collaborating centre for research in Human Reproduction, Karolinska Hospital, head of the research group at the WHO-centre. Supervisor of 3 PhDs and 9 PhD students. research nurses and laboratory technicians.
Secretary Swedish association of Obstetrics and Gynecology, task force on Family Planning
Board member of FIAPAC (International federation of abortion and contraceptive associates), and ICMA (International consortium of medical abortion)
Medical abortion with a combined regimen of mifepristone and a prostaglandin analogue was first approved in France in 1988 followed by approvals in the UK and Sweden, and has been used in China since 1992. In China and France medical abortion is used to 49 days amenorrhea. In the UK and Sweden the method is approved to 63 days amenorrhea. Today medical abortion is available in around 30 countries. During the last 15 years since introduction of the method research has focused mainly on the following issues: To find the optimal dose of mifepristone, the optimal type, dose and route of administration of prostaglandin and to increase acceptability of the method
Pharmacokinetic studies have shown that single doses of mifepristone above 100 mg resulted in similar serum concentrations. Randomised controlled trials have shown that 600 mg of mifepristone is equally effective as 200 mg when followed by a sufficient dose and suitable type of prostaglandin. The prostaglandin most commonly used today is misoprostol (Cytotec, Pfizer), a prostaglandin E1 analogue widely available for the prevention of gastric ulcer in patients taking non-steroidal anti-inflammatory drugs. Although licensed for oral use vaginal administration of misoprostol is becoming a common practice in medical abortion. Several clinical studies have found that vaginal administration is more effective than oral administration. When the absorption kinetics was compared between oral and vaginal treatment it was shown that the systemic bio-availability after vaginal misoprostol was three times higher than after oral misoprostol. This was directly reflected in the effect on uterine contractility. A drawback with the vaginal route is the large individual variation in plasma levels suggesting inconsistent absorption through this route. Furthermore most women prefer to take the tablets by the oral route. Recently the new route of sublingual administration has been described. Preliminary studies suggest that sublingual administration is a promising method for medical abortion. This is supported by pharmacokinetic and uterine contractility data indicating that this is probably the most potent route to administer misoprostol in its present form.
Current research also focuses on the possibility to reduce the time interval between mifepristone and misoprostol. Furthermore home administration of prostaglandin has been shown to be safe and effective, to reduce the number of visits to the clinic and to be preferred by many women in both developed and developing countries
Getting to hard to reach places: expanding access to rural Nepal through nurse provision of first trimester medical abortion
Alison Edelman1, Kusum Thapa2, Deeb Shrestha Dangol2, Indira Basnett2 1Ipas, Chapel Hill, North Carolina, USA, 2Ipas Nepal, Kathmandu, USA - firstname.lastname@example.org
In Nepal, abortion was legalized in 2002. It is permitted for any reason to 12 weeks, for rape or incest up to 18 weeks and for maternal or fetal indications at any gestational age. First trimester abortion services became more readily available in 2004. However, Nepal is a country of extremes with mountainous regions that are challenging to access and areas that are impassable at certain times of the year. Health care services are also limited by the number and type of provider. Creating access for women seeking life-saving care such as safe abortion and contraceptive services entails innovative strategies including task sharing. The Nepali Ministry of Health and Ipas have been working to increase abortion access in these hard to reach places. A pilot project was performed in 2010-2012 to train auxiliary nurse midwives (ANMs) from primary health centres/health posts in first trimester medical abortion (MA). As of June 2012, 216 ANMs were trained. Following training, 89% (233) have provided MA with 6056 women served [mean 4.6 women/month (SD=3.3)]. Overall service quality was high; 100% of women received pain management and 88% received postabortion contraception. Perceived enabling factors for MA provision identified by providers and facility managers included community awareness through media and volunteers, well-established referral mechanisms, support by facility administration and clients' beliefs about MA. Similarly, perceived barriers included a stable supply of MA drugs and equipment, insufficient counselling areas, inability to manage severe complications, medication costs and service disruption due to transfer of trained providers. Overall, 98% of women reported being very/mostly satisfied with services. Expanding the abortion provider base to include ANMs has increasing availability of safe services to Nepal's predominantly rural population. With the success of this pilot project, the Nepali government has incorporated the training of ANMs in MA into their national curriculum.
