Profession: Specialist in gynaecology and obstetrics
Affiliation: Karolinska University Hospital, Sweden
Ingrid Sääv, MD and Kristina Gemzell Danielsson, Professor, MD, PhD, Dept of Woman & Child Health,
Div of Obstetrics & Gynaecology, Karolinska University. Hospital / Karolinska Institutet, Sweden
Background: Today a majority of early abortions are conducted medically, in accordance to the woman’s choice. When opting for an IUS/IUD as contraception method, the insertion routinely takes place at the check up visit 3-4 weeks after the abortion. This means an obvious risk of a new pregnancy.
Objectives: We wanted to study if early post abortion insertion of Mirena IUS could be conducted in a safe way and without increased risk of expulsion or infection. Furthermore, we wished to investigate however early insertion would have an impact on the bleeding patterns during the first 4 weeks, and if Mirena use during the first year is comparable between the two groups.
Material and methods: 65 women undergoing elective early medical abortion up to 9 weeks gestation and opting for a Mirena IUS were included. They were randomized to either early insertion on day 5-9 (34 women), or routine insertion at 3-4 weeks (day 21-31) (31 women). The medical termination was performed according to clinical routine. Antibiotic prophylaxis was not administered routinely, but a screening test for Chlamydia infection and bacterial vaginosis was performed. An ultrasound examination was performed before Mirena insertion. Hb and S-hcg was determined on day 1 and at the day of insertion. The patients were scheduled for control visit 4 weeks after Mirena insertion and complications such as infection and expulsion was recorded, and a diary of the bleeding pattern was collected from the patient. Hb was determined, and a urine pregnancy test was performed.
Results: 34 women were randomized to early insertion (day 5-9). 4 women were excluded, of these one was diagnosed with missed abortion and scheduled for vacuum aspiration, one was booked to late by mistake, one did not show up and one woman had regrets and requested a cupper IUD instead. 31 women were randomized to routine insertion (day 21-31). 3 women were excluded, one was diagnosed with a viable pregnancy and was scheduled for a vacuum aspiration and two did not show up for insertion. There were no infections in either group. There were 5 expulsions (17%) in the early group, compared to 3 (11%) in the late group. The bleeding pattern post IUS insertion did not differ between the groups; neither did the acceptability of the patient regarding insertion of the IUS or further use.
Conclusion: There was no difference in safety between the groups. There was no case of endometritis or pelvic infection. Acceptability and bleeding patterns did not differ between the groups. The expulsion rate was substantially elevated in both groups, compared to routine insertion in a non-pregnant woman. We conclude that all women undergoing post-abortion insertion should be scheduled for a control visit
Sublingual misoprostol for cervical dilatation prior to insertion of an IUD
Sääv I, MD. Aronsson A, MD, Marions L, MD.PhD, Gemzell Danielsson K. MD, PhD,
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/ Karolinska Institutet,
The IUD is highly effective contraceptive method also in young nulliparous women. The
cupper-IUD is the most effective emergency contraceptive method available.
Complications at insertion are not more common postcoitally at any time during the
menstrual cycle than routine insertion. However, a disadvantage in nulliparous women is
that insertion of an IUD through a narrow cervix may be technically difficult and painful.
Failed insertion, complications and side effects are significantly more common among
women who have no previous delivery. The fear of painful insertion may make women to
hesitate to use an IUD.
Misoprostol (Cytotec) is a prostaglandin (PG) E1 analogue commercially widely available
and used to decrease the ulcerogenic effects of non-steroidal anti-inflammatory drugs.
Misoprostol is used for termination of first and second trimester abortion, and cervical
dilatation prior to surgical abortion.
Another possible indication for use of misoprostol is cervical priming prior to insertion of an
The aim of this study is to compare the route of sublingual misoprostol and diclofenac with
only diclofenac treatment and to evaluate the effect on cervical dilatation, side effects,
pain, bleeding and acceptability.
We randomise 80 healthy nulliparous women requesting IUD insertion to 400 microgram
of misoprostol and pain medication to only pain medication one hour to prior to IUD
Our preliminary results show that sublingual misoprostol is effective for pre-operative
cervical dilatation in non-pregnant women.
Sublingual versus vaginal misoprostol for cervical dilatation, 1 or 3 hours prior to surgical abortion, a placebo-controlled, double-blind study
Ingrid Sääv1 ,2, Helena Kopp Kallner1, Majken Ullmark2, Madelaine Dahlin2, Eva Broberg1, Kristina Gemzell-Danielsson1 ,2 1Dept of Women & Child Health, Karolinska Institutet, Stockholm, Sweden, 2Div of Obstetrics & Gynaecology, Karolinska University Hospital, Stockholm, Sweden - firstname.lastname@example.org
Background: Woman undergoing surgical abortion are treated routinely with misoprostol, administered 3 hours before surgical termination of pregnancy. Many women complain of side-effects, and some have bleeding and expulsion before the abortion. Shorter priming time would make it possible to treat women in clinic. Misoprostol reduces the risk of surgical damage, heavy bleeding and incomplete abortion. Vaginal administration has been shown to induce less side-effects. Objective: We wanted to study if a reduction of priming time from 3 to 1 hour could give equal priming effect. We also compared vaginal to sublingual administration. Material and methods: 186 nulliparous women undergoing surgical abortion during the first trimester were recruited. They were randomized to 4 groups, in which they received misoprostol vaginal or sublingual, 1 or 3 hours prior to the abortion. The study was performed in a double-blind fashion. The resistance of the cervical os was measured objectively using a tonometer during the dilatation. The amount of bleeding was noted, and the patients were asked if they had experienced any side-effects, and which administration route they preferred. Results: There was no difference in priming effect between 1 and 3 hours when given sublingually (p=0.62). However, when given vaginally, there was a significant difference with higher force needed in the group with 1 hour priming time (p=0.028). Fewer women started bleeding when the priming time was reduced to one hour. Most women preferred vaginal treatment, in most cases due to bad taste in the mouth for a long time when taken sublingually. Conclusion: It is safe to reduce the priming time to one hour with misoprostol prior to surgical termination of pregnancy. When the priming time is reduced to one hour, sublingual treatment should be used. Shorter priming time induces less side-effects, and fewer women experience bleeding and expulsion prior to the abortion.
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.
Cervical priming made easy
Ingrid Sääv1 ,2, Kristina Gemzell Danielsson1 ,3
1Karolinska Institutet, Stockholm, Sweden, 2Norrtälje Hospital, Norrtälje, Sweden, 3Karolinska University Hospital, Stockholm, Sweden
Before the development of medical priming agents, mechanical methods were used to dilate and soften the cervix before surgical intervention. Different roots, screws and dilators were used and later intracervical tents that were allowed to swell and slowly dilate.
Misoprostol induces a softening, "priming" effect on the cervix making mechanical dilatation less difficult. The action seems mainly to affect the collagen tissue of the cervix causing disintegration and dissolution. Compared with osmotic dilators misoprostol gives equal cervical dilatation in a shorter time, is easier to administer and is more convenient to the patient.
Misoprostol reduces the rate of complications after surgical abortion when administered as a medical priming agent prior to vacuum aspiration, both in nulliparous and parous women. Prostaglandins have been proven to reduce blood loss associated with vacuum aspiration.
Misoprostol is also used in non-pregnant women to facilitate IUS insertion or dilatation prior to hysteroscopy. However, studies indicate that no effect is achieved in postmenopausal women.
Misoprostol can be administered orally, sublingually or vaginally. Its plasma concentration and half-life, and subsequently effect, differ greatly depending on the route of administration. This gives great opportunity to choose the most convenient, effective and practical way of administration. Plasma half-life after oral administration is only 20-40 minutes, whereas it has a lower plasma peak level but much prolonged duration after vaginal administration. After sublingual administration, the plasma peak is the highest, combined with a prolonged half-life, giving the most rapid effect on cervical priming - but also more side-effects comparing to vaginal administration.
When administered to achieve cervical ripening misoprostol can be administered sublingually, only one hour prior to surgery, or if preferred vaginally with 3 hours interval. This gives great opportunities to choose the most convenient regimen depending on patient preference and practical aspects.
Intrauterine contraception after medical abortion
Ingrid Sääv1 ,2, Kristina Gemzell Danielsson1
1Karolinska Institutet, Stockholm, Sweden, 2Norrtälje Hospital, Norrtälje, Sweden
Background: Today a large proportion of early abortions are medical terminations, in accordance with the woman's choice. Intrauterine contraceptives (IUC) provide highly effective, reversible, long-acting contraception but the effects of timing of IUC insertion after medical abortion are not well known. Routine insertion after the first menstruation means an obvious risk of a new pregnancy.
Methods: Women undergoing early medical abortion with mifepristone and misoprostol up to 63 days gestation and opting for IUC were randomised to early insertion (day 5-9 after mifepristone) or delayed (routine) insertion (at 3-4 weeks after mifepristone). The primary outcome was the rate of IUC expulsion six months after IUC insertion. Secondary outcomes were rate of insertion, use at 6 and 12 months, and adverse events.
Results: A total of 129 women were randomised and 116 women had a successful IUC insertion. There was no difference in expulsion rate between the groups (p=0.65) with 6 expulsions in the early insertion group (9.7%) compared to 4 in the late insertion group (7.4%). Significantly more women returned for insertion in the intervention group (p=0.03) and more women (41%) had unprotected intercourse prior to insertion in the delayed group (p=0.015). Adverse events were rare in both groups.
At the follow ups no differences could be found in regard to bleeding patterns, menstrual pain or compliance with the IUC.
Conclusions: Early insertion of IUC after medical abortion is safe and well tolerated with no increased incidence for expulsions or complications. Women are more likely to return for the IUC insertion if scheduled early after the abortion and less likely to have had an unprotected intercourse prior to insertion. Early insertion should be offered as a routine for women undergoing first trimester medical abortion.
Key words: IUC, medical abortion, insertion, intrauterine contraception
Medical abortion, early treatment
Peter Safar MD, Head of Department of Obstetrics and Gynaecology
Humanis-Klinikum Korneuburg, Austria,
Board member of the Regional Executive Commitee of the IPPF/EN
Most women are faced with unnecessary obstacles in access to termination of a very early pregnancy, even when their decision for termination is clear.
Frequently the treatment of medical abortion is delayed until a foetal cardiac activity can be seen on ultrasound. Additionally women are sometimes subject to several ß-hCG tests in the serum. Treatment is delayed until a viable intrauterine pregnancy can be diagnosed, usually around 6 1/2 weeks LMP.
Our experience is presented with medical abortion in very early pregnancy. We also follow patients and repeat ß-hCG in these cases, but we start medical abortion immediately. Patients are counselled about the possibility of an ectopic pregnancy or a missed abortion in cases where no foetal cardiac activity or even no gestational sac can be seen on ultrasound.
Serum ß-hCG is done prior to treatment and repeated at follow-up after one week. There is a marked decline below 20% of the initial value when the abortion has been successful. Sometimes the combination with the serum level of progesteron could be precise the diagnosis.
