Fatim Lakha

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    Impact of emergency contraception (EC) on contraception and abortion


    Fatim Lakha, MD, Contraceptive Development Network, University of Edinburgh, UK


    Emergency contraception (EC) has the potential to reduce the numbers of unintended pregnancies and thus reduce both rates of abortion and total fertility rates. However, this is only if everyone uses it every time the need arises.

    A pilot study undertaken in Edinburgh in 1997 demonstrated that having an advanced supply of EC led to increased use of EC and a trend towards a decreased relative risk of unintended pregnancy (relative to not having advanced supplies).

    A large Lothian-wide study followed in 1999. Women aged 16 to 29 were offered 5 packets of EC to keep at home.

    At the end of 2001 25% of the targeted population had been reached.

    A random sample of 11 general practice (GP) clinics and the family planning clinic (FPC) were used to audit data. Women who had supplies from these clinics were asked to complete a questionnaire. 5,543 questionnaires were analysed.

    It was estimated that at least 8,800 courses of EC had been used during the study. 75% of women who had used EC had within 24 hours. This indicated increased but responsible use of EC with home supplies. The trend was for women to move to a more effective method of contraception after being supplied with advanced EC.

    Disappointingly, whilst advanced provision increased use, it did not result in a reduction in numbers of unintended pregnancy. 

    74% of those followed-up who had had an unintended pregnancy had not used EC to prevent that pregnancy because they had not recognised the risk.

    Regardless of potential efficacy of EC, effectiveness depends on the user and their individual perception and acknowledgement of risk.

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    New perception on contraception


    Fatim Lakha,  MD, Contraceptive Development Network, University of Edinburgh, UK


    Abortion is inevitable. Intuitively, one would hope that numbers of abortions could be reduced by women using contraception more consistently. In practise this is difficult to achieve.

    In first world countries where awareness of contraceptive methods is good, correct utilisation, if at all, remains poor.

    There are very few data on the effectiveness of counselling to reduce rates of unintended pregnancy.

    A small study from Switzerland investigated behaviour modification following professional counselling six months post termination of pregnancy. It demonstrated a high prevalence of contraceptive use after abortion. A similar small UK study of women undergoing repeat abortion indicated inconsistent counselling leading to women opting for less effective methods of contraception. In depth interviews with a group of women following abortion in London described little change in behaviour and contraceptive counselling was shown to have been superficial.

    Two randomised control trials have attempted to evaluate counselling as an intervention designed to improve contraceptive use after abortion. One from Iceland showed no significant difference in contraceptive use, the second from Scotland demonstrated an increased uptake of long-acting methods. Follow-up in both these studies was too short to confirm a reduction in repeat abortion rates.

    Further studies are needed to evaluate strategies to improve contraceptive uptake and continuation rates, and to determine their effectiveness in reducing unintended pregnancies.

Ann Lalos

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    Psychological impacts on men

    Ann Lalos (Sweden)

    Department of Obstetrics and Gynecology, Umeå University, Umeå, Sweden

    In general, men involved in induced abortion constitute an invisible group and there is scarcely any knowledge about their reactions and reflections. Thus, to increase knowledge and understanding of the complexity of the abortion situation 75 Swedish men involved in abortion were studied.

    Most men were found to live in stable relationships with a financially good position. A quarter had previously experienced an abortion. Wanting an abortion did not imply that the men experienced their standpoint as easily conceived. Contradictory feelings towards the pregnancy appeared among more than one third and more than half used both positive and painful words to describe their feelings in connection with the abortion. Nearly half of those who solely expressed positive initial feelings towards the pregnancy also stated that they wanted an abortion.

    Twenty-six of the men participated in a follow-up study 4 and 12 months post-abortion. Nearly all of them were happy with the women’s decision to have an abortion at both follow-ups. They experienced the abortion as a relief and a responsible act. Simultaneously, abortion could also be experienced as a painful and ethically problematic act. Overall, most men had only positive experiences post-abortion, such as a feeling of maturity. However, it was also found that 1-year post-abortion, more than a third consistently did not use a reliable contraceptive method.

    For deeper understanding of the complexity of the abortion situation it is of great importance that men’s ambivalence and experienced paradoxes also become visible. In the work to prevent induced abortions it is of fundamental importance that a gender perspective is incorporated.

Margareta Larsson

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    The adoption of the Emergency Contraceptive Pill in Sweden


    M Larssona*, K Eureniusa, R Westerlingb, T Tydéna,b

    aDepartment of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden

    bDepartment of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden

    Margareta Larsson, RNM, PhD (in May)


    Aim To examine the adoption of the emergency contraceptive pill (ECP) in Sweden before and after the deregulation in 2001 and to evaluate a community-based intervention including a mass media campaign and information to women visiting family planning clinics in one of two cities in mid-Sweden.


    Method Waiting room questionnaires were administered to abortion applicants in the two cities during 2000(N=361), 2002(N=187) after deregulation of ECP and 2003 (N=448) after the intervention. The main outcome measures were; knowledge, attitudes and practices of ECP and exposure to the intervention.


    Results The overall response rate was 88%. General awareness about ECP had increased from 83% to 92%, and the proportion of women who had ever used ECP increased from 22% to 35% over time. Almost two-thirds (63%) of the targeted women had noticed the information campaign and one out of three (33%) who had visited a family planning clinic during the intervention year recalled being given information about ECP. Media and friends were the most cited sources of information on all occasions. The belief that ECP could have a negative influence on regular contraceptive use decreased over time from 36% to 25%. The majority of women (58%) would have used ECP if it had been available at home. Women’s knowledge of how to access ECP had improved after the intervention and the percentage of women who had an abortion within the previous year had decreased.


    Conclusion ECP is gradually becoming a more widely known, accepted and used contraceptive method in Sweden .

Barbara Laschalt


Francoise Laurant


Antonella Lavelanet

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    WHO strives for a world where all women’s and men’s rights to enjoy sexual and reproductive health are promoted and protected, and all women and men, including adolescents and those who are underserved or marginalized, have access to sexual and reproductive health information and services. Access expressed through laws, policies, and guidelines is a key component of the enabling environment for safe abortion. However, abortion laws and policies can be punitive or protective;  specific or non-specific; confusing and even contradictory at times, all of which may exacerbate a chilling effect on those who seek, provide or advocate for access to services.
    Launched in June 2017, the Global Abortion Policies Database (GAPD) contains abortion laws, policies, standards and guidelines for UN and WHO Member States designed to strengthen global efforts to eliminate unsafe abortion by facilitating comparative analyses of countries’ abortion laws and policies. The abortion laws, policies, and guidelines within the GAPD are juxtaposed to information and recommendations from WHO safe abortion guidance, national sexual and reproductive health indicators, and UN human rights bodies’ guidance to countries on abortion. 
    This presentation provides a brief overview of the GAPD, an analysis of selected countries, and demonstrates the vagueness and complexities that exist in laws and policies.