25 years of mifepristone
Kristina Gemzell Danielsson
Karolinska Institutet/ Karolinska University Hospital, Dept of Woman and Child Health, Division of Obstetrics and Gynecology, Stockholm, Sweden - Kristina.Gemzell@ki.se
Based on the combined regimen of a progesterone receptor modulator, RU 486, developed by Roussel Uclaf and the Nobel prize awarded discovery of prostaglandins, medical abortion with mifepristone and a prostaglandin analogue was developed into a safe and effective method for induced abortion in the 1980ies. A team of researchers led by Pr. Baulieu was critical in the development of mifepristone (RU486) as was the French Ministry of Health. Further researches from Pr. Bygdeman’s team in Sweden described the combined regimen with prostaglandin. Then the WHO and later the company Exelgyn further endorsed this method which provided women with an alternative to surgery. Since the 1980ies research has focused on improving the regimen and care of medical abortion. Today the prostaglandin analogue of choice is misoprostol and medical abortion is a safe option for termination of pregnancy at all gestational lengths. An increasing number of women worldwide benefit from this development. Besides even if there are still differences from country to country not only in access to medical abortions (legal situation, home use, gestational age) but also in the clinical routines of medical abortion care (protocol, reflection delay), Medical methods for termination of pregnancy tend to replace the surgical options in many countries. There is also an increasing recognition that medical abortion can improve access to safe abortion in countries with restrictive abortion laws or lack of abortion providers. However, several barriers remain that limit global access to safe abortion services. Simplifying medical abortion could potentially contribute to increased access and acceptability. Possible approaches include the option to self-administer misoprostol at home, also beyond 9 weeks of gestation. Another possibility is task sharing with midlevel providers to allow these health care professionals to be more involved with the care of healthy women undergoing medical abortion. These possibilities have major impact to increase access to safe induced abortion in countries were medical resources are scarce.
Abortion among minors. A French perspective
A. Durrieux, Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)
University Hospital of Marseille, France
Objective.The rate of abortions among teenagers is steadily increasing in France. We aimed to analyse the medical and social characteristics of minor patients requesting an abortion in order to improve preventive actions.
Patients and Methods.A retrospective analysis of 184 minor patients requesting an abortion in our department between 2005 and 2007. Minors represented 16% of the population requesting an interruption of pregnancy in our center.
Results.Mean age was 16.2 years (rang 14-17), 10% had already a child and 5% had repeat abortions during this period. Mean gestational age at abortion was 63 days. One third had a medical abortion and 70% surgical aspiration with general anaesthesia. The adolescents were accompanied during the procedure by their companion in 26% of cases. In 35% of cases, teenagers came with no family members and were accompanied by a social counsellor. Teenagers had been referred to the abortion clinic through a family physician in 47% of cases, through the Family Planning associations in 11% and had come directly to our center in 43% of cases. Concerning contraception, 51% had declared using a condom, 25% used no method and 16% used an oral contraceptive. None of our patients used a dual contraception combining a condom and hormonal contraceptives. Only 5% had used an emergency hormonal contraception. Post abortum contraception prescriptions were : 75% oral contraception, 6% long term reversible contraceptions (IUD or implant) and 4% contraceptive patch or vaginal ring. 15% of the teenagers refused a contraception prescription. At the post abortum visit 46% did not show up for further explanations on their contraceptive method.
Conclusion.Minors accessed at our abortion center at advanced gestational ages often unaccompanied by their companions. Condoms were frequently used by minors but seem insufficient in preventing unwanted pregnancies. Use of emergency contraception was exceptional. Post abortion contraception was mainly tailored on oral contraceptives and follow-up visit attendance for further contraceptive counselling was low. Other contraceptive options such as IUD or implants were underutilized in post abortum and need to be evaluated.
Abortion care over the Internet: New options for women
Rebecca Gomperts (The Netherlands)
Unsafe abortion causes the death of 70 000 women every year. 1 in 300 women undergoing an unsafe abortion dies. These death are totally preventable. Medical abortion with Mifepriston and Misoprostol has a mortality risk of less than 1 per 500.000.
Women on Web is a service which uses telemedicine to help women access mifepristone and misoprostol in countries with no safe care for termination of pregnancy (TOP). After an online consultation, women with an unwanted pregnancy of up to nine weeks are referred to a doctor. If there are no contraindications, a medical TOP is conducted by mail. The presentation will discuss the impact of the online abortion help service by looking at women’s acceptability, efficacy and curettage vacuum aspiration rate after the medical abortion.