So far we have not had one persistent ectopic pregnancy in more than 5 years and over 2.000 cases. If an ectopic pregnancy would be detected at follow up the treatment option with MTX or laparoscopy can be discussed in time.
Medical abortion with mifepristone and misoprostol in the early and very early pregnancy is safe and very well accepted by women. The success rate is high and side effects of strong bleeding or pain are infrequent.
Very early medical abortion
Peter Safar MD Head of Department*,**, Christian Fiala MD, PhD**
Humanis Klinikum Korneuburg*, Gynmed Clinic Vienna, Austria**
Positive heart rate,fetal viability or at least the presence of the cul de sac in ultrasonografic
scanning are at the moment still the basic conditions for most of the abortion service
providers to start with the medical induced abortion.
But the wish of many women, after a clear decision making is different:
they want to start the procedure as soon as possible!
Presenting case reports we describe our standarts, procedures and follow up programmes
for patients which allowes us to start medical abortion with Mifepristone and Misoprostol
right after the early detection (postive HCG test) of an unwanted pregnancy..
Following our guidelines we are able to minimize the risks and the complications of
undetected ectopic and molar pregnancies.
And after the Referendum?
Matilde Salta, Mara Carvalho, Vasco Freire (Portugal)
Médicos pela Escolha – Doctors for Choice in Portugal
In Portugal, in the past 11th of February of 2007, a certainty became evident: that an important majority of the Portuguese society identified clandestine, illegal abortion like a Public Health problem, legitimizing the right to safe abortion by the woman’s request, as part of a plenum exercise of Sexual and Reproductive Rights, Universal Human Rights.
The new abortion law respects a person’s autonomy as an ethical principle, ensuring a free and universal access to safe abortion, a procedure performed by or with the help of qualified health care professionals. This new legal setting allows us to have concrete numbers about abortion, so that, by evaluating the numbers, we identify vulnerable groups, try to know its causes and consequences and provide the necessary support and interpret possible variations over the time, with longitudinal studies.
The DGS – Direcção Geral da Saúde (General Health Bureau in Portugal) predicted for the year after the implementation of the law 20000 abortions. In a study made by APF – Associação para o Planeamento da Família (the Family Planning Association) the number predicted was around 17000 abortions a year. Still awaiting annual results, in the first 5 months of law application, 6000 abortions were registered, and after eleven months the number was 12000, numbers a bit low when compared with the initial predictions. Why this happened and what can happen next are important discussions in terms of evaluating the effectiveness of the system and constantly, the level of information of the people.
Regardless of if the next annual numbers corroborate or not the tendency of the first eleven months, it is necessary to stretch the experience in other European countries where abortion is legal for several years: clandestine abortion tends to become almost absent with the legalization, but it’s a process with several years of evolution; the diminishing of the abortion rate and the raising of the women/couples doing effective contraception (to avoid unwanted pregnancies) is fundamentally related with the implementation of an effective Sexual Education and Health Care policies that improve the access to Family Planning and modern Contraception. In Portugal, one year after the implementation of the law, it’s still urgent to:
Improve the Family Planning and abortion network. For example: creating conditions so that medical abortion is accessible to women in all the public primary care health services; equip the national health system with more human and technical means that answer not only to the needs of the women that want to interrupt their pregnancies, but also to the ones related to requests for definitive chirurgical contraceptive methods; all the hormonal contraceptives should be freely distributed.
Different strategies to legalize abortion: Successes and lessons from Mexico
María Luisa Sánchez Fuentes (Mexico)
On April 24, 2007, abortion became legal on demand up to 12 weeks of gestation in Mexico City. Women for the very first time were considered full citizens with fundamental rights that must be recognized and protected by the Mexican constitution. What were the key factors that explain this historic change, in spite of the power and belligerence of the Catholic Church hierarchy in Mexico and the Latin American region? What strategies were vital to seize the political opportunity? What has changed after a year of legal abortion services? What are the most important social changes and what challenges lie ahead?
Resistance in the US
National Abortion Federation, Washington, DC, USA
In the last several years anti-choice legislators have made restricting abortion access a priority in the United States. We have seen a record number of anti-abortion restrictions being introduced and passed at state and federal levels. These restrictions have made it increasingly difficult for women to access the care that they need and have even forced clinics to close.
In the last year, we have also endured a smear campaign using highly-edited, misleading videos to target and demonise abortion providers. This anti-abortion campaign has led to increased investigations against providers and a dramatic increase in hate speech and internet harassment, death threats, attempted murder and murder targeting providers.
We have been active in fighting back against these attacks, particularly in the courts. NAF immediately sued the individuals and organisations behind the illegal undercover videos in order to protect the safety and security of our members. Earlier this year the Supreme Court heard arguments in Whole Woman's Health v. Hellerstedt - a challenge to Texas abortion restrictions designed to close more than half of the clinics in that state. The outcome of this case could have implications for abortion restrictions throughout the United States.
Policy of the US
Vicky Sapporta, MD, President of NAF (National Abortion Federation),
The Religious Right has grown as a political force in the United States. With widespread
access to the White House, members of Congress and state legislators, they have been
trying to restrict women’s access to abortion care by introducing legislation that would ban
abortion, require parental involvement for minors, reduce public funding, require biased
informed consent and waiting periods, and force clinics to comply with other politically
Abortion providers can play a key role in countering the Religious Right by providing the
medical, scientific and provider perspectives in public policy debates about abortion. NAF,
as the professional association of abortion providers in the United States and Canada, has
successfully brought forward providers and patients to highlight the real-life consequences
of restrictive legislation and regulations. As a result, we have been able to expose and
defeat initiatives supported by the Religious Right to further restrict women’s access to
Vicki Saporta, President and CEO, National Abortion Federation, USA
In the 1990s, obstetrics and gynecology (OB/GYN) residency programs were falling short of their responsibility to train new physicians in abortion care and contraceptive services. Through targeted efforts, organizations addressed this problem with the introduction of a wide range of training opportunities, including newly established residency- and fellowship-based training programs in family planning and abortion care.
Residents receive hands-on training through residency program partnerships with freestanding clinics and private medical practices. Current providers have also partnered with some of these sites to learn abortion techniques, including later abortion procedures to expand their practices. Additionally, providers stay current in abortion practice through continuing medical education (CME) opportunities such as educational conferences and accredited online resources.
Despite the fact that OB/GYN residents have had more training opportunities in the past 15 years, this has not necessarily resulted in increased numbers of clinicians providing abortion care. Efforts are underway to train physicians in other specialties such as family practice, as well as to train advanced practice clinicians. By integrating abortion care into other broader practices, we hope to see an increase in the number of providers who actually go on to offer abortion care.
What happens if society opts out?
Vicki Saporta (United States)
National Abortion Federation (NAF), United States
Abortion has been legal in the United States since the Supreme Court decided Roe v. Wade in 1973. However, during the last thirty-five years, abortion opponents have launched legal, legislative, and judicial challenges that have resulted in more restrictions and obstacles being placed in the way of women seeking abortion care. The most onerous of these restrictions is the lack of public funding for abortion care. In the United States where abortion is legal and safe, access continues to be a challenge especially for low-income women.
In the United States, low-income individuals rely on the government for basic and long-term health care. Medicaid is the joint federal-state program that finances health care for 55 million low-income people. In 2006, 37% of women of reproductive age in families with incomes below the Federal Poverty Line were enrolled in Medicaid, according to the Guttmacher Institute.
When abortion was legalized in 1973, Medicaid covered abortion care without restriction. In 1976, Congress passed a provision to limit federal funding for abortion care. Current law requires coverage of abortion only in cases of rape, incest, and life endangerment; however, it can be very challenging for a woman to actually obtain a publicly-funded abortion even in these limited circumstances. The Guttmacher Institute has found that 20-35% of Medicaid-eligible women who would choose abortion carry their pregnancies to term when public funds are not available.
When society opts out of providing women access to abortion care, the burden is shifted to the private sector. Since 2001, NAF has been operating a modest Patient Assistance Fund through our toll-free Hotline. With limited resources, we were only able to fund the most desperate cases and often had to turn away more women than we were able to help. However, through increased private sector funding, we are now able to subsidize the cost of abortion care for low-income women at or below 150% of the Federal Poverty Level. In order to be eligible for this funding, a woman must live in one of the 35 states or the District of Columbia where Medicaid does not cover abortion except in very limited circumstances, and obtain abortion care at a NAF member clinic. We have received hundreds of letters from women thanking us for helping them obtain abortion care that they otherwise would not have been able to afford.
Low-income women are four times as likely to experience an unplanned pregnancy as higher-income women, according to the Guttmacher Institute. It is incumbent upon us to continue to use the voices of these women to educate the public about the barriers low-income women face when accessing abortion care, and the necessity for public funding. When society opts out, the private sector becomes critical in helping women obtain the abortion care they need.
Empowering providers and patients as advocates
Vicki Saporta National Abortion Federation, Washington, DC, USA - email@example.com
Although abortion has been legal in the United States for 41 years, we continue to see attacks on women's access to abortion care. In the last few years, anti-choice legislators have made restricting abortion access a priority and we have seen a record number of anti-abortion restrictions being introduced and passed at the state and federal levels. The stigma surrounding abortion has also contributed to this hostile political environment and a lack of understanding for abortion providers and women who access abortion care. One of the most effective ways to fight these attacks and work to dispel stigma is to ensure that the voices of providers and patients are included in the public debate about abortion. We have helped women come forward and speak out about their decision to obtain abortion care and to explain how proposed restrictions would have affected their ability to make the decision that was best for them. These stories have been successful in combating political stigma and challenging restrictions. We must continue to help women share their abortion stories. We have also worked to train and mobilize abortion providers to advocate with lawmakers and speak to the media. Abortion providers are invaluable messengers, who can offer expert medical testimony and dispute false claims made by abortion opponents. Abortion providers are also uniquely qualified to discuss the public health consequences of unsafe abortion and the necessity of ensuring that abortion care is safe, legal, and accessible.
Wendy Savage and Colin Francome, Middlesex University, United Kingdom
In 2008 questionnaires were sent to a one in six random sample of British gynaecologists which asked about their attitudes and practice.. After three mailings the response rate was 70%. The major findings were that there was less satisfaction about the way the 1967 Abortion Act operated than 20 years before and support for less bureaucracy.
Support for a limit of 24 weeks was lower than 20 years before with only half accepting this limit in 2008 compared with two thirds accepting 24 weeks or above in 1989. A majority of consultants were no longer involved in providing second trimester abortions which has implications for training. 60% thought abortion should be separated from general gynaecology and over half thought that there should be separate abortion units for gestation over 13 weeks and that fertility control (abortion sterilization and contraception) should be a sub-specialty, an increase since 1989.
The range of attitudes remains wide with clear implications for women seeking abortion. We conclude that streamlining the service and decriminalising abortion would reduce the number of later abortions.