Jitsai Lawantrakul et al.

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    Emergency contraceptive pills: Knowledge, experience and dominions of undergraduate students in a University in Southern Thailand

    Jitsai Lawantrakul and Pranee Pongpaiboon, Assistant Professors Faculty of Nursing Prince of Songkla University, Jitti Lawantrakul, Obstetrician & Gynecologist Hatyai Hospital, Sopen Chunuan, Associate

    Professor Faculty of Nursing Prince of Songkla University, Thailand.

    Adolescents’ sexual behavior leads to the problem of unwanted pregnancies and unsafe abortions, which contributes significantly to maternal morbidity and mortality The purposes of this descriptive study were to explore the levels of knowledge, experiences, and opinions of Emergency contraceptive pills (ECPs) of undergraduate students in a University in Southern Thailand.

    The subjects were undergraduate students from the Prince of Songkla University, Thailand. The sample size was determined using Yamane’s equation and there were 200 participants. The questionnaire was developed by researchers with KR-20 (0.78). The subjects completed a questionnaire dealing their demographic characteristics, knowledge about ECPs, experiences of using ECPs, and their opinions of ECPs.

    The results revealed that the subjects’ knowledge level was moderate (55%).  Most of the subjects (84.5 %) had heard about ECPs. Only 7 % had ever used them and nearly half of the users (42.86 %) had experienced side effects of ECPs. The sources of subjects’ knowledge were schools, friends, internet, journals or magazines. As to preferred sources, the subjects would like to get information from friends and health personnel. Regarding who should give information about ECPs, they favored health personnel especially pharmacists, physicians, and nurses. As to opinions about ECPs, they agreed that adolescents should have knowledge about ECPs and know how to use them. They disagreed that male adolescents should be the ones to decide to use ECPs for their partners.

    This study provided the information that the level of adolescents’ knowledge was moderate and they need more information and accurate knowledge from health personnel. Thus, health personnel, especially nurses, should take a proactive role in educating, advocating, and supporting adolescents and the general population by providing information about ECPs.

Gunta Lazdane

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    Experience of application of WHO tools and guidelines in the WHO European Region

    in improving quality of abortion services

    Gunta Lazdane, MD, PhD, Regional Adviser Sexual and Reproductive Health and Research, WHO Regional Office for Europe


    Prevention of unsafe abortion is one of the five core aspects of the WHO Global Reproductive Health Strategy adopted by the World Health Assembly in 2004. However, up to 20 % of all deaths during pregnancy in several countries of the European Region are due to unsafe abortion. There is a lack of reliable data on morbidity after abortion. Many Member States and ministries of health (in the countries of central and eastern Europe, France, Luxemburg, the Netherlands, Sweden) have focused on prevention of unwanted pregnancy and unsafe abortion and improvement of reproductive health services at primary

    health care.

    The role of the WHO in the Region includes distributing existing evidence on abortion, assisting countries in evaluating health systems’ response to the needs of women with unwanted pregnancies and building the capacity of health care professionals in counselling and abortion care. 

    WHO has assisted governments and professional organizations in developing national policies on sexual and reproductive health policies based on the detailed analysis of the country situation in prevention and management of unwanted/unplanned pregnancies and quality of abortion services. Recently this exercise has been carried out in Azerbaijan, the Republic of Moldova, the Russian Federation, the former Yugoslav Republic of Macedonia, and Ukraine. In most of these countries WHO’s Strategic Approach tool has been used to answer the question on how to reduce the recourse of abortion and improve the existing health services. National guidelines on safe abortion have been developed with the WHO assistance in Armenia, the Republic of Moldova, the former Yugoslav Republic of Macedonia, Tajikistan, and Ukraine. Summary of the challenges in improving access to quality abortion services in the WHO European Region will be presented.

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    Recent developments in Eastern Europe
    Gunta Lazdane, MD WHO Regional office for Europe, Regional Adviser
    for Reproductive Health and Research, Copenhagen, Denmark
    During the last two years, several countries in the eastern part of the WHO European
    Region have developed and approved national reproductive health strategies and
    programmes including the component of reproductive choice and access to abortion
    services. The analysis of the present situation has been made based on the official
    statistics as well as results of surveys and research projects carried out in these countries.
    The trend of declining in abortion rates is obvious in eastern Europe; however, the number
    of abortions in adolescents and young women remains high. Different barriers have led to
    discrepancies between official and survey-based abortion rate, for instance, in Georgia
    according to official data the number of induced abortions per woman in 2005 was 0.3, but
    it was 3.1 according to the Reproductive Health Survey carried out by the Ministry of
    Labour, Health and Social Affairs of Georgia, Center for Disease Control USA, United
    Nations Population Fund and United States Agency for International Development.
    The number of death cases from unsafe abortion has decreased as well, however, it some
    countries it is still almost 20 per 100 000 live births: the quantitative target of the WHO
    European Regional Strategy on Sexual and Reproductive Health (2001) is less than 5 per
    100 000 live births.
    Since 2003 when “Safe Abortion: Technical and Policy Guidance for Health Systems” was
    published by WHO, it has been translated into Russian and used in many countries
    (Armenia, Georgia, Kyrgyzstan, the Republic of Moldova, the Russian Federation,
    Tajikistan, Ukraine, etc.) to develop national guidelines and to improve access to
    reproductive health services and the quality of care.
    With WHO assistance, strategic assessment of reproductive health services, including
    those for abortion, has been carried out in the Republic of Moldova and the outcomes will
    play an important role in further development of the plan to implement the recently
    approved National Reproductive Health Strategy. In 2006-2007 strategic assessment
    projects are planned in the Russian Federation and Ukraine.

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    Situation of induced abortions in Europe and policy changes


    Gunta Lazdane , WHO Regional Office for Europe


    There are 52 Member States in the European Region of WHO with a diverse political, economic, religious and social situation. There are countries with diversity of legal grounds to perform abortion, and countries with the lowest and highest numbers of induced abortions in the world.