Abortion in Portuguese Health Primary Care
Cunha José Manuel, C. Ribeiro, R. Aguiar, C. Lomba, A. Mateus, F. Fonseca, A. Simões, L. Campos, C. Silva (Portugal)
Administração Regional de Saúde do Norte, Porto, Portugal
Introduction. The fulfilment of the new Portuguese legislation on the interruption of pregnancy by woman’s free option made it necessary the creation of a public care rendering net that involved Hospitals and Health Care Centres. The Centres were attributed the generic function of women reference to the hospitals where if it carried the medical and surgical interruption takes place. The availability of some professionals allowed to organise in three Centres a consultation of medical interruption of the pregnancy by option of the woman until 10 weeks. There is a protocol of joint with the nearby hospitals that answer to the complications and the situations of medical abortion failure.
Objectives. Description of medical abortion practice by the woman’s option, done by general practitioners in family health services.
Method. The women appeal to the consultation voluntarily or referred by other institutions. The process consists of previous consultation where dating of pregnancy is confirmed by ultrasonographic scan. The law imposes three days of reflection, followed by a 2nd consultation where the therapeutic with Mifepristone starts; 36 - 48 hours later the process is completed with Misoprostol. Pregnancy termination is confirmed 2- 3 weeks later by ultrasonographic scan.
Results. Since October 2007 until May 2008, 118 abortions had been carried through. There were 4 medical abortion failures which required surgical termination and 1 case of hemorrhagic complication that needed curettage.
The study of the evaluation of the women’s satisfaction confirms a high level of satisfaction.
Conclusions. The results of abortions by the woman’s option done in these family Health Services are similar to the published ones in literature.
Abortion providers' resilience to anti-choice tactics in the United States and Canada
Maureen Paul1, Katharine O'Connell White2, Wendy Norman3, Edith Guilbert4, E. Steve Lichtenberg5, Heidi Jones6 1Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA, 2Baystate Medical Center/Tufts University School of Medicine, Springfield, Massachusetts, USA, 3University of British Columbia, Vancouver, British Columbia, Canada, 4Institut National de Sante Publique du Quebec, Quebec City, Quebec, Canada, 5Family Planning Associates Medical Group, LTD, Chicago, Illinois, USA, 6CUNY School of Public Health, Hunter College, New York, New York, USA - email@example.com Objectives: To estimate the prevalence of anti-choice tactics on abortion facilities and to evaluate abortion providers' experiences with stigma in the United States (USA) and Canada. Methods: We conducted a cross-sectional survey of abortion facilities identified via publicly available resources in the USA (N=705) and Canada (N=94) from June through December 2013. Clinic administrators responded to facility-level questionnaires; surgical and medical abortion clinicians responded to individual-level surveys which included a 15-item validated stigma scale. Results: 690 clinicians and 456 facilities participated; 54% of USA facilities and 83% in Canada. 83% of USA and 33% of Canadian facilities experienced at least one form of harassment in 2012, most commonly picketing without blocking (66%). These experiences were more common in private offices (88%) or ambulatory centres (83%) than hospital-affiliated facilities (29%). Only 7% of facilities (all in the USA) reported staff resignations due to harassment. 41% of USA-based clinicians and 18% of Canadian clinicians reported personally experiencing harassment in 2012. 99% disclosed being an abortion provider to their partner or close friend, 88% to a parent, and 74% to a child. The stigma scale showed high reliability with a Cronbach's alpha of 0.80. Only 1% had high stigma scores, 26% moderate to high, 65% moderate to low and 8% low, with no differences by facility type. One third reported always/often/sometimes feeling marginalized by other health workers, but 87% reported always/often feeling they are making a positive contribution to society. Conclusion: Abortion providers and facilities experience several forms of harassment, which is more commonly reported in the USA than Canada. However, providers demonstrate resilience to stigma in both settings.
Abortions at home in Gothenburg
Monika Axelsson, Liselotte Holmqvist (Sweden)
Sahlgrenska University Hospital, Gothenburg, Sweden
Background. This poster describes patient satisfaction in women choosing to perform their abortions at home. Since 1975, the number of abortions in Sweden has varied between 30 000 and 38 000 annually; some 2 500 per year are performed at the Abortion Department at Sahlgrenska University Hospital/Östra. New abortion methods have been introduced since the Swedish Abortion Act was passed in 1975. Medical abortion in early pregnancy is undergoing constant development and more women currently choose it over the surgical method. An increasing number of women, currently 20-25%, want the possibility to conclude their abortions at home. A quality review was performed in order to develop and improve the method.