Attitudes and practice of gynaecologists towards abortion in Northern Ireland
Women from Northern Ireland have to travel to Britain and pay for their terminations as the 1967 Abortion Act does not apply in Northern Ireland (NI). This article analyses the attitudes of gynaecologists. The response rate was nearly ninety per cent of the 42 practicing in the NHS in NI. We found that a clear majority favored a liberalization of the law in Northern Ireland. Over one in three wanted unrestricted access in the first trimester which is a more liberal position than the British law.
Almost five out of six gynaecologists were in favor of free abortions for Irish women as is largely the case in England and Wales. Furthermore a majority were in favor of the abortion charities being licensed to carry out legal abortions in Northern Ireland
Irina Savelieva, MD, Russia
The growing economic difficulties have made it hard to implement universal access to health in Russia. Significant cuts in the public health care budget have resulted in a decrease of state-guaranteed health services for women and children. Due to the lack of appropriate contraceptives and counseling services, abortion was and still remains the principal means of fertility regulation in Russia, sometimes exceeding the number of live births by two or three times. Though the number of abortions performed annually has declined drastically over the past decade (the abortion rate was 100.3 per 1,000 in 1991 compared with 47.7 per 1.000 women of reproductive age in 2001) abortion remains to be an important cause of preventable morbidity and mortality among women of reproductive age. In 2001, abortion accounted for 27,7% of maternal deaths in Russia, as compared with an estimated 13% of maternal deaths attributable to abortion globally. At the same time the number of post-abortion complications remains high, and according to some research can reach 40-60% with high level of incomplete medical abortions, of which nearly half (46.2%) required hospitalization. There are also several safety issues (abortion in nulliparous women, multiple pregnancy terminations, second trimester abortion) which have not be addressed adequately and need special attention, not to mention the psycho-social effects of multiple abortions and possible secondary infertility, and the growing interest and practice of assisted reproduction techniques, such as in vitro fertilization (IVF). These data demonstrated that quality abortion care in Russia does not satisfy world standards and WHO recommendations.
Abortions are more common among women ages 20 to 34 (approximately 70%), with 15.3% women who were pregnant for the first time; the mean number of abortions is 2.8-3.07. Almost 40% of abortion clients had already terminated a pregnancy by abortion during the previous 12 month. About half (43%) were using contraception at the time of their last pregnancy (39% were using condoms, 20% - natural family planning, 12% - spermicides and 11% - pills). The principal reasons for abortions (62,3%) were indicated as socioeconomic reasons; and 20,0% did not want more children. Only 36,9% of abortion clients, including young adults and primigravidae, what is of a crucial importance, received family planning counseling prior to the discharge and only 22,0% left medical facility with a contraceptive method of their choice. Since many women who are terminating an unwanted pregnancy intend to have a child later, it is extremely important to identify high level of post-abortion complications on subsequent reproductive function. The entire population is covered by a national health insurance, but abortion as a procedure has not been included. The country has adopted the Essential Drug Policy but has not included contraceptives in the Essential Drug List.
Clinical abortions are performed in medical facilities. The services are provided in maternity hospitals, consultancies of obstetrics and gynecology, private practices and Family Planning Centers. According to state regulations and laws all state institutions provide family planning counseling and abortions free of charge, but the present socio-economic situation has triggered a growing habit of charges made for clinical abortions.
Increasing and more human counseling, improved and good quality of services, good technology (including new medications), good facilities, better information through well-trained providers, careful follow-up, offer choices of contraceptive methods to women and help them to avoid unwanted pregnancies and consequent maternal health risks.
Activity of a termination of pregnancy department
Scassellati, G; Bologna, M; Di Felice, M;
San Camillo Forlanini Hospital, Rome, Italy
Termination of pregnancy (TOP) has been carried out in our
hospital since 1978, the year in which TOP became legal in Italy.
Our department is one of the most important TOP departments
in Rome: during 2011, 2098 women were admitted to our hospital
for a TOP, almost 30% of TOPs performed in the Lazio region. It
is also the only hospital in Rome to use pharmacological TOP
Our department provides a complete service for women in the
event of unwanted pregnancy. Besides the clinical activity, we
guarantee psychological support during all the phases of a TOP.
Since 2001, with the increase of the number of TOP requested
by immigrant women, our department established a service of the
so-called ‘intercultural mediation’ with the aim of preventing
unwanted pregnancy and spreading the regular use of
contraception among immigrants.
A relevant part of our activity is dedicated to the clinical
follow-up of women to ensure counselling and to encourage and
help them to use a contraceptive method. We also ensure
gynaecological consultation, a speciﬁc space for reproductive
health care, with the aim of reaching women with difﬁculty
accessing gynaecological treatments (women with lower level of
education, housewives, immigrants) and to facilitate their access
to public hospitals.
Cultural and linguistic mediation
Giovanna Scassellati and Teresa Perales, San Camillo-Forlanini Hospital – Rome
Since 2002, at the gynaecological ambulatory of the DH/DS 194 there is a service of cultural mediation. This service, supported by the Rome municipality, is particularly useful in order to establish continuative relationships with foreign women with the aim of clarifying the motivations of voluntary abortion and enacting preventive measures for abortion. 1.120 women were examined in the year 2002, 1.315 in 2003, and 407 in the first four months of 2004. The service is precious because often medical and paramedical personnel lacks adequate time for such activities, since an interview with a patient requires around 40 minutes on the average in order to be useful and explicative. Furthermore, the service is a useful tool to understand the real motives that drive foreign women to resort to abortion.
Doctors working in a public hospital
Giovanna Scassellati, MD,
Hopsitial St. Camillo, Rome
Abortion is legal and part of medical practice in Italy since 1978.
In these 28 years it is allowed only if interruptions of pregnancy are performed in public
Pharmacological abortion, widely used in many countries in Europe, is not allowed in Italy
and this because mifepristone (RU 486) is not registered yet.
This limitation causes frustration on doctors and nurses and it is necessary operate on
patients all the times even though a lot of patients could succeed using medical abortion.
In Turin, northern Italy, in S. Anna Hospital, Dr. Viale has been the first doctor who
received special permission by the Ministry of Health to start a clinical trial with RU 486, on
It seems a little strange to start experimentations using a drug well known in the whole
medical world since 1980.
Italian women are not different from the French or Spanish ones.
Local Anaesthesia compared to General Anaesthesia
Giovanna Scassellati (Italy)
Azienda Ospedaliera S.Camillo, Rome, Italy
We beavered to abait the general anaesthesia in the IVG operation.
We have dispensed to women 250 questionary on the 2008, with psycologic and pain ratings and we have allocated the questionary at first of abortion and after abortion, so we have perceived that women prefer local anaesthesia and they are supported in the rate.
On patients undergones in local anaesthesia operation, 30 minutes before the operation to be effected pre-medication.
Medicated IUD after induced abortion
Giovanna Scassellati (Italy)
Azienda Ospedaliera S.Camillo, Rome, Italy
We report our experience of the use of progesterone medicated IUDs (Mirena® Bayer Schering) as contraception after induced abortion.
Between February 2007 and February 2008 255 women who came to our centre for the implementation of Law 194/1978 (the one that legalised induced abortion in our country) were enrolled.
Among these patients who underwent IUD insertion we selected a number of those who, because of specific clinical situations (history of menometrorrhagia, uterine fibromatosis, endometriosis, etc.), needed the application of the progesterone medicated IUD. These women, in number of 22, underwent a gynaecological examination and a transvaginal pelvic ultrasound examination immediately after application of the device, two weeks after the operation and then every six months.
All these 22 patients demonstrated a perfect situation and satisfaction both on the basis of clinical and ultrasound objectivity and also regarding the symptomatology, with a progressive reduction of menstrual flow and dysmenorrhoea. None of the IUDs had to be removed or repositioned, to our great satisfaction and that of the patients. Thanks to this positive experience, which is still underway, we are strongly in favour of an increasing use of post-surgical IUDs.
Giovanna Scassellati, Daniela Valentini, and Maurizio De Felice,San Camillo-Forlanini Hospital – Rome
Since January 2004 we executed 34 THERAPEUTIC TERMINATIONs using Misoprostol for vaginal application with a dosage of 600 mg and continuing, after 8 hours, with a dosage of 200 mg every hour. In all cases we never exceeded the total dosage of 800 mg. 30 of the 43 patients have easily reached the expulson within the first 12 hours with a maximum of 24 hours. We performed 2 Ceaserian cuts as a result of a lack of response to the induction (one in a woman with a pulmonary neoplasia at the 4th stage and the other without cervical dilatation in a woman that had already undergone a Ceaserian cut). The vaginal application has proved to be better than that per os, with greatly reduced side effects.
The utilization of misoprostol per os in therapeutic termination
Giovanna Scassellati, MD,San Camillo-Forlanini Hospital – Rome (Italy)
From January 2000 to December 2003 we peformed 223 THERAPEUTIC TERMINATION with Misoprostol at the following dosage: 600 mg per os every 3 hours with a maximum of 3 applications a day. Of the total, 220 cases ended in a vaginal delivery and 3 required the execution of an operative delivery (Ceasarian Cut) because of a lack of response to induction. The utilization of Misoprostol has reduced the times of abortive labour that in some cases ends within 24 hours since the beginning of the treatment. Side effects, whenever present, were contained (vomit, diarrhoea, fever). [Only one patient showed an allergical reaction that imposed an immediate stop of the treatment.]
Use of misoprostol for priming in Italy
Giovanna Scassellati, Daniela Valentini, Maurizio Bologna and Maurizio De Felice
San Camillo-Forlanini Hospital, Rome - Italy
We report our clinical experience with Misoprostol, a drug registered in Italy exclusively for its gastroprotective action, in the pharmacological induction of VIP within the 90th day of gestation. The protocol that we used provided for the vaginal application of Misoprostol, with the dosage of 400 mg one hour before surgery, in a randomized sample of 50 women (double-blind trial), all adult and consenting, and this in order to induce a passive dilatation of the cervical channel, thus making the surgical intervention easier. Besides the excellent clinical result we underline its low cost, especially if compared with other drugs with a similar therapeutic action.
What do women want in Italy?
Giovanna Scassellati, Maurizio Bologna, Maurizio De Felice, Daniela Valeriani andAntonietta Turi, San Camillo-Forlanini Hospital – Rome, Italy
In the year 2003, 500 women using the services of DH/194 filled a questionary:
- 80% of them responded that prefer medical abortion, although they did not have a thorough knowledge of the technique, because they want to avoid any kind of surgery;
- they find the present bureaucratic procedure extremely long and inquiring;
- foreign women, especially Rumanian, live hospital procedures with great annoyance because they are not culturally accustomed to undergo presurgery analyses and the interview with the anaesthetist.
No compulsory counselling: The advantages for women
Margot Schaschl (Austria)
Gynmed Clinic, Vienna, Austria
Austrian law only requires counselling by the medical doctor. This is usually no more than a standard medical conversation about informed consent. There are no other regulations, and no requirement for further counselling, nor does the law provide for any compensation for such counselling.
Our experience has shown that more than 90% of the women who come to us for an abortion have already made their decision. In most cases, the decision is made quickly, within a few days, usually with advice and support from a partner, family, or friends. Many women also search the Internet for information. But most women do not need professional counselling to make a decision.