    The numbers of induced abortions have been decreasing all over the Region for the last 10 years, yet the rate of abortions per 1000 women 15-19 years old is much more stable and even increasing in some parts of the Region. The same trend is observed in some migrant groups or in ethnic minorities.

    Despite the improved access to information, reproductive health services and contraception that decreases the number of unwanted pregnancies, there are still many problems to be solved:

    -   in some countries more than 20% of maternal deaths are due to the complications of abortion,

    -   the complication rate after abortion is high,

    -   there is a lack of statistics in many countries,

    -   there is a lack of political will to face and solve the problems related to abortion.

    The Reproductive Health and Research programme in the WHO Regional Office for Europe has included the reduction of induced abortions as one of the objectives and targets in the WHO European Regional Strategy on Sexual and Reproductive Health (2001) and recommends the implementation framework to reach this target. WHO assists those Member States who have prioritized this problem as one of the major causes of women’s ill-health in their countries.

Medard Lech

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    Combined oral contraception and weight changes

    Medard Lech, Fertility and Sterility Research Center Warsaw and L.Ostrowska, Medical University of

    Białystok, Poland

    Obesity is associated with a host of medical conditions, including diabetes mellitus, osteoarthritis, cardiovascular diseases, sleep apnea, breast, colon and uterine cancer, pregnancy and reproductive disorders.  Last but not least, overweight [and obesity] is of great  concern to most women in today’s world.

    There are many, complex, inter-related reasons for overweight and obesity in women, a phenomenon which is related to genetic, endocrine, social and other factors.  The most common reason for obesity is high food intake and low levels of physical activity. Some pharmaceutical products may also affect the energy balance in women and thus lead to overweight and obesity.  The list of such pharmaceuticals is not fully defined, but steroids (and most commonly, hormonal contraceptives) are often included here.

    As combined oral contraception [COC] is the most popular method of hormonal contraception, there is a large number of publications discussing the unwanted side-effects of COC. Generally the discussion focuses on cardiovascular problems, whereas the most common concerns of patients concentrate on weight gain and cancer risk, especially the risk of breast cancer.  This discrepancy between scientific concerns and the problems arising in clinical settings is even greater due to the long list of possible unwanted side-effects mentioned in COC pack inserts. 

    Clinical practice during the 60’s and 70’s showed that COC use was linked to estrogen related nausea, vomiting, headache and breast tenderness.  Since that time, the estrogen dose in COC has been markedly diminished, largely to reduce the rate of unwanted, cardiovascular effects, but also as the method of lowering the number of side effects related to quality of life [headache, breast tenderness, nausea and vomiting]. Most controlled clinical trials found neither a correlation between COC use and body weight nor any possible mechanisms affecting body weight in COC users.

    Although there is no - scientifically-proved - relationship between COC use and weight gain, many women have discontinued their use of hormonal contraceptives due to “weight gain”.  More than half of US women believe that COC causes weight gain. Gynecologists from all over the world report that their patients frequently consider COC one of the causes of their “weight gain”, but neither early [with COC containing more than 35 mg ethinyloestradiol] nor recent [with COC containing 20 – 35 mg ethinyloestradiol] placebo-controlled trials confirm this.

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    Concerning contraception


    Medard Lech, MD, Director of the Fertility and Sterility Research Center in Warsaw, Poland. He is also a Senior Consultant Gynecologist in ENELMED Medical System in Poland. After earning his medical degree from the Medical University of Warsaw in 1967 he has completed his postgraduate education at Bielanski Teaching Hospital of Warsaw obtaining the Fellowship Diploma of the Obstetrics and Gynecology College of Poland. He is also a specialist in Public Health. He has obtained broad clinical and educational experience during his service in State Postgraduate Medical Education Center of Poland, State University of Maiduguri (Nigeria) and St Luke’s Teaching Hospital of the University of Malta. The author of more than 100 published abstracts, peer-reviewed papers and reviews, he has served as Principal Investigator and Investigator on numerous clinical trials. He is Editor-in-Chief of Polish Quarterly Journal Antykoncepcja – Aktualności. He is a member of the Polish Gynecology Society and Society of Social Medicine and Public Health. He is a member of Board of Directors and the Executive Committee of European Society of Contraception.


    It is important that couples have easy access to a  wide range of methods of birth control so they can freely exercise their choice in the matter of procreation. This can be achieved in several ways; sterilization (male or female), effective contraception, or abortion. Abortion  should be a “last resort method” of birth control. Wherever the availability of effective methods of contraception is restricted, the rates of induced abortions are high.

    51.5% out of 377.5 million of European women live, in Eastern/Central Europe (year 2003). Historically, induced abortion has been a common method of birth control in this part of Europe, mostly due to the lack of modern contraceptives (ie any method other than the rhythm method or coitus interruptus). In these countries in 1994, 43% of women aged 15-44 years used no contraceptive method, 27% relied on withdrawal and 6% the rhythm method. In 1996 the contraceptive prevalence rate was still only 35%. As a consequence of a low  usage of modern methods of contraception these countries have high birth rates in very young women (ie. 6% in Czech Republic, 7.4% in Poland, 9.1% in Hungary). The increased use of modern contraceptives is directly correlated with declining abortion rates.  As an example, the annual number of abortions in the Czech Republic declined by 65% from 107,100 in 1990 to 37,200 in 1999  as modern contraceptive use increased seven fold in the same period of time. Inverse correlation can be seen between the abortion rate and use of modern contraception in Romania and Bulgaria is very well documented for the years 1950 – 2000.

    Prevalence of contraceptive usage in Central/Eastern Europe (in women aged 15-49 years) varies from 20-23% in Lithuania, Moldova and Ukraine to 73-76% in Hungary and Bulgaria, In some countries, modern methods of contraception are unpopular (eg in Romania; use of all methods – 57%, but modern methods only - 14%.  Total fertility rates all over Central/Eastern Europe - in recent years - have fallen, and in most countries have reached less than 1.9 (excluding Albania). It seems unlikely that this is due to a decrease  in sexual activity of  the people; it must be due to increased use of birth control methods, especially the use of modern contraception. The increase availability of modern methods of contraception is a signum temporis for people living in Central/Eastern Europe, but from the other hand quality family planning services are getting less and less available in these countries. In many of these countries there are still barriers to proper information and sexual education of young people

Mariet Lecoultre

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    Counselling in 2nd trimester: What do women need?