Method. A questionnaire was filled out by 60 women at their follow-up appointment with at midwife four weeks after the ”home abortion”.
Results. The average age was 34.3. Seventy-one percent had given birth, of whom 64.5% had given birth vaginally. Previous abortions were reported by 34.9%; 90.7 appreciated being scheduled for all abortion-related appointments at the first visit; 69.8 found the interval from the positive pregnancy test to the completed abortion appropriate, while the rest thought that the interval was too long.
Conclusion. Women choosing to conclude their abortions at home report that the method works well for them and they are satisfied with their choice. Questionnaire results also show that information and access to care are important.
Acceptability of medical termination of pregnancy
up to 63 days of gestation with home
administration of misoprostol: assessment of
Kopp Kallner, H1; Fiala, C2; Gemzell-Danielsson, K1
1 Department of Obstetrics and Gynaecology, Karolinska Institute 7,
Stockholm, Sweden; 2 Gynmed Clinic, Austria
Objective: The objective of this study was to identify signiﬁcant
factors affecting acceptability of home administration of
misoprostol for medical termination of pregnancy (TOP) up to
63 days of gestation.
Methods: This study was conducted in a University Hospital
Outpatient Family Planning Clinic. Women who were in good
general health, above 18 years of age, with no contraindication to
medical TOP, requesting medical TOP with home administration
of misoprostol and with pregnancies up to 63 days of gestation as
evaluated by ultrasound were asked to participate. Women
received 200 mg of mifepristone in the clinic and were instructed
to self-administer 0.8 mg of misoprostol vaginally at home 36–
48 hours later. Women ﬁlled in questionnaires which were
answered after the TOP and at follow up. Patients also ﬁlled in
daily symptom diaries. Follow-up was 2 weeks later with physical
examination and low sensitivity urine-hCG according to clinical
practice. All factors extracted from the questionnaires which could
potentially affect acceptability were analysed using multivariate
Results: In total, 395 women who opted for home administration
of misoprostol for medical TOP were recruited. We found that
the presence of a partner/friend during the TOP affected
acceptability in a positive direction (P = 0.021). In contrast,
having a positive low sensitivity urine hCG at follow up affected
acceptability negatively (P = 0.002), although most of these
women had a successful and complete TOP. In contrast to other
studies on medical TOP, we could not ﬁnd an inﬂuence of age,
gestational length or the requirement of extra pain medication on
overall acceptability of the procedure.
Conclusions: Home administration of misoprostol for medical
TOP up to 63 days of gestation is highly acceptable. Women
should be encouraged to have a partner/friend present during the
TOP if possible as this affected acceptability of the procedure in
this study. In order to further increase acceptability of home
administration of misoprostol, focus of future research should be
directed towards increasing the number of complete TOPs in a
shorter time frame.
Access in different countries and current status
Elisabeth Aubény, gynecologist, President French Association for Contraception, Hopital Broussais, Paris. Co-founder and Past President of Fiapac
The early medical abortion method is authorized in Europe in many countries. The authorized method, in France(since1989), Austria, Belgium, Denmark, Holland, Germany, Spain, Switzerland, Slovenia (since 1999), until 49 days of amenorrhea, is Day 1: mifepristone 600 mg taken at the abortion center with the patient going home immediately afterwards, Day 3: misoprostol 400 µg taken orally, followed by medical supervision for 3 hours in the center; Day 10-15: check-up visit. In Sweden (1993) in U.K,(1994) this method is authorized until 63 D.A. with gemeprost, as prostaglandin, taken vaginally. But among these countries, the use differs from one country to another. It is used in Sweden and Switzerland more than 50 %, in Belgium, France and Finland around 30 %, it is used in Holland and U.K, around 15 % and less than 5 % in others authorized countries. The use of medical abortion in a country depends of many factors: length of legal authorization, price of the abortion and its reimbursement by assurance to the patient, fee of doctors paid by assurance, but also reticence of doctors to change their habits for a method they don’t know exactly. In the future ameliorations can be bring to this method specially used without any hospitalization, practice by trained general practitioners in their on practice. Women who have the possibility to choice this method are very satisfied. It is our medical duty to propose it.