The advantages of the Austrian system for women are:
The basis for the counselling is accepting and respecting the woman’s decision. To challenge her decision is neither fair nor professional. On the contrary, being too investigative can lead to paternalism.
Another key element of the counselling is that each woman knows best about her present life circumstances. Therefore, only she can decide if she needs assistance in her situation.
Professional counselling is good and necessary. Nevertheless it should be voluntary, patient-directed, and individually adapted for each woman.
There are few things that could do more harm than biased counselling that tries to lead the woman to a particular decision. That can lead to indoctrination.
Monitoring the Abortion Process: Home Use Of Misoprostol in the United States
Eric Schaff, MD
Professor of Family Medicine and of Obstetrics and Gynecology
University of Rochester School of Medicine
New York, USA
The United States medical abortion experience has been unique. Frustrated with not having mifepristone, U.S. researchers explored the combination of methotrexate and misoprostol for medical abortion in the mid-1990s. The experience was mixed because the regimen often took several weeks to be successful. But, it provided abundant opportunity to explore different approaches to medical abortion.
Lessons from Methotrexate Medical Abortions
We learned early on with methotrexate abortions, that vaginal misoprostol was more effective than oral misoprostol. We also learned that repeating the misoprostol dose was necessary, safe and increased the effectiveness rates. We had to monitor the medical abortion with ultrasound because at two weeks, despite a history of bleeding, as many as 15-20% of pregnancies had not been expelled and the decision to perform an aspiration completion depended on the results of the viability of the pregnancy by ultrasound. And lastly, we learned that women could have a medical abortion safely at home as long as they had access to emergency medical care, if needed. Women also found home use of misoprostol highly acceptable.
Abortion Rights Mobilization Trials
In 1996, the Abortion Rights Mobilization (ARM), a non-profit advocacy group in New York City, contracted with the University of Rochester medical abortion researchers to coordinate trials with mifepristone. We applied the information learned from the U.S. experience with methotrexate, i.e., use of vaginal misoprostol, home administration of misoprostol, a repeat dose of misoprostol if needed, and routine ultrasound monitoring.
Over the following four-year period, the ARM trials have enrolled 7000 women in seven multicenter trials. These trials have recently come to a halt as the commercial product has come to market.
Summary of ARM Trials
In 1966, the first ARM trial used mifepristone 600 mg and vaginal misoprostol. It was an open label, non‑randomized, prospective trial at one site, up to 56 days gestation. The first follow up occurred within the first 7 days. There were 166 subjects with a 97% effectiveness up to 8 weeks. Four percent of subjects used a second misoprostol dose, 34% bled prior to misoprostol, and 11% did not require misoprostol. There were no transfusions, but there was 1 hospitalization related to bleeding.1
The second trial in 1997 used mifepristone 200 mg and vaginal misoprostol and was an open label, non‑randomized, prospective trial at 7 geographically diverse sites. There were 933 subjects with a 97% effectiveness up to 8 weeks pregnant. 2% used a second misoprostol dose and there were no transfusions and no hospitalizations.2
The third trial in 1998 extended the gestational age to 9 weeks pregnant using mifepristone 200 mg and vaginal misoprostol at 15 geographically diverse sites. Women used home misoprostol. There were 1137 subjects and 308 between 56‑63 days gestation. The regimen was 97% effective up to 8 weeks, 96% after 8 weeks, and 2% uses a second dose of misoprostol. There were one transfusion and two hospitalizations.3
The fourth ARM trial randomized misoprostol at 1, 2, or 3 days after mifepristone 200 mg. Again, it was an open label, prospective trial at 15 geographically diverse sites. There were 2255 women enrolled up to 8 weeks pregnant. The regimen was 98% effective at 1 and 2 days, and 97% effective at 3 days (2% used a second dose). There were no transfusions and 2 hospitalizations.4
We have had another trial completed comparing mifepristone 200 mg and Oral vs. Vaginal misoprostol at 24 hours. We used two doses of oral misoprostol 400 mcg two hours apart on day 2 up to 63 days pregnant. There were 1168 women enrolled. The effectiveness at first follow up was 89% in the oral group and 97% in vaginal group, ( p<0.001). In oral group, the regimen was 90% effective up to 7 weeks and 88% effective between 8‑9 weeks gestation. After a second vaginal dose of misoprostol was used, the overall effectiveness, 94% in oral group, 99% in vaginal group. There was more diarrhea with oral 33% v 18% vaginal misoprostol,( p<.001 ). There were no transfusions and no hospitalizations.
A sixth completed trial of 1000 women is still being analyzed to determine whether experienced US clinicians report that they need routine ultrasound.. Preliminary results show that about 57% of the time, clinicians report that ultrasound is not indicated. Ultrasound was reported to be indicated in about 22% of the time and “not indicated but desired” in the remaining 21%.
We have just finished our seventh trial which was a randomization of oral v vaginal misoprostol after mifepristone 200 mg at 48 hours up to 9 weeks pregnant. We used two doses of oral misoprostol 2 hours apart. There will be about 750 subjects enrolled. The results are pending. Low dose mifepristone and one dose of oral misoprostol 400 mcg after 49 days was not effective and the study was amended. There was 1 transfusion.
1. A 200 mg dose of mifepristone with vaginal misoprostol is as effective as the 600 mg standard mifepristone dose. Effectiveness rates with vaginal misoprostol have ranged from 96-98%.
2. With the use of vaginal misoprostol, we have demonstrated high effectiveness rates above 95% up to 9 weeks gestation.
3. A repeat dose of misoprostol in women with a persistent gestational sac at first follow up in the first week, was both safe and might improve effectiveness. A randomized trial of a repeat dose of misoprostol in initial non-responders would help to answer this question. Since there are few (5%) women who do not respond initially, it would require a large sample.
4. Vaginal misoprostol provided increased flexibility in the regimen and could be given 1, 2 or 3 days after mifepristone with effectiveness rates above 95%.
5. Home use of misoprostol is safe. Only 2 women out of 7,000 have needed an emergent aspiration curettage within 4 hours of using misoprostol, i.e., the time period when medical observation is required in France. Four transfusions occurred in these 7000 women (<0.1%). Of note, they all were delayed ranging from 1-3 weeks after using mifepristone.
6. Ultrasound dating of the pregnancy and confirming the abortion is highly accurate. It allows women to return earlier for evaluation, as soon as one day after using misoprostol, at a time when the serum hCG may still be elevated and the uterus has not fully involuted. It can also allow an early ectopic pregnancy to be detected. The French experience has demonstrated that ultrasound need not be routine.
From these studies, we conclude that the best regimen is mifepristone 200 mg in women up to 9 weeks pregnant (by ultrasound) followed 24-72 hours later by vaginal misoprostol at home, with a repeat dose of misoprostol in initial non-responders.
1. Schaff EA, Stadalius L, Eisinger SH, Franks P. Vaginal misoprostol administered at home
after mifepristone for abortion. J Fam Pract 1997;44:353‑360.2.
2. Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low‑dose mifepristone
200 mg and vaginal misoprostol for induced abortion. Contraception 1999; 59:1‑6.
3. Schaff EA, Fielding, SL, Eisinger SH, Stadalius LS, Fuller L. Low‑dose mifepristone
Followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception
2000; 61:41‑ 46.
4. Schaff EA, Fielding SL, Westhoff C, Ellerston C, Eisinger SH, Stadalius, LS, Fuller L.
Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion (< 56 days gestation): a randomized trial. JAMA 2000;284(15):1948‑1953.
Who is doing the translation
Thea Schipper RN, Managing director of the Abortion Clinic “Beahuis & Bloemenhove” , Heemstede, the Netherlands. Co-founder and member of the FIAPAC Board.
In early 2003 the story of a Moroccan woman whose pregnancy was terminated against her will in a Dutch abortion clinic attracted a lot of media attention. A political reaction from our State Secretary for Public Health quickly followed.
How can staff at Dutch abortion clinics deal with patients with whom they cannot, or can barely, communicate through language?
When should a professional interpreter be called in and when is it sufficient to allow the accompanying partner, family member or friend to act as interpreter?
How can it be known what the woman wants when there is a language barrier and does the choice to involve a professional interpreter depend on her wishes?
What can the referrer contribute?
How can healthcare laws be respected without bringing into question the integrity of the woman and the professionalism of the worker in the field of abortion?
Can wilful deception be prevented?
Who should do the counselling: doctor – non doctor?
Karen Schlie , Family Planning, Hamburg - Germany
The first question arising in this connection is the question of what is at issue in the counselling. As a counsellor having graduated in pedagogic with additional therapeutic qualifications I have to focus on the client’s issues.
What are her needs and wishes concerning counselling prior to an abortion.
- Does she need support in taking her decision or rather an opportunity to reflect whether she has taken the right decision?
- Does she require information about abortion: medical information, the selection of the right method, the procedure, framework conditions or the steps to go – just to mention a few examples?
- Or does the client rather wish information about social/financial support in order to reconsider whether this would influence her decision?
- Are there any specific legal conditions concerning abortion to be observed in different countries?
- Are there any legal conditions for the physician such as her duty to inform about complications?
- Does the client wish any counselling at all?
This range of questions shows that different qualifications are required to provide adequate and professional help for the respective problem.
Therefore I would not ask who should do the counselling prior to an abortion but rather which qualifications the physician or other professional should have.
I work as a counsellor at the family planning centre in Hamburg/Germany. I have a university degree in pedagogics with additional qualifications in social work and psycho-therapy. These are qualifications from which I benefit in my pre-abortion counselling work.
As counselling prior to an abortion is compulsory in Germany, we often have to deal with resistance and fear. Frequently, our clients are insecure and don’t know what they have to expect from the counselling.
In our counselling work we distinguish between clients who have already taken their decision to have an abortion (which is the case for about 80 % of our clients) and those who rather seek support in their decision-taking process (some 20 %). The latter need a therapeutically trained counsellor.
Mostly, both types of clients wish to also receive medical information.
Therefore, medical knowledge about the performance of an abortion and any potential complications is required. In our team at the family planning centre, we have physicians and perform abortions ourselves. If the client has any questions I cannot answer, I can refer her to a physician or can acquire the relevant knowledge myself. Vice versa, the physicians can refer to me or one of my colleagues, if they become aware that the client has not yet taken her decision or is in a crisis due to an inner conflict.
Of course, these opportunities are not available at every institution or clinic; and therefore it is essential to try to establish a good network of cooperation and, if necessary, to take part in specific training.
Regardless of your profession, I think it is important to reflect your own inner processes as well as your practical work. Counselling competence, such as certain communication techniques, might also be of help in the medical context.
Thus, in supporting the client in her choice of the appropriate abortion method you should also talk about her personal situation taking into account her particular needs.
- Are there, for example, small children but nobody who could take care of them?
- Is she afraid of surgical abortion because of past bad experience with operations?
- Does she consider Mifegyne to be a more self-determined way which she would prefer while a surgical abortion might give her the feeling of being in someone’s hands (“there’s someone doing I don’t know what to me”) – possibly due to a history of sexual abuse?