    Mariet Lecoultre (The Netherlands)

    Beahuis & Bloemenhove Kliniek, The Netherlands

    From 7 weeks LMP onwards, the Dutch Pregnancy Termination Act (1984) provides for a mandatory five-day consideration period. The actual abortion can take place in at least 5 days after a first consultation with a doctor. During this initial doctor’s appointment the GP/MD must inform the woman of the alternatives available to her. The woman herself decides whether she continues her pregnancy or not.

    In 2006 32,992 abortions were performed in the Netherlands. 13.7 percent of these interventions concern women who are non residents of the Netherlands. Due to the restrictive law in their respective countries, these women have to travel to another country for the intervention. As in the previous year, 15.2 percent involved second-trimester abortions from 14 weeks LMP onwards. 70% of these second trimester abortions concerned non Dutch residents. The great majority (94.3 percent) of the interventions in Holland takes place in one of the 16 specialized abortion clinics and is done by general practitioners.

    The Centre where I work is specialized in second trimester abortions. We perform interventions till 22 weeks am. Many of the women we see have gone through various and sometimes difficult stages in their demand for a termination due to the fact that they have passed the legal delay for an abortion in their home country or have consulted a doctor who has ethical difficulties in dealing with second trimester abortion and refuses to refer her to a clinic where she could have the intervention.

    Although there is not much difference in second and first trimester counseling it is our  experience that all women have to be offered the possibility to discuss their demand. The true conviction of our entire staff is that it is only the woman who can decide and consequently counseling should be superfluous unless the woman indicates that she needs a consultation about her decision with a professional. However, as we are bound to a law which is not so liberal – contrary to what many may believe from the Netherlands – I will focus my presentation on the typical Dutch model we have developed to work within the framework of this law and at the same time leave the responsibility of the decision to the woman.

Philippe Lefèbvre

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    Choice between medical and surgical abortion,


    Philippe Lefèbvre  MD, Président de l’ Association Nationale des Centres d’Interruption de grossesse et de Contraception, Chef du Service d’Orthogènie – Hôpital La Fraternité, Roubaix, France


    Interrupting her pregnancy is a decision which belongs to the woman and only to her. However, once this decision is made, since a medical environment is required to guarantee her safety, the choice of a technique will take place whereas medical power is potentially at risk of being overbearing. The purpose of this paper is to evaluate if the objective and subjective elements of choice are the sole factors to intervene in the choice of the TOP method.


    The duty of informing the patient about the various available options , their respective efficiency, and their potential risks, allows in theory , the woman to make an informed choice.


    However, the medical practices are subject to numerous contingencies such as : access time, availability of mifepristone, presence of an anesthesist practitioner, economical viability of the medical act, implementation of the hospital-city network, lack of training, and sometimes , the difficulty for a doctor to challenge himself his own practices or habbits.


     The litterature about good practices and clinical guidelines states that the type of technique , medical TOP or chirurgical TOP, is defined by the gestationnel age. But working by this sole criteria is obviously not enough, while the choice of a technique should be reached through a good medical consultancy , establishing a dialog between the patient and the professional (counsellers, nurses, doctors,) developping appropriate proposals.


    The buy-in of the patient to the chosen method plays an essential role in the physical as well as psychical acceptance of the TOP.


    Experience in the field shows that the TOP method will be all the more accepted by the patient that her buy-in shall have been seeked and reached.


    Despite the ongoing upgrades of the techniques for the last 30 years , it is a shame that making a true choice available to the patient remains so highly dependant on some practitioners good will. 

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    Comparison between local and general anaesthesia

    Philippe Lefèbvre, Marie Duriez (France)

    Service d’Orthogénie (Hospital Family Planning Service), Roubaix, France

    Aim. To identify potential risk factors of inefficiency for elective medical termination of pregnancy based on records of failures of this technique in a hospital environment.

    Patients and methods. A retrospective study was conducted on elective medical pregnancy terminations performed up to 49 days post amenorrhoea in the Family Planning Service of Roubaix hospital between January 1st 2001 and December 31st 2005.

    The service's termination protocol consists in an oral dose of 600mg mifepristone, followed by an oral dose of 400mg misoprostol 48 hours later. A 2nd oral dose of misoprostol (400mg) is given 3 hours later if there has been no expulsion. Every patient is required to return 15 days later to check their bHCG levels.

    Failure is defined as ongoing pregnancies, total or partial retentions, and cases requiring emergency surgery. Success is defined as complete abortion requiring no additional surgical or medical treatment.

    Five items were analysed: patient age, patient parity, duration of pregnancy, bHCG levels on the day mifepristone (D1) was given, and the dose of misoprostol received.

    Results. 1,975 medical terminations were performed during this period. 125 (6.33%) of these patients did not return to be checked and have been excluded from the study. The analysis was thus performed on 1,850 patients.

    The method was a success in 97.08% of cases (1,796/1,850). 54 failures (2.92%) were recorded, including 7 ongoing pregnancies (0.38%). Patients for whom the method resulted in a success compared to patients who had failures have a significantly lower age. The duration of pregnancy was not different for the two groups. Nulliparous (873/1,850) patients had significantly fewer failures (12/873: 1.37%) than multiparous patients (42/977: 4.30%). Age is significantly higher for failures amongst the nulliparous patients. Conversely, for patients who have had at least one child, age is not a determining factor.

    28 patients did not receive any misoprostol because they expulsed prior to the 48th hour (1.51%). Amongst the 673 patients who received only a single dose of misoprostol, 11 (1.63%) required additional actions including one emergency admission for haemorrhage. Amongst those who received two doses of misoprostol, 43 failed (3.74%), including 2 re-admitted the same day for haemorrhages and 1 for pelvic pains.

    Discussion and conclusion. The overall efficiency results for the method are excellent despite an exhaustive and detailed analysis of the failures. The various studied factors have demonstrated that there is an increase in failure rates for the method with parity and, to a lesser extent, with the patient's age. High plasma beta HCG levels are also seem to be more often associated with failures of the method. The addition of a second dose of misoprostol is likely to increase the chances of an expulsion during the hospital stay but, this non-comparative retrospective study can not conclude on the beneficial effect of a second dose of misoprostol on overall efficiency.

    Finally, it should be noted that none of the criteria evaluated in this study can be used as a diagnosis factor to predict the outcome of an elective termination as none of them has the sensitivity / specificity that is required to identify 'at risk' patients from amongst other patients.

Lena Lennerhed

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    Abortion and psyche - Myths on abortion and mental disorder

    Lena Lennerhed, Professor in History of Ideas, Södertörn University and President of RFSU, the Swedish

    Association for Sexuality Education, Sweden

    In the presentation, the assumption that abortion leads to trauma or has other mental aftereffects, will be discussed. In particular, the theory on the so-called PAS, Post Abortion Syndrome (or PASS, or Post Abortion Stress Syndrome), and its impact on public debate on abortion in several countries since the 1980´s, will be focused.  PAS is not included in the International Classification of Diseases ICD or the Diagnostic and Statistical Manual of Mental Disorders DSM, and never was or is an acknowledged diagnosis or condition. The PAS theory plays a central role in the rethoric of many anti choicegroups.

    It will be shown, from swedish examples, that beneath psychiatric arguments often lies ethical ones; that trauma or disorder are related to the killing of the fetus and that this is unethical, and that these arguments sometimes goes back to religious ones. In addition, some references will be made to scientific studies on the issue. A result shared by many psychologists, psychiatrists, gynecologists and sociologists is that distress after abortion is moderate and temporary and that more severe reactions are rare. There are also studies showing that predominant reactions are relief and mental growth.

Roberto Lertxundi

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    The scientific community emphasizes the evident need to utilize an effective contraceptive method as rapidly as possible following an abortion. After surgical procedure: There is no question in regards to the convenience of inserting intrauterine contraceptives immediately after a surgical termination, if the woman so desires. Like many other groups we offer this presentation with 250 IUD inserted immediately after a surgical termination, at the end of the procedure through out 2015 and 2016. The results after a year of follow up, are equivalent to others that are usually published on the the subject of continuation, expulsion, failure and satisfaction of the IUD. When shall the IUD be inserted following a MToP? In our opinion, as soon as possible, that is, in the first follow up visit after the procedure. There is no benefit in delaying the insertion. Therefore we refuse the notion of delayed insertion (3-4 weeks after the abortion) and we recommend an early insertion (between 5 and 14 days after the MFP intake.) Often, the follow up visit is the only opportunity for the patient to begin using an adequate  contraceptive. The benefits of LARC over SARC are evident. We will present a study of the early insertion of 115 IUD after MToP through out 2015 and 2016. The results, as we will prove, are similar to in IUD users in general.
    Our recommendation:
    -Insert the IUD as soon as possible
    -Take advantage of the opportunity of follow up visit
    -Let none leave the follow up visit without an adequate contraceptive.
    1.-Heikinheimo O, Gissler M,Suhonen S. Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion. contraception. 2008;78:149-154
    2.-Cameron ST, Berugoda N,Johnstone A, et al.Assesment of a “fast track” referral service for intrauterine contraception following early medical abortion. J Fam Plann Reproductiva Health Care. 2012;38:175-178
    3.-National Institut for health and Welfare. official Statistics from Finland. Induced abortion 2015 (Internet). Published Oct 2016. Available from: http/

Gaël Lévéder


Hang Wun Raymond Li

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    There is wide variability in contraceptive choices and preferences among different populations.  None of the commonly available contraceptive methods is perfect, and each method has its own merits and limitations.  Important factors that commonly determine women’s contraceptive choice include effectiveness, safety and side effects, affordability and accessibility, user friendliness as well as non-contraceptive benefits.  The relative importance of these attributes varies between different users and is influenced by one’s own fertility planning as well as her physical, social and cultural circumstances. While effectiveness is emphasised by most providers, the acceptance and satisfaction is greatly determined by the perceived or actual safety and side effect profile.  Menstrual bleeding changes may positively or negatively affect method satisfaction and continuation.  


    Concerns about weight gain, effects on sex life and other side effects are also important reasons for method discontinuation, and these may be exaggerated by myths and misconceptions. Affordability and accessibility do vary with specific populations. Improved user-friendliness can be conferred by promoting the use of long-acting reversible contraceptives which are generally easy to use, more “forgettable” and less user-dependent.  Non-contraceptive benefits such as improvement of menstruation-related symptoms and acne by hormonal methods and prevention of sexually transmitted infections by condoms are additional merits to some users.  Healthcare providers generally have great influence on the contraceptive choice of most women. The tiered-effectiveness approach combined with shared decision making can be a useful way of contraceptive counselling. Within the effectiveness framework, the most effective methods are discussed first, while addressing the user’s own concerns, preferences and reproductive goals.  This aims at achieving the optimal balance between effectiveness and other attributes based on the user’s personal circumstances.

Steve Lichtenberg

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    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 -

    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.

Michel Lièvre

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    Meta analysis of 200mg vs 600mg
    Michel Lièvre
    Clinical Pharmacology Unit of Lyon, Faculté de Médecine Laënnec, Lyon, France
    Although mifepristone has been approved in Europe, USA and Israel for termination of
    pregnancy (TOP) at a dose of 600 mg in combination with prostaglandins, 200 mg is a
    widely used dose, and has even been recommended by the WHO. We have therefore
    assessed the evidence in favor of using 200 mg instead of 600 mg mifepristone for TOP.
    Two main end points have been considered jointly: success (complete expulsion of the
    conceptus) and ongoing pregnancy, the worst modality of failure. Because it is impossible
    to prove the identity of two treatments, choosing between 200 mg and 600 mg
    mifepristone has been dealt with as a non-inferiority issue. Non-inferiority limits have been
    set from the pivotal studies used to grant the marketing authorization in France, resulting
    in absolute values of -4% for success and 0.5% for ongoing pregnancy, corresponding to a
    consented loss in success of 4% and a consented increase in ongoing pregnancies of
    67%. The results of the 4 randomized trials comparing 200 mg with 600 mg mifepristone
    (in combination with either oral misoprostol or intravaginal gemeprost) have been
    summarized by a meta-analysis (rate difference method). These studies involved 1739
    women allocated to 200 mg and 1743 to 600 mg mifepristone at up to 63 days
    amenorrhea. Success ranged between 89.3% and 93.6% in the 200 mg and between
    88.1% and 94.3% in the 600 mg group. Ongoing pregnancy ranged between 0.55% and
    2.78% in the 200 mg and between 0% and 1.89% in the 600 mg group. The meta-analysis
    showed a 0.4% [-1.4%, 2.3%] absolute difference in rate of success, allowing to conclude
    to the non-inferiority of 200 mg compared with 600 mg mifepristone. For ongoing 

    pregnancy, the difference was 0.4% [-0.3%, 1.0%], which did not allow to consider 200 mg
    non-inferior to 600 mg mifepristone. Two sensitivity analyses gave similar results.
    Conclusion. Although similar rates of success can be expected from 200 and 600 mg
    mifepristone combined with either misoprostol or gemeprost, it cannot be excluded that the
    use of 200 mg may lead to a clinically significant increase in the number of ongoing

Katarina Lindahl

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    Women’s right for induced abortion within the EU
    Katarina Lindahl, secretary general RFSU, The Swedish Association for Sexuality

    What is neded to make Womens right to safe abortion a real possibility in all Europe!
    The presentation will discuss the current situation for women in Europe concerning
    access, legislation and security as well as changes that lately have been made.
    Political and legal obstacles to safe and legal abortion will be discussed and the
    consequences for women when laws are restrictive.
    In that part comparison between countries like Sweden and countries with very strict
    legislation will briefly be made.
    Here a brief mentioning of the arguments in a more global context will be made, e.g. if or
    to what extent arguments are imported to Europe from e.g. USA?
    I will also discuss abortion as a right and touch on the most important arguments when
    abortion is discussed in Europe.
    Abortions as a right or as a health issue are two often discussed strategies. What is the
    best way to argue in Europe, and where shall the issue be discussed? Is the European
    parliament a useful arena?


Meta Lindström

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    Selfperception of Swedish gynaecologists performing abortions
    Meta Lindström, Umeå University, Department of Clinical Sciences, Obstetrics and
    Gynecology, Sweden 
    Background. The Swedish gynecologists possess three decades of experiences of
    working with legal abortion. It is of great importance both for women in society and for the
    gynecologists themselves to learn from their experiences. The aim of our study was to
    describe Swedish gynecologists’ clinical and emotional experiences when working in
    abortion care. Further aims were to elucidate their perception of women’s motives for
    having abortion as well as looking for possible demographic and gender differences.
    Methods. A questionnaire comprising both structured and semi-structured questions was
    sent to a random sample of 269 Swedish gynecologists. The response rate was 85%.
    Results. The female gynecologists were younger (27-59 yrs) and numerically more than
    the males (33-66 yrs). Almost all believed that gynecologists should be involved in abortion
    care, and half were opposed to the privilege of refusing to work with TOP (termination of
    pregnancy). The gynecologists supported the shift from surgical to medical abortions but
    not to them being managed in primary healthcare. A few gynecologists (n=42) had
    considered changing their job because of TOP being part of their work. Misgivings
    occurred sometimes in connection with surgical and late abortions (n=60 and n=108
    respectively). Few gynecologists (n=33) had felt inadequate when encountering abortion
    patients and more than half thought that working with TOP was a positive experience. The
    gynecologists expressed that continuing professional development and ongoing guidance
    of TOP matters were important.
    Conclusions. In general, Swedish gynecologists have no doubts about taking part in and
    performing TOP. However, there are differences in opinions especially regarding surgical
    and late term abortions. Due to the fact that female gynecologists were younger and
    therefore had fewer years of work with TOP comparisons of females’ and males’
    experiences could not be done. Trends of gender differences were noticed concerning the
    right of having possibility to refuse taking part in TOP on personal grounds and with male
    gynecologists feeling to a higher extent inadequacy compared with females meeting the
    abortion seeking women. Gynecologists’ clinical and emotional experience, as expressed
    in this study, as well as their perception of women’s motives for abortions, indicate that
    they have gained deep insights and developed their professionalism in their work with

Olga Loeber

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    Challenges in contraceptive counselling in abortion care

    Olga Loeber (The Netherlands)

    Mildredhuis, Centre for Contraception, Sexuality and Abortion, Arnhem, The Netherlands

    Use of contraception prior to abortion


    One would assume there is no problem: all forms of contraception are possible after an uncomplicated first trimester abortion. Moreover in the clinics in the Netherlands there is always attention to contraceptive counselling after abortion. So, why is the repeat abortion so high?

    In the eighties this percentage was around 25%, now it is more than 36%. The abortion rate is also higher: in 1992 this was 5,5 per 1000 women in the fertile age, in 1999the rate was 7,4  and in 2006 the rate was 8,6.

    Apparently for some women effective use of contraception is a growing problem. Ineffective use of contraception is directly related to use of less effective methods but also to personal factors. Personal ideas that can cause ineffective use are opinions like: all those hormones cannot be good for you, he should use something; using contraception means you have a stable relationship or want to have sex.

    A survey in Sweden of the characteristics of the women with a repeat abortion showed a psychological vulnerability: they had many problems and a feeling of insecurity towards partners and contraceptive use. The cause of the contraceptive failure was not the lack of knowledge or information, but the lack of the ability to integrate this in actual behaviour.

    Other research in the Netherlands showed that these women do not seem to learn from former experiences.

    A last factor seems to be related to country of origin. In the Netherlands many women who have a (repeat) abortion come originally from other countries. About 57% of our abortion clients is born in another country, a huge overrepresentation compared to the general population. This group uses more often no contraception at all and makes more mistakes in using the pill, condoms are unpopular. Among the countries of origin differences are apparent because of differences in background, per region and in culture.

    Compared to the Netherlands the contraceptive use in other countries can be very different from that of the Netherlands due to

    • different man/woman relations,
    • religious conceptions,
    • availability of contraception,
    • fear of some forms of contraception,
    • fertility wishes,
    • discussion of sexual matters can be taboo.

    These differences are important in counselling women about contraception after abortion, so as to find the best contraceptive choice for this one individual patient in front of you.

    Conclusions and recommendations.

    • Thorough knowledge of contraceptive problems and solutions
    • Attention to factors responsible for failure of contraception
    • Knowledge of cultural factors
    • Counselling with these factors in mind
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    Contraceptive counselling after abortion


    Olga Loeber  MD, Mildredhuis-Rutgershuis, Centre for Contraception, Sexuality and Abortion, Arnhem, The Netherlands


    In the Netherlands contraceptive counselling forms an integral part of the intake procedure. Almost all forms of contraception is feasible after an uncomplicated first trimester abortion. Still the number of repeat abortion is relatively high in most countries even if there are a broad knowledge about and availability of contraceptive possibilities.


    Knowledge and availability are only partly the prerequisite for effective contraception. Social personal factors (for instance fears, myths, ambivalence towards pregnancy, ability to negotiate, characteristics of the relationship with the partner) are equally important. Personal counselling with tailored advice is of utmost importance. This counselling could be done not only by doctors but also by various other personnel with a broad understanding and knowledge of contraception and underlying personal factors as for instance nurses and  midwives.

    Possible explanations for the repeat abortion rate and practical solutions will be discussed.

    Cases and points of view dealing with this topic will be the basis of a discussion with the participants of the workshop. Comparison between countries could lead to a better understanding of the subject.

Patricia Lohr

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    Gender-biased sex selection

    Lena Luyckfasseel IPPF European Network, Brussels, Belgium -

    Sex selection can take place before a pregnancy is established, during pregnancy through prenatal sex detection and selective abortion or following birth through infanticide or child neglect. Nevertheless, the discussion seems to focus especially on abortion. Sex selection is sometimes used for family balancing purposes but far more typically occurs because of a systematic preference for boys. Practised on a large scale it can result in skewed sex ratios at country-level. The root causes of gender-biased sex selection are situated in persistent gender inequality leading to son preference. Other conditions that need to be present for prenatal sex selection are low fertility (people choosing smaller sized families) and the availability of the technology. In 2011 the Parliamentary Assembly of the Council of Europe in their resolution on "Prenatal Sex Selection" stated that there is "strong evidence that prenatal sex selection is not limited to Asia [...] and has reached worrying proportions in Albania, Armenia and Azerbaijan". This has put gender-biased sex selection firmly on the European agenda. It is important to frame the discussion on gender-biased sex selection in such a way that it does not impede women's access to safe abortion services. Following a short introduction to the topic a diverse panel will explore the following questions: What does gender-biased sex selection mean for us? How do we respond to gender-biased sex selection; towards individuals, practitioners, decision makers and anti-choice?

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    RU OK? Provider perspectives on follow-up with remote technologies after early medical abortion

    Lesley Hoggart1, Patricia Lohr1, Jeanette Taylor1, Chelsea Morroni1, Hillary Bracken2, Beverly Winikoff2 1bpas, Stratford Upon Avon, UK, 2Gynuity Health Projects, New York, USA - Objective: Guidelines from the World Health Organization and Royal College of Obstetricians and Gynaecologists suggest that routine in-clinic follow-up is not required after early medical abortion. New diagnostic and communication technologies promise to allow women to assess their abortion outcome at home. Yet little is known about healthcare providers' attitudes and opinions about the elimination of clinic follow-up. Methods: Providers in 4 clinics in the bpas clinic network in the United Kingdom were interviewed after participating in a randomized clinical trial testing the feasibility of using remote communication technologies for follow-up after early medical abortion. Clinicians and non-clinical staff (N=10) at participating clinics and the bpas call centre participated in 3 focus group discussions guided by a qualitative researcher. Participants were asked about their perspectives on in-clinic follow-up and home follow-up by phone, text message or email. Focus group discussions were recorded, transcribed, and analyzed thematically by the authors. Results: Participants were open to alternative approaches to follow-up after medical abortion. Staff recognized the need to improve follow-up rates but were sceptical improvement was possible, and uncertain about how to balance time management issues with women's needs. Providers described a tension between two imperatives: to respect women's postabortion preferences and to ensure contact and knowledge of postabortion outcomes. Providers felt responsibility for follow-up was part of their duty of care; although some acknowledged that retaining this responsibility clashed with the bpas culture of trusting women to control their own bodies and reproductive lives. Conclusions: Overall, although there was an evident diversity of views, clinic staff felt that they had a responsibility to follow-up women after early medical abortion. Efforts to introduce home follow-up after medical abortion must be accompanied by training that addresses providers' concerns and ambivalence about allowing women to manage the procedure at home.

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    Very early surgical abortion

    Patricia Lohr, MD, MPH, Medical Director bpa, United Kingdom

    The availability of highly sensitive pregnancy tests means women are now able decide very early in pregnancy if they want to have an abortion, often before an intrauterine gestation can be visualised on ultrasound. Medical abortion with mifepristone and misoprostol is one method of terminating very early gestations; however for some women a surgical option will be preferable. This talk will review safe and effective means of performing surgical abortion before 7 weeks gestation and discuss the risks and benefits as compared to medical abortion with mifepristone and misoprostol.

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    Before the 1967 Abortion Act, unsafe abortion was a leading cause of maternal mortality in the UK, responsible for 14% of maternal deaths. The Royal College of Obstetricians and Gynaecologists (RCOG) has identified as a key priority the need to ensure today’s abortion services are sustainable into the future. Changes to the commissioning and delivery of abortion services have had a significant impact in recent years. The shift towards provision of abortion services by the independent sector has directly led to a reduction in the training opportunities and placements available to doctors working within the NHS. This has resulted in a smaller number of doctors with the requisite skills to deliver abortion care to women across the UK. The low prestige and stigma that can be associated with abortion care are also affecting morale within the profession. 

    To help overcome the challenges with the healthcare provider workforce, the RCOG has established an Abortion Task Force, led by the College President, Professor Lesley Regan. The Taskforce works collaboratively with the main independent-sector providers and engages with politicians to develop system-wide solutions to ensure that women have access to safe, sustainable, high-quality care.
    This presentation will present the different elements of the RCOG's Abortion Task Force and its vital role in improving abortion services in the UK.

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    Medical and surgical methods of abortion are highly effective, safe, and acceptable to women. Women value being offered a choice of methods and receiving a preferred method is a strong predictor of satisfaction with care. For women who do not have a strong preference for a particular method, clinical trial evidence suggests that randomisation to a surgical abortion results in higher satisfaction rates than randomisation to a medical abortion.
    While providers may wish to optimise women’s abortion experience by offering a choice of methods, this can be challenging with the increasing shift toward medical methods and the very early gestational ages at which women now present for abortion care. Surgical abortion under general anaesthesia may be cost-prohibitive and the predominance of medical abortion in some settings can reduce opportunities for obtaining surgical skills. Providers may be uncertain of whether or how to offer surgical abortion in the earliest weeks of pregnancy.
    This talk will address the evidence supporting the offer of a choice of abortion methods and will discuss less resource intensive models of outpatient surgical abortion care as well as a protocol for providing surgical abortion before a gestational sac is visible on ultrasound.

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    Identifying and managing on-going pregnancy after medical abortion

    Patricia Lohr
    British Pregnancy Advisory Service, Stratford Upon Avon, UK

    The incidence of on-going pregnancy after early medical abortion with mifepristone and misoprostol is about 1%. Early detection is important so that further management can occur within the skill-set of the provider and any country-specific gestational age limits for abortion. A common method of identifying the success or failure of medical abortion is to undertake an ultrasound scan during an in-clinic visit. However increasing evidence supports the effectiveness and acceptability of remote methods of follow-up, typically using a single or multi-level urine pregnancy test and a symptom checklist.
    This talk will review how on-going pregnancy after early medical abortion may be detected, surgical and medical management of failure and the risk of continuing a pregnancy that has been exposed to mifepristone and misoprostol.

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    Methods of surgical abortion in the second trimester

    Patricia Lohr British Pregnancy Advisory Service (BPAS), Stratford Upon Avon, UK -

    Vacuum aspiration, hysterotomy, hysterectomy, dilatation and evacuation (D&E), and a variant of D&E called intact dilatation and extraction (D&X) are all procedures used for second trimester surgical abortion. Vacuum aspiration is effective up to 16 weeks' gestation, but forceps are often required to remove larger fetal parts. Hysterotomy and hysterectomy are reserved for cases where neither a medical induction nor a trans-cervical surgical approach is feasible. Dilatation and evacuation remains the most commonly performed method of surgical abortion in the second trimester, with D&X often utilized when preservation of fetal anatomy is desired. This talk will briefly review the safety and prevalence of second trimester surgical abortion and then will focus on pre-operative assessment, cervical preparation, surgical technique and post-operative care.

Mette Løkeland

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    Medical abortion overtaking surgical in Norway

    Mette Løkeland, Department of Obstetrics and Gynecology, Haukeland University Hospital, Norway

    Co-author: Line Bjørge

    Norway has abortion on request, completely free of charge and easily accessible at every gynaecology ward up to 12 weeks of gestation. Health personnel have the right to opt out form performing the procedure but not to treat the patients. Each clinic is obliged to make sure they have enough staff that is willing to do the procedure.

    Medical abortion with mifepristone and misoprostol was introduced for abortion up to 9 weeks gestation in 1998. Gradually medical abortion has become an option at the majority of all gynaecology wards in Norway. In 2005 medical abortion for gestational age 9-13 weeks was introduced and is now available in all the five health regions.

    At Haukeland University Hospital medical abortion was made the method of choice for early termination of pregnancy up to 9 weeks gestation and in 2007 for terminations of pregnancy at 9-13 weeks gestation. Medical abortion was made method of choice due to the general medical view that conservative treatment should always be preferred to surgical when the methods give equivalent treatment outcome. If there are personal or medical reasons the surgical method will be used instead. Home use of misoprostol was introduced as a voluntary choice in 2006 for terminations up to 9 weeks gestation.

    Since 1998 the percentage of all abortions in Norway performed medically has increased every year. In 2007 the amount was 45.3% and the preliminary figures for 2008 show 55.9%. This give us reason to think there is a change in Norway from surgery to medical abortion.

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    Women’s choices: Why do they opt for medical abortion?

    Mette Løkeland, Line Bjørge (Norway)

    Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway

    Background. Norway has abortion on request, completely free of charge and easily accessible at every gynaecology ward up to 12 weeks of gestation. Up until April 1998 when medical abortion with mifepristone and misoprostol were implemented for pregnancies terminations performed at less than 9 weeks gestational length all first trimester abortions were performed surgically at Haukeland University Hospital. In 2003 medical abortion was made the method of choice for early first trimester abortions. Medical abortion for 9-12 weeks of gestation was implemented in 2005 and made method of choice in 2007. If there are personal or medical reasons the surgical method will be used instead.  In 2006 97.3% of all the abortions up to 9 weeks and 54.5% of those between 9-12 weeks were performed medically.

    Choice versus medical recommendations. A woman’s choice is dependent on different factors. Her personal experience, experiences of people she knows and relates to, what she believes is the best method and what health personnel advise her to. Most women do not have a strong opinion but will generally prefer what health personnel recommend them to do.

    The success rate of medical and surgical abortion methods are the same.The general medical view is that conservative treatment should always be preferred to surgical when the methods give equivalent treatment outcome. Surgical abortion in a safe and legal environment preformed by skilled personnel has few complications. In comparison medical abortion has a lowere complication rate ; especially the severe complications are few. Medical abortions should therefore be offered as the method of choice.

    To make an informed consent and be able to choose a method one need thorough information.Our experience is that women who opt for surgical abortion often do so because their family doctor or others who have no knowledge of medical abortion have told them that it would be the best method for them. They will normally change their opinion when informed about medical abortion. Less women opt for surgical abortion today than ten years ago.

Lena Luyckfasseel

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    Gender-biased sex selection

    Lena Luyckfasseel IPPF European Network, Brussels, Belgium -

    Sex selection can take place before a pregnancy is established, during pregnancy through prenatal sex detection and selective abortion or following birth through infanticide or child neglect. Nevertheless, the discussion seems to focus especially on abortion. Sex selection is sometimes used for family balancing purposes but far more typically occurs because of a systematic preference for boys. Practised on a large scale it can result in skewed sex ratios at country-level. The root causes of gender-biased sex selection are situated in persistent gender inequality leading to son preference. Other conditions that need to be present for prenatal sex selection are low fertility (people choosing smaller sized families) and the availability of the technology. In 2011 the Parliamentary Assembly of the Council of Europe in their resolution on "Prenatal Sex Selection" stated that there is "strong evidence that prenatal sex selection is not limited to Asia [...] and has reached worrying proportions in Albania, Armenia and Azerbaijan". This has put gender-biased sex selection firmly on the European agenda. It is important to frame the discussion on gender-biased sex selection in such a way that it does not impede women's access to safe abortion services. Following a short introduction to the topic a diverse panel will explore the following questions: What does gender-biased sex selection mean for us? How do we respond to gender-biased sex selection; towards individuals, practitioners, decision makers and anti-choice?

Richard Lyus

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    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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    Wondering how to manage second trimester medical abortion or dilation & evacuation in the setting of an abnormally implanted placenta?

    Looking for advice on advancing the gestational age at which you and your team provide? Have questions about cervical preparation, offering a choice of method, managing prolonged inductions, or anything else related to medical or surgical methods of abortion after the first trimester? Bring your questions along to this panel of five leading experts in second trimester abortion care. Experienced, new and curious providers are all welcome to contribute to what should be a lively and wide-ranging discussion.