IPPF monitors quality of care throughout its abortion programme in order to assess and improve clinical service delivery. However, the current measures are largely focused on clinic and staff capacity, and do not fully capture the client’s perspective of abortion care beyond broad measures of satisfaction. IPPF aimed to explore women’s perception of quality abortion services to better understand their concerns and priorities. In collaboration with Ibis Reproductive Health and IPPF’s Member Associations in India and Kenya, data was gathered from women who had previously obtained abortion services. 24 women in Kenya were interviewed, while in India 10 women were interviewed and 11 took part in two focus group discussions. A structured set of questions was developed and refined to elicit responses on what women felt comprised a good quality abortion, how they felt about the abortion care they received and the impact of abortion-related stigma on their experience. These responses were coded and analysed by Ibis. Results showed that women in both countries had low expectations of the abortion experience before their procedure, had little knowledge of what it would involve and feared pain, dangerous side-effects and stigmatising treatment from providers. Aspects of care mentioned as most important included kind and polite staff, a successful and safe procedure, and clear explanations to prepare clients. IPPF will use these findings to inform its abortion programme and improve quality in abortion care. Abortion quality of care monitoring will be refined so that these dimensions of quality are adequately captured and measured. This will involve developing indicators that focus on these concerns and integrating these into client exit interviews and other methods of monitoring.
Hopes for new male contraception: Are they realistic?
Eberhard Nieschlag (Germany)
Centre of Reproductive Medicine and Andrology, University Hospitals, 48149 Münster, Germany
The world population continues to grow rapidly while resources for sustainable living dwindle and manmade ecological problems increase proportionally to the overpopulation. Family planning is required to reduce population growth in developing countries and to stabilize populations in developed countries. Contraception makes abortion superfluous and provides the key to family planning. Women increasingly demand that men share the burden and risks of contraception and – as opinion polls show – men would be willing to use contraceptives if they were available. Research has established the principle of hormonal male contraception based on suppression of gonadotropins and spermatogenesis. All hormonal male contraceptives use testosterone, but only in East Asian men can testosterone alone suppress spermatogenesis to a level compatible with contraceptive protection. In Caucasians additional agents are required of which progestins are favoured. Clinical trials concentrate on testosterone combined with norethisterone, desogestrel, etonogestrel or DMPA. The first randomized, placebo-controlled clinical trial performed by the pharmaceutical industry demonstrated the effectiveness of a combination of testosterone undecanoate and etonogestrel in suppressing spermatogenesis in volunteers. However, the two companies involved left the field of male contraception when they were taken over by other firms. Hopes now rest on organisations such as WHO and the Population Council that they may develop modalities for male contraception attractive enough to be marketed by industry.
Maarit Niinimäki, MD PhD, Department of O&G, University Hospital of Oulu, Finland
Pregnancies among teenagers, mostly unplanned, offer a special challenge to family planning. Vast majority, about 80%, of teenage pregnancies are unintended (Guttmacher Institute Report 2010). In 2009 9.5% of all abortions were performed for girls <18 years in UK. Also in Finland teenage abortions are relatively common. In the youngest age group (15-19 years) the abortion rates were higher than in the whole population (12.8 vs. 8.8/1000 women in the same age) in 2009.
Despite the widespread use of medical abortion, data concerning the safety and feasibility of medical abortion among adolescents is scarce. A small prospective study found medical abortion to be highly effective and well tolerated among minors aged 14 to 17 years in duration of gestation 56 days maximum (Phelps 2001).
The present study aimed to compare the incidence and risk factors for adverse events among adolescents and adult women. The study was based on the national registry-based cohort in which all the medical abortions during 2000-2006, 27.030 women, were included. The duration of gestation was 5 to 20 weeks. The cohort was divided into two subgroups; adolescent < 18 years (n=3024) and adults ≥ 18 years of age (n=24.006). The categories for adverse events were: I hemorrhage, II post-abortal infections, III incomplete abortions, IV injuries or other reasons for surgical operation, V thromboembolic disease, VI psychiatric morbidity and VII death. The classification was based on that reported in the Joint Study of the Royal College of General Practitioners and the Royal College of Obstetricians and Gynaecologists and modified for the present study. Codes for interventions and diagnoses (ICD-10) found in a national Hospital Registry were linked with the abortion registry. For 2004-2006, individual data on STDs (Chlamydia trachomatis and gonorrhea) in this cohort was also available. The screening for Chlamydia infections has been recommended in the national guidelines for termination of pregnancy.
The overall number of adverse events was higher in adult cohort. Also the incidence of hemorrhage, incomplete abortion and surgical evacuation was significantly higher among adults. The incidence of infections was similar in the cohorts. However, adolescents had more psychiatric morbidity. In subanalysis of primigravid women, the overall rate of adverse events and hemorrhage was higher in cohort of adult women. The risk factors for adverse events (e.g. age, duration of gestation) were mostly similar in the two cohorts.
In 2004-2006, the incidence of STD was significantly higher among adolescents (5.7% vs. 3.7%). No difference in the rate of post-abortal infections emerged between the two cohorts among women positive in the preabortal STD-screening. Also, positive preabortal STD screening had no effect on rate of postaboral infections when compared to STD-negative women in the whole cohort.
In conclusion, we find that the rate of adverse events and complications following medical abortion in adolescents is similar or lower than that seen among adult women. Thus medical abortion is not to be evaded as a method among adolescents once the decision of termination of pregnancy has made. In addition, based on these data, preabortal screening for STDs (“screen and treat”) seems to be a feasible strategy in all women.
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.