- In case the pregnancy is too advanced for medical abortion so that she has to choose the surgical way, it may be important to reflect whether it is more appropriate for her to get local anaesthesia as she could then participate consciously in the entire process.
- Or would she rather prefer not to live consciously through the surgical abortion process because it might lead to retraumatization due to past experience with violence? Then general anaesthesia might be her choice.
For all these questions it is useful if I as a counsellor can reflect my own feelings while I inform the client about the various methods. Am I able to go with the client and her decision even if I would choose a different method in a similar situation? And by the way, what is my way of informing? Do I conduct the dialogue in a way ensuring that the client can take a self-determined decision about the method she considers most appropriate? Am I the one determining what is “self-determined” or am I rather able to put aside my own concepts of what might be best for the client.
Summarizing I come back to the one central question: What are the qualifications required by a counsellor to deal with abortion, no matter whether she is a physician or another health professional?
In my opinion we are not looking for an either-or solution but rather for an as-well-as solution. This means that physicians and other professionals should cooperate and support each other in order to participate from each other’s competence in striving for the greatest possible benefit for the client.
Why is local anaesthesia done so rarely?
Stephen Searle, MD, Clinical Director/Consultant in Contraception & Sexual Health, UK
The talk will cover:
MVA, Evidence Worldwide
Practical Advantages & disadvantages of LA TOP>
Practical Advantages of MVA:
Effective up to 12/40 & down to 5/40; Moves TOPs out of theatre; Less frightening for
women; One visit, short stay; Inexpensive, low-tech; Enables non-gynaecologists to
evacuate Ut; Simple, safe & effective for ERPC; No need to undress; No need to be
starved; Can drive home; Less risk of uterine damage - GENTLE; Often suitable when GA
STOP or MTOP are relatively contraindicated eg gross obesity, oral steroid treatment
Pain: Audit indicates there is less pain with LA than with MTOP and possibly less than
after women awake from GA STOP
Pain more likely with Primips, teenagers, if frightened or depressed, higher gestations.
However: 70-90% would choose LA again
Evidence on Analgesia
less pain with Cx block than none
20ml better than smaller vol
inj @ 4 and 8 o'clock
N2 O. x2 RCTs:
Entonox: BPAS 1st 501
22% used N2 O - of these:
28% - very helpful
58% - Moderately helpful/some help
11% - no help
CONCLUSION: After 1st 250, staff were reminded to routinely offer N2 O.
"..hospitals should abandon curettage.. and adopt the aspiration methods, selecting
manual evacuation and/or electric aspiration, according to the expertise available."
Ref: Final Report, FIGO/WHO Task Force, March 1997
Contraindications to MVA:
Gestation > 12/40
Anticoagulant Rx/Prolonged bleeding time
Haematocrit < 30%
GA STOP £430
LA VTOP £190 (4 on list)
Appendix. USA Complications
Local vs. General Anaesthetic. Grimes 1979, Am J Ob Gyn.
36,430 LA vs 17,725 GA
Blood Transfusion, Cervical Tears, Perforations: x3 - x4 greater with GA
Anaesthetic deaths: a GA complication
BPAS + MSI: 1998-2000. N = 2,026
ERPC = 6 (0.29%)
Blood transfusion = 0
Hospital admission = 2 (0.09%)
1 confirmed ectopic
1 pain, anxiety, continuing pregnancy
André Seidenberg is a general practitioner in Zurich.
He performs abortion treatment in his medical practice.
He is the president of APAC-Suisse and a member of the board of FIAPAC.
He is a Research Fellow of the Institut für Hausarztmedizin und Versorgungsforschung, University Zurich
Andre Seidenberg, Switzerland
Local anaesthesia as the safest analgesic method for a surgical abortion up to 12 weeks could fall into oblivion in many high standard countries. WHO (2003), British (RCOG 2004) and French (ANAES 2001) official guidelines recommend to favour local in preference to general anaesthesia.
These guidelines refer mainly to an old but very large American CDC study on mortality (Peterson 1981, Lawson 1994). Nevertheless the evidence to favour local in preference to general anaesthesia was confirmed by several new studies with morbidity parameter as end points (Osborn 1990, Thonneau 1998, Pons 2004).
Deaths from abortion are very rare in developed societies with good access to legal medical care. In the US 8.5 deaths per 1 million abortion were registered in the CDC-study. Nearly four times more death cases were recorded after general than after local anaesthesia. In-depth analysis of the large data set revealed this disadvantage of general anaesthesia, both among those woman whose death was directly caused by the anaesthesia as well among those whose died through causes not directly connected to the analgesic technique. Confounding factors like sterilizations, pre-existing diseases or gestational age had no crucial influence: general anaesthesia remained 2.5 times riskier than local anaesthesia.
No doubt general anesthesia techniques have improved during the past 3 decades. E.g., Halothane had undesired effects on the uterus. Nevertheless, the younger studies exhibit more perforations of the uterine wall, cervical lesions and severe bleedings through general anaesthesia than through local anaesthesia (Soulat 2006, Osborn 1990).
Even so, we want to point to the fact that local anaesthetics could be lethaly overdosed. Experience and good surgical technique are of high importance for surgical abortion (Hern 1990). The technique of local anaesthesia for surgical abortion was described in a dissertation monograph by Ambassa 2007. Independent of the lower costs, many women prefer to have an abortion under local anesthesia rather than under general anesthesia, when given the choice (Bachelot 1992).
Anatomy and clinical aspects
André Seidenberg (Switzerland)
Local anesthesia is the method of choice for an induced abortion by the surgical suction method. This is the evidence based recommendation of the WHO (2003) and the official British (RCOG 2004) and French guidelines (ANAES 2001). A general anesthesia is not recommended as method of choice for an induced abortion by the surgical suction method.
These recommendations are mainly based on an old CDC-study comparing the mortality following abortion with local anesthesia versus general anesthesia (Peterson 1981, Lawson 1994). Deaths caused by induced abortion at less than 12 weeks gestation are rare in developed countries offering a good access to contraception and abortion treatment: In the USA 8.5 deaths among 1 million legal induced abortion cases were found. According to the CDC-study almost four times more woman died by general anesthesia than by local anesthesia for an induced abortion by the surgical suction method. These correlations were also visible analyzing only deaths not directly caused by the method of the anesthesia: 3½ times more woman died after general anesthesia than after local anesthesia. The same correlations revealed when biases as sterilization, preexisting diseases, or duration of the gestation were considered for the calculations: general anesthesia remained minimally 2.5 times riskier than local anesthesia. Younger studies with morbidity end points revealed the same technical advantages of the local anesthesia compared to general anesthesia for an induced abortion by the surgical suction method (Pons 2004, Thonneau 1998, Osborn 1990). With general anesthesia (without Halothane®) more uterine perforations, cervical lesions, and severe bleedings were recorded (Soulat 2006, Osborn 1990).
Experience and good surgical technique (Hern 1990) are crucial. A French thesis (Ambassa 2007) of last year gives an overall view on local anesthesia for an induced abortion by the surgical suction method. Priming (with 2 tabs Misoprostol intra vaginally) is recommended 3 hours before the operation. Only the cervix is anesthetized, which alleviates dilation. The pain caused by the uterine contraction during and after the suction procedure is not influenced by the local anesthesia. The sensible nerve fibers deriving from the inferior hypo gastric plexus enter at the isthmus of the uterus. Be aware of the close neighborhood of these blood vessels and be careful with avoiding intra vascular injection. The maximum of 3 mg / kg Lidocain (≈ 20 ml of a 1% solution) should not be exceeded. All deaths caused directly through local anesthesia were due to overdose (Peterson 1981).
Para Cervical Infiltration / Para Cervical Block
Intra Cervical Infiltration
Trans Canalicular Infiltration
Sub Epithelial Infiltration Modified acc. Ambassa 2007
There are principally 2 techniques for the infiltration of the local anesthetic (Ambassa 2007): the para cervical block and the intra cervical Infiltration. Many variants are used in practice. For the para cervical block the anesthetic depot is injected at 4 and 8 a clock in 2-5 mm depth. For intra cervical infiltration often a 2% solution of Lidocain is used. Addition of Adrenalin is not recommended because diffusion is suppressed and a longer effect of the anesthetic is not needed for cervical the dilation. Adrenalin additionally accentuates side effects as there are oppression and palpitations.
Comparing pains the local anesthesia for induced surgical abortion causes an acceptable level of analgesia (Ambassa 2007). E.g. pains during the cervical dilation are comparable to menstrual pains.
Regardless of the lower costs many woman prefer the local anesthesia to general anesthesia for induced abortion by the surgical suction method (Bachelot 1992).
Experiences of health care professionals
André Seidenberg (Switzerland)
Not only by the general public but also by health professionals induced abortion is regarded as something special. Emotional, ethical, and psychological considerations were inevitable and a matter of course. We conducted a little survey on opinions and measures in the region of Zurich, Switzerland. Medical directors of gynaecological clinics take precautions for their staff, who is involved in induced abortion treatment.
Ibuprofen and paracetamol for pain relief during medical abortion
D.S. Seidman, A. Livshitz, R. Machtinger, G. Yerushalmi, Y. Ben David, M. Spira, A. Moshe-Zahav, L. Lerner Geva, E. Schiff (Israel)
Department of Ob. & Gyn., Women and children's research unit and Gertner Institute for Epidemiology, Sheba Medical Center, both affiliated to Sackler School of Med., Tel-Aviv University, Tel-Aviv, Israel
Background. Non-steroidal anti-inflammatory drugs (NSAIDs) have long been avoided in pain relief protocols for medical abortion because of concern over their potential inhibition of prostaglandin induced uterine contractions.
Objective. To determine whether the use of the ibuprofen for pain relief is effective and whether it can adversely affect the outcome of medical termination.
Methods. In a prospective double-blind controlled study 120 women undergoing medical abortion with 600 mg oral mifepristone and 400 mcg oral misoprostol were randomized to receive ibuprofen or paracetamol when pain relief was necessary.
Results. Ibuprofen was found significantly more effective (p<0.0001) for pain relief after medical abortion compared with paracetamol. Other parameters that significantly influenced the pain score after administration of the analgesics included the pain score before the analgesia and abortion in the past. There was no difference in the failure rate of medical abortion, and the frequency of surgical intervention was slightly higher in the group that received paracetamol (16.3% versus 8.5%).
Conclusions. Ibuprofen was found highly efficient for pain reduction during medical abortion and more effective than paracetamol. We also found that a past history of a surgical or medical abortion was predictive for high pain scores. Importantly we found that despite its anti prostaglandin effects ibuprofen did not interfere with the action of misoprostol and was not associated with an increase in surgical interventions.
Legal but Limited: Abortion Access and Abortion Tourism in Canada
Christabelle Sethna, Professor, University of Ottawa
Marion Doull, Doctoral Candidate, University of Ottawa
In 1969, the Canadian government liberalized the conditions under which a legal
therapeutic abortion could be performed. These conditions proved, however, to be so
restrictive that many women were forced to turn to "abortion tourism," or travel to other
provinces, cities and countries to access an abortion. In 1988, the Supreme Court of
Canada struck down the abortion law as unconstitutional. Yet despite the fact that
abortion now is completely legal in Canada, regional disparities have seriously limited
many Canadian women's access to pregnancy termination.
These disparities have again forced many women to travel far from home to access
abortion services. This paper will provide a history of abortion legislation, abortion services
and abortion tourism in Canada from the 1960s onward.
In Nigeria, abortion is illegal except to save a woman’s life, and data on abortion are limited. Performance, Monitoring and Accountability 2020 (PMA2020), in conjunction with the Centre for Research, Evaluation Resources and Development, are collecting nationally-representative survey data on abortion perceptions, norms and stigma in seven states in Nigeria. This study aims to characterize abortion stigma and its correlates, and assess its relationship to perceptions of abortion in the community and the performance of survey-based abortion estimation techniques.
Using a two-stage cluster design, women aged 15-49 in households are interviewed by resident enumerators using smartphones. Women are asked about a range of reproductive health issues, including their perceptions and experiences around abortion, as well as those of their closest confidantes. Survey administration will be complete in May 2018 with a final sample of approximately 11,000 women. Here we report on preliminary analyses of bivariate associations and estimates of lifetime abortion experience. Multivariate regression analysis will be conducted upon attainment of the final sample.
Overall, approximately 70% of respondents felt that a woman who has an abortion brings shame to her family, and 45% reported abortion as common. A higher percentage of women who perceived abortion as shameful reported it as uncommon compared to women who didn’t perceive it as such (47% vs 43%, p<0.001). Estimates of reported lifetime prevalence of a likely abortion amongst a woman’s closest confidante were lower among women who perceived abortion as stigmatized versus not stigmatized (18% vs 22%, p<0.05). We recorded a difference in self-reported lifetime likely abortion prevalence among women who perceived abortion-related stigma versus those who did not (13% vs 17%, p<0.001).
Our study incorporates data on stigma, perceptions of abortion prevalence, and two methodologies (self-report and confidante) for abortion estimation, allowing consideration of the empirical associations between stigma and these measures.
The law is strict in theory but flexible in its application. Two doctors must
assess the physical or mental risk to the patient, and give their consent.
Termination is allowed up to the 24th week of amenorrhoea.
The situation in Northern
Abortion is legal in Northern Ireland but only in
very restricted circumstances. Rape, incest and
fetal abnormality are not grounds for an abortion.
Women and girls resident in Northern Ireland with
a crisis or unplanned pregnancy who decide to
end their pregnancy have to travel to England
and other European countries and pay for a
private abortion. Despite being UK citizens they
are not entitled to a free abortion in Britain unlike
women resident in Britain. This presentation will
explore the ﬁnancial, practical and emotional
consequences of this denial of sexual rights and
the political dynamics which underpin this denial.
Trends in induced abortion Background: Abortion levels and trends often
mirror patterns in the incidence of unintended
pregnancy. We present estimated safe and unsafe
abortion levels globally and in all the major world
regions and subregions for 2008, the most recent
year available, and trends in abortion incidence
between 1995, 2003 and 2008. We also explore
the association of the legal status of abortion with
the abortion rate. Finally, we examine abortion
rates and the distribution of abortion by age, and
variations in these measures across geographical
areas and over time.
Select Findings: The global abortion rate was
steady between 2003 and 2008 following a period
of decline between 1995 and 2003. Worldwide,
49% of abortions were unsafe in 2008, compared
to 44% in 1995. About one in ﬁve pregnancies
ends in abortion. Restrictive abortion laws are not
associated with lower abortion rates. Adolescents
account for a smaller share of abortions than their
population size would predict in most countries
with data. The proportion of abortions obtained
by adolescents is higher in North America than
in Europe, though Northern Europe resembles
North America in this respect. Findings and their
implications will be discussed in greater detail.
Future contraceptive methods: What to look forward to?
Regine Sitruk-Ware (United States)
Rockefeller University and Population Council, New York, United States
Contraceptive research will build upon advances in biomedical research, which have created new opportunities for studying the basic biology of reproduction. Basic research could, in turn, lead to the discovery of novel targets for contraception. The novel technologies of genomics, proteomics, lipidomics, and glycomics, has great potential in the identification of protein targets and their regulatory genes specific to the reproductive system. Developing small molecules that will inhibit these targets to stop the reproductive processes would allow more specific approach to contraception. In addition the progress made in the drug delivery area may also facilitate the development of advanced contraceptive systems in the future.
New methods currently under development are designed to meet the challenges of expanding contraceptive choices for both women and men and, of answering an unmet need for contraceptives that would satisfy new categories of users. Long-acting systems would be preferred to improve compliance and easiness of use. Both IUDs and implants are now widely available; transdermal gels and sprays are in early stages of research and a one-year contraceptive vaginal ring is in the last stages of development. All these delivery systems are based on the use of steroidal hormones delivered continuously at very low doses, which suppresses ovulation in cycling women.
In other cases, the provision of an additional health benefit may increase compliance with contraceptive use. Current contraceptive methods do have many benefits: some improve menstrual bleeding patterns, alleviate dysmenorrhea and acne, and sometimes pre-menstrual syndrome. Others can produce amenorrhea and help prevent anemia. Should new contraceptive methods provide additional protection against breast cancer they would also have wide appeal. In addition, dual-protection methods which join contraceptives to antiretroviral agents to protect women against both unwanted pregnancy and transmission of human immunodeficiency virus (HIV), would meet a major need. Men now tend to accept the concept of taking responsibility for the control of the couple’s fertility, leading to a growth in requests for male contraceptives, an emerging and challenging area of research.
Above all, new contraceptives, which are designed to be used by healthy men and women, should be very safe and easy to use, reversible, as well as affordable.
New developments in contraception
Regine Sitruk-Ware, MD
Adjunct Professor Rockefeller University and Population Council, New York, USA
By 2015, the population growth rate will decline but the total world population will reach the
6 billion mark, a 25% increase above today population. Although a steady increase in
contraceptive use has been observed both in developed and less-developed countries, the
contraceptive needs of a significant percent of couples have not yet been met, with an
increase in unplanned pregnancies. Several new products have reached the market during
the last 2 years. Among these are new implants, medicated intrauterine systems,
contraceptive vaginal rings, transdermal patches with longer duration of action, and
several new combined oral contraceptives. In addition new options such as transdermal
sprays and gels, progesterone receptor modulators for a bleed-free, estrogen-free
contraception are under evaluation. These new methods have been developed to meet the
objectives of expanding contraceptive choices for both women and men and, of answering
an unmet need for contraceptives with long-term action that meet the expectations of
consumers. Women give preference to methods that do not interfere with sexual
intercourse and that result in regular withdrawal bleeding or, at least, no unpredictable
bleeding. Men now tend to accept the concept of taking responsibility for the control of the
couple’s fertility, leading to a growth in requests for male contraceptives, an emerging area
of research. Simplicity, reversibility, and effectiveness are the desired features of a male
contraceptive. Implants, gels and combinations of orals and injections are under clinical
development for male contraception.
New areas of basic research include the genomic and proteomic as well as studies of
enzymes involved in the reproductive system. Identifying specific genes and the proteins
induced by these genes and finding molecules that specifically antagonize gene action will
open new avenues for the development of contraceptives that do not modify the hormonal
profile of the individual. The new methods will be targeted to specific interactions within
the reproductive system at the level of the ovary and testis, as well as between
spermatozoa and the ovum. These new approaches also require the engineering of
original drug-delivery methods that reach the target very specifically but do not interact
with other tissues in the body.
In the future, contraceptives may be combined with other medicinal agents to provide dual
protection against both pregnancy and another preventable condition, such as sexually
transmitted infections. Vaginal gels are under development to meet this goal. Some
existing methods prevent other disorders, such as menorrhagia and the anemia it causes.
When a contraceptive method provides dual benefits, women or men may have a greater
motivation to use a contraceptive method, thus reducing contraceptive failures and
New frontiers in contraception research
Regine Sitruk-Ware USA
Regine L. Sitruk-Ware is a reproductive endocrinologist and holds the position of executive director of product research and development at the Population Council’s Center of Biomedical Research. She organizes pre-clinical research and clinical development of new molecules designed for reproductive healthcare in men and women suitable for use in developing countries. She is a program director for a cooperative contraceptive research center of the NICHD. Prior to joining the Council, Sitruk-Ware had successively an Academic career and then a career in Industry in Research and Development. She taught and conducted clinical research in reproductive endocrinology at the University of Paris for ten years. She was a member of the International Committee for Contraceptive Research, which was established by the Population Council in 1970. She is a member of several national and international medical societies.
Sitruk-Ware has written eight books and over 200 articles and reviews, mostly dealing with women’s healthcare issues. She served as adviser in several ad hoc committees of the WHO and the NIH. She received her medical doctorate at the University of Paris and is currently an Adjunct Professor at Rockefeller University.
Estimates predict that by 2015, the population growth rate will decline but that the total world population will reach the 6 billion mark, a 25% increase above the present day population. More than 26 million new couples will need contraceptives. Although a steady increase in contraceptive use has been observed both in developed and less-developed countries, the contraceptive needs of a significant percent of couples have not yet been met, and the number of unplanned pregnancies continue to increase. The actual usage of contraception differs from region to region. Although no new methods were registered for many years, several new products have reached the market during the last 2 years. Among these are new implants, medicated intrauterine systems, contraceptive vaginal rings, transdermal patches, and several new combined oral contraceptives.
New methods have been developed to meet the objectives of expanding contraceptive choices for both women and men and, of answering an unmet need for contraceptives with long-term action that meet the expectations of consumers. When interviewed, women request affordable methods that are highly effective and reversible, easy to use, and under their own control. Preference is given to methods that do not interfere with sexual intercourse and that result in regular withdrawal bleeding or, at least, no unpredictable bleeding. Men now tend to accept the concept of taking responsibility for the control of the couple’s fertility, leading to a growth in requests for male contraceptives, an emerging area of research. Simplicity, reversibility, and effectiveness are the desired features of a male contraceptive but no method is yet available.
New areas of basic research include studies of genes, proteins, and enzymes involved in the reproductive system. Identifying specific genes and the proteins induced by these genes and finding molecules that specifically antagonize gene action will open new avenues for the development of contraceptives that do not modify the hormonal profile of the individual. The new methods will be targeted to specific interactions within the reproductive system at the level of the ovary and testis, as well as between spermatozoa and the ovum.
Genes involved in the regulation of human reproduction are explored first in animal models but these models must then be validated by studies in humans. As an example, spermatogenesis requires a complex interaction between various cellular compartments of
the testis, and proteins involved in these interactions are now targets for contraceptive methods. These new approaches also require the engineering of original drug-delivery methods that reach the target very specifically but do not interact with other tissues in the body.
This futuristic approach still keeps in mind the need for better access to existing contraceptive methods, as well as the discovery of new contraceptives that are simple to use, safe, reversible and inexpensive. In the future, contraceptives may be combined with other medicinal agents to provide dual protection against both pregnancy and another preventable condition, such as sexually transmitted infections. Some preliminary studies suggests that certain contraceptive methods, given alone, may not only prevent pregnancy but may also prevent common disorders of the female reproductive system, such as menorrhagia and the anemia it causes. When a contraceptive method provides dual benefits, women may have a greater motivation to use a contraceptive method, reducing contraceptive failures and unwanted pregnancies.
Regine Sitruk-Ware, MD, Population Council & Rockefeller University, New York, USA
The synthetic progestins used for contraception are structurally related either to testosterone (estranes and gonanes) or to progesterone (pregnanes and 19-norpregnanes). Several new progestins have been designed to minimize side-effects related to androgenic, estrogenic or glucocorticoid receptor interactions. Dienogest (DNG), and drospirenone (DRSP) exhibit antiandrogenic activity and DRSP has predominent antimineralocorticoid properties. The 19-norpregnanes include Nestorone® (NES), nomegestrol acetate (NOMAc) and trimegestone (TMG) and possess a high specificity for binding to the progesterone receptor with no or little interaction with other steroid receptors. DRSP has been developed as combination oral pills with ethinyl-estradiol (EE) and dienogest which shows 40 percent of the antiandrogenic action of cyproterone acetate, has been successfully combined in contraceptives either with EE and more recently with estradiol valerate (E2V). NOMAc, exerts a high antigonadotropic action and has been used as a progestin only method and more recently combined with estradiol (E2) in an oral monophasic contraceptive. Nestorone* is not active orally but proved to be the most active antiovulatory progestin when used parenterally. It has been developed in various formulations such as implants, one-year vaginal ring, in combination with EE, or transdermal gel or spray, in combination with the natural estrogen E2. Active derivatives of older progestins have proven high effectiveness in preventing ovulation and low doses of these steroids have been used combined with EE in non-oral delivery systems e.g etonogestrel in a 3-year progestin-only contraceptive implant or combined with EE in a monthly vaginal ring; norelgestromin in combination with EE in a transdermal weekly patch. Risks and benefits of the newer progestins used in contraception depend upon the type of molecular structure, the type of estrogen associated in a combination and the route of administration.
*Nestorone has been developed by the Population Council with grants from USAID, NICHD and UNFPA
Update on contraceptive
developments Although contraceptive use showed a steady
increase worldwide, the needs of a signiﬁcant
percent of couples have not yet been met, as
unscheduled pregnancies increased.
While implants and IUDs require a health provider
for a proper insertion, vaginal rings, a mid-acting
method, have the advantage of being user-
controlled. While long-acting methods seem
preferable for women with compliance issues,
daily transdermal gels or sprays have shown high
acceptability as the methods can be used privately.
Progesterone receptor modulators (PRMs) to be
used within 120 hours of unprotected intercourse
have a deﬁnite role as emergency contraceptives.
Continuous low-dose administration of a PRM
from a vaginal ring has been shown to block
ovulation and induce amenorrhoea.
Contraceptives combined with other agents
should provide dual protection against both
pregnancy and another preventable conditions.
Dual protection methods are tested as vaginal
gels or rings delivering both a contraceptive and
an agent active against HIV transmission. In
addition, the potential of PRMs to prevent breast
cell proliferation or the neuroprotective effects
of progesterone and derived molecules are new
areas of research for contraception with added
medical beneﬁts. These dual-purpose methods
may increase users’ compliance, thus reducing
failures and unwanted pregnancies.
Men now tend to accept responsibility for the
couple’s fertility control, leading to a growth in male
contraceptives needs. Non-hormonal methods
for men target the maturation of germ cells, or the
sperm motility and activity. Novel approaches in
women target meiosis as well as genes involved
in follicular rupture. These methods will hopefully
enter clinical testing during the current decade.
Why do we need new contraceptives?
Regine Sitruk-Ware (United States)
Rockefeller University and Population Council, New York, United States
The total world population is predicted to reach the 6 billion mark in 2015. Although a steady increase in contraceptive use has been observed both in developed and less-developed countries, the contraceptive needs of a significant percent of couples have not yet been met, with an increase in unplanned pregnancies of which 60% lead to abortion.
Although several methods of contraception are available, access may be limited due to poor quality of services or to costs of methods not endorsed by health systems and insurances. In addition, a high discontinuation rate is observed during the first year of use of currently available methods due to inconvenience or poor tolerability. Safer methods are still needed in order to minimize the side-effects and increase compliance.
In addition different needs appear according to the stage of reproductive life. Adolescent girls would need easy to use and remember methods that would improve compliance. Also, on-demand methods for occasional sexual relationship may be favored. During their reproductive life, men and women would need methods that may help to space out pregnancies and both partners may alternate the endorsement of a contraceptive method. Finally women who would have completed their family may rather need long-acting methods that would also treat possible gynecological diseases of the later years of fertile age.
In other cases, the provision of an additional health benefit may increase compliance with contraceptive use. Current contraceptive methods do have many benefits: some improve menstrual bleeding patterns, alleviate dysmenorrhea and acne, and sometimes pre-menstrual syndrome. Others can produce amenorrhea and help prevent anemia. Should new contraceptive methods provide additional protection against breast cancer they would also favor wider use and compliance.
New methods under development are designed to meet the challenges of expanding contraceptive choices for both women and men and, of answering unmet needs for contraceptives such as pre and post-coital methods, user-controlled long-acting delivery systems, long-acting methods for men, methods with dual protection and additional medical benefits.
Is there a need for male contraception?
Régine Sitruk-Ware Population Council, New York, USA - firstname.lastname@example.org
New contraceptive methods have been developed to meet the objectives of expanding contraceptive choices for both women and men and answering an unmet need for contraceptives with a long-term action that meet the expectations of consumers. Simplicity, reversibility and effectiveness are the desired features of a male contraceptive, but no new male contraceptive method is yet available. In comparison to female methods, the two existing male methods, condom and vasectomy, appear limited and are not always well accepted. Vasectomy is an irreversible method although new micro-surgical techniques would allow reversibility in some men. While clinical research on hormonal methods is advanced, and several combinations of androgen and progestin proved effective, no method has been fully developed and approved. Currently development of a tissue specific androgen 7-methyl nortestosterone (MENT), a molecule that does not affect the prostate, is ongoing as a method bringing additional health benefits. Non-hormonal methods are still at an early stage of research. New areas of basic research include studies on genes, proteins and enzymes involved in the reproductive system. New approaches target the maturation of germ cells, a critical component of sperm development, or the sperm motility. These methods aim at inducing reversible infertility without interfering with hormones secreted by the hypothalamus, pituitary gland, and testis. There is an obvious need to provide men with choices for their fertility regulation but advocacy for this research needs to expand and convince the industry that there is a market with unmet needs that deserves attention and investments.
Abortion then and now: New Zealand Abortion
Istar Limited, New Zealand
Based on a social history book by Dame Margaret Sparrow
available from Victoria University Press www.victoria.ac.nz/vup/.
In the 1940s deaths from septic termination of pregnancy
(TOP) were an ever-present fear.
In the 1950s, due to antibiotics, deaths were less common but
there was a network of clandestine abortionists.
In the 1960s the contraceptive pill and feminism brought
changes for women but New Zealand and Australia did not follow
the 1967 law changes introduced in the UK. Those who could
afford it went overseas.
In the 1970s TOP was catapulted into the public arena with
protest and debate bringing signiﬁcant law changes in 1977–78.
Finally doctors took responsibility for safe TOP services.
From the years when illegal TOP was usually the only option
for women, the author has collected personal stories from some
70 contributors, women who had a TOP, doctors, police and
activists. Some of the stories relate to women from New Zealand
struggling with accessing abortion while living in the UK.
The themes are universal and remind us that these injustices
must never return.
Abortion then & now
Margaret Sparrow MD, New Zealand
Abortion has been present throughout history and in all cultures. This historical perspective
is to remind us of what has happened in the past, so that we have a better understanding
of the present which will assist us as we develop good practice guidelines for the future. In
the past women frequently risked their health, their fertility and their lives with unsafe
procedures and in many parts of the world they still do. The use of traditional methods has
been common but many treatments for self-abortion are unsafe or ineffective. Whenever
safe medical services are unavailable illegal abortionists will flourish. Poor women are the
most vulnerable often paying with their lives. In many countries including my own, New
Zealand, abortion is still regarded as a crime rather than as a medical procedure or as a
matter of personal human freedom. Laws in many countries have been a barrier to change
but changes have occurred through public and professional awareness, protest activity,
commissions, petitions, court cases, feminism and by advances in medical technology.
Now, in developed countries where abortion is legal, it is the most common gynaecological
operation and one of the safest.
How to introduce medical abortion in a country, the example of NZ
Margaret Sparrow; MD, New Zealand
In 1999 New Zealand abortion providers considered that New Zealand women should be
offered the choice of medical abortion. As no pharmaceutical firm was interested in
importing mifepristone, five doctors formed a not-for-profit company Istar Ltd. The name is
derived from Ishtar or Istar, an ancient Babylonian goddess of love, fertility and war.
In May 2000 Istar signed an agreement with the French manufacturer, Exelgyn and
applied to Medsafe, Ministry of Health for approval of a new prescription medicine.
On August 30 2001 Mifegyne 200mg was approved by the Minister of Health Hon Annette
King and gazetted for use in New Zealand for abortion only.
To comply with the law all abortions in New Zealand must be “performed” in a licensed
institution. For fear of prosecution most clinics except the one at Wellington Hospital,
chose not to use Mifegyne. Second trimester abortions in hospitals were not affected and
the first medical abortion using Mifegyne was carried out in Wellington Hospital in October
In April 2003 Mr Justice Durie in the High Court Wellington ruled that a woman must take
both sets of pills (Mifegyne, followed 48 hours later by prostaglandin) in a licensed
institution, but she does not need to stay on licensed premises between taking the pills,
nor does she need to stay on licensed premises until the abortion is complete. Clinics are
now able to perform early abortions within these limits.
Our experience demonstrates that with persistence, obstacles can be overcome.
John A D Spencer, Senior Clinical Consultant, Marie Stopes International, London, United Kingdom
A review of the management of all surgical abortions with a gestation between 19 and 23 weeks was undertaken during 2009 by prospective collection of data. All were day-cases, admitted subsequent to clinical assessment, blood tests, and consent. Cases not suitable for general anaesthesia in our centres were referred for hospital management. Cervical preparation was by intracervical Dilapan rods (a hygroscopic dilator) and vaginal Misoprostol. Dilatation and Evacuation was performed after waiting at least four hours.
Of a total of 770 cases in two London centres data were collected on 726 (94%). Three of the four doctors performed 94% (37%, 37% and 20%) of cases respectively. The number of cases each month varied between 50 and 84 and there were no significant differences between the two centres. Cervical preparation began before 1100 hours in 95% of cases.
The age range of clients was 14 to 46 years (96% were between 15 and 39). 38% were multiparous (parity 1-4) of which 17% had a history of one or more caesarean sections. 95 % experienced noticeable abdominal cramps during the cervical preparation interval but only a small minority requested analgesia. The incidence of diorrhoea was 5% and vomiting 3%. One client began bleeding sufficient to require transfer to hospital before surgery.
Analysis of the treatment patterns showed that the dose of Misoprostol administered was influenced by age (more if younger), gestation (more if 22 or 23 weeks) and parity (less if multiparous). Most clients had 3 Dilapan rods inserted through the internal cervical os and difficulty were noted in only a few nulliparae. The preparation interval was significantly longer if the gestation was 22 or 23 weeks, and if a higher dose of misoprostol was given. Multipara had a shorter preparation interval.
The cervical dilatation found prior to commencing Dilatation and Evacuation was significantly greater after the higher dose of misoprostol, with higher gestations, in multiparae. The procedure duration was longer with higher gestations, and was shorter if the cervical dilatation was greater and in multiparae. Metal (Pratts) double-ended cervical dilators were rarely (less than 5%) required. Recovery was uneventful in all cases not already transferred to hospital, and all clients were discharged within 2 hours.
There were only four serious complications which required transfer to the local hospital. The case of haemorrhage from a low-lying placenta had a placenta accreta related to a previous caesarean scar and required subtotal hysterectomy. Three cases had a laceration of the internal cervix or lower uterus,
directly related to surgery, and were successfully managed with an intrauterine balloon and suturing.
Table to summarise treatment and outcomes by gestation
n (%) of study group
Mean age for each gestation
Intracervical Dilapan x 3 (%)
Intracervical Dilapan x 4 (%)
Misoprostol 600 mcg PV (%)
Misoprostol 800 mcg PV (%)
Cervical preparation for 4-6 hrs (%)
Cervix pre-op Cx dilat >18mm (%)
Procedure duration <20 min (%)
Collection of induced abortion data in Italy and its results
Angela Spinelliab, Michele Grandolfoa, Marina Pediconia, Ferdinando Timperia, Silvia Andreozzia, Mauro Bucciarellia, a Istituto Superiore di Sanità, Rome; b Agenzia di Sanità Pubblica della Regione Lazio, Rome
In 1978, a law was passed in Italy which set forth the regulations governing the procedures for obtaining an induced abortion. According to this law, pregnant women may request an abortion during the first 90 days of gestation, for health, economic, social, or familial reasons. To obtain an abortion, the woman must first obtain a certificate attesting to the state of the pregnancy from her general practitioner, a private physician or a public maternal-child health clinic. The abortion is performed free-of-charge either at a health care structure in the National Health Care System or in a private structure with a contract from the regional health authority
Since 1980, the Istituto Superiore di Sanità (Italian National Institute of Health) has maintained a surveillance system for legal induced abortions. This system is based on quarterly reporting by the regional health authorities. For each induced abortion, a standardized form is completed in the hospital where the procedure is performed. This form contains data on major socio-demographic characteristics of the woman (age, place of birth, citizenship, education, occupation, marital status, reproductive history) as well as details about the procedure (weeks of gestation, whether the procedure is elective or performed on an emergency basis, where the certificate was issued, type of procedure and location where it was performed, duration of stay, and immediate complications). The Istituto Superiore di Sanità examines data quality and performs data analysis of trends, geographic distribution, and characteristics of women undergoing abortion. These analyses are performed by the ISS, in collaboration with the Ministry of Health and the National Statistics Institute (Istat), and presented annually to Parliament by the Minister of Health. Thanks to this surveillance system, Italy has very accurate and timely abortion data which is used to monitor the phenomenon and to suggest areas for research and intervention for prevention .
After the legalization of abortion in 1978, there was an initial increase in incidence, with a peak of 234,000 abortions performed in 1982 (abortion rate=17.2 per 1000 women ages 15-49 years, abortion ratio=380.2 per 1000 live births). Subsequently, there has been a steady decline, with 130,000 abortions performed in 2002 (abortion rate=9.3/1000). This reduction represents a decline of 46% over the past 20 years, with an estimated 100,000 fewer abortions in 2002 compared with 1982.
The incidence of abortion in Italy is similar to that of other countries in north-western Europe (where rates range from 6.5/1000 in the Netherlands to 18.7/1000 in Sweden), but it is much lower than in Eastern Europe (where rates are around 50/1000) and in the United States (22.9/1000).
As with many other health conditions, there are major differences within Italy between regions and geographic areas: in 2001, the abortion rate was 9.6/1000 in the North, 10.7/1000 in the Center, and 8.8 in the South. The declining rates over time have been observed in all areas of the country, with a trend toward convergence. The greatest decreases have occurred in those regions where women obtain the required certification through maternal-child health clinics rather than from their general practitioner or private physician. In addition to the legal abortions described above, the ISS has estimated, using mathematical models, that illegal abortion persists, with an estimated 21,100 performed in 2000. These illegal abortions are not equally distributed throughout the country and are more common in the South. As is the case with legal abortions, illegal procedures have also decreased dramatically over time. Applying the same mathematical models, it has been estimated that in 1983 there were approximately 100,000 illegal abortions. The estimated number of illegal abortions has thus decreased by 79% since the early 1980s.
From other studies, it has been observed that in most cases, abortion is not considered to be the family planning method of choice, but instead results from the failure to control fertility using contraception. More than 70% of women who undergo abortion report that they were using some method of contraceptive at the time of conception (primarily coitus interruptus).
The finding that the number of repeat abortions is lower than that estimated by mathematical models that assume no changes in contraceptive behavior, support the hypothesis that the observed reduction in induced abortion is the consequence of a greater diffusion and more effective use of contraception.
There do appear to be some subpopulations in which abortion rates are higher: women with children, those with lower levels of education, and housewives. The most consistent declines in abortion rates are seen among married women, among women aged between 25 and 34 years of age, and in those with children.
In recent years, there has been an increase in the number of abortions requested by immigrant women. Among the 132,234 abortions in 2001, 25,094 (19.4%) were performed on foreign citizens, a large increase from the 9,850 observed in 1996. This increase is most likely due to the rising number of immigrant women in Italy; the resident permits, for example, according to the data of the National Statistics Institute (Istat), have increased from 678,000 in 1995 to 1,500,000 in 2002. Based on estimates of the population of immigrant women aged 18-49, Istat has calculated that the abortion rate for immigrant women was 30/1000 in 2000, three times higher than that observed in Italian women. Indeed, the increase in the numbers of immigrant women may be the main cause of the recent leveling-off of the abortion rate in Italy. If the analysis of trends is limited to 1996-2001, years for which the information on citizenship is most complete, the number of abortions in Italian women declined from 127,700 in 1996 to 106,166 in 2001.
In conclusion, the reduction of induced abortion appears related to the improved use of contraception and to the important role of the maternal-child health clinics. The social-demographic characteristics of the women who have had abortions in recent years imply that further reductions are undoubtedly possible, especially if the maternal-child health services can be further strengthened.
Survey of immigrant women who have an induced abortion in Italy
Angela Spinellia, Michele Grandolfob, Emanuela Forcellaa, Giovanni Baglioa,
Giovanna Scassellatic, Augusto Colombod, Graziella Sacchettie, Paola Serafinif, Maria Giovanna Caccialupig, Gabriella Guasticchia
aAgenzia di Sanità Pubblica della Regione Lazio, Rome; bIstituto Superiore di Sanità, Rome; cOspedale San Camillo, Rome; d Clinica Mangiagalli, Milan; e Ospedale San Paolo, Milan; f Ospedale Sant’Anna, Turin; gCentro per la salute delle donne straniere e dei loro bambini, Bologna
The number of foreign women who have abortions in Italy is increasing; the number of induced abortions performed on foreign women has increased from 8967 in 1995 to 13826 in 1998 and to 25094 in 2001, the last being 19% of all abortions in Italy. In some regions of Italy, particularly where more immigrants have settled, this percentage is even higher. For example, in Lombardia it is 30%, while in Emilia Romagna, Lazio and Piemonte it is 26%.
The Istituto Superiore di Sanità ( the Italian National Institute of Health) which for many years has monitored induced abortion in Italy, has collaborated with the Agenzia di Sanità Pubblica (Regional Health Authority) of Lazio to launch a project in six regions of Italy to understand the rationale which leads these women to seek abortions, to identify risk factors and understand the ways and means by which these women have achieved their abortions.
The project is in two parts: the first is a quantitative survey, while the second is an in-depth interview of a smaller sample of the women. Given that the attitudes and use of contraceptives depends very much on the country of origin, it has been decided to concentrate on women from Ecuador, Peru, Nigeria, Marocco, China, Romania and the Ukraine, these being the six largest immigrant groups.
In the quantitative survey, about 600 foreign women who have had a termination of pregnancy will be questioned by interviewers who have been specifically trained, using a tailored questionnaire. The sample will be all the women from these countries who have had an abortion in one of four hospitals in the period March to June 2004. The questionnaire contains closed questions which seek information about knowledge and use of contraceptives, use of local family planning clinics, how the women discovered how to use the health services to obtain their abortions, their reproductive history and social-demographic information.
The in-depth study will be on about 50 women from the same countries, who have had a termination in the last six months, using a semi-structured questionnaire. The questions will include information on their immigration to Italy, their knowledge and use of contraceptives, the reasons why they decided to seek an abortion and the assistance they received from the local health services.
The preliminary results of this project will be presented at the conference.
Supply of emergency hormonal contraception without prescription
in Swiss community pharmacies
Spycher C, Beutler M, Lemke S, Bruppacher R, Hersberger KE,
PLANes – Lausanne , CH
Introduction: Levonorgestrel for emergency hormonal contraception (EHC) is used by the Familiy Planning Center of the Department of Obstetrics and Gynecology, Inselspital Bern since 1999 (along with guidelines and a specific EHC-protocol). Experiences have been analyzed and were favourable. Levonorgestrel was officially introduced in Switzerland as EHC in November 2002. It is available without prescription (‘pharmacist only’). The same Guidelines and a specific EHC-protocol were implemented to assure safe and rational drug use.
Objectives: Monitor in a pilot study the demand and the pharmacists’ counselling activities and search for improvement potential concerning supply and pharmaceutical care.
Design: Retrospective analysis of the EHC-protocols, collected from pharmacies to elicit request and supply problems as background for the development of a questionnaire.
Prospective query of all women requesting EHC in 4 community pharmacies with enlarged opening hours and known supply of EHC of more than 20 times a month. A 13 items questionnaire, filled in by the customers immediately after triage in the pharmacy, was linked with the respective EHC-protocol.
Setting: Random sample of 14 community pharmacies in German speaking Switzerland offering access to their EHC-protocols; 4 of them with frequent requests approached their customers for answering the questionnaire.
Results: In 14 pharmacies a total of 205 protocols were documented during the first 6 month after introduction of Levonorgestrel for EHC. Only 44 missing data (3.0% out of 1435 items) demonstrated that triage was based on complete information.
During 10 weeks the 4 pharmacies approached 177 women requesting EHC, of them 141 (71%) (median age 23 years, range 16 - 47) filled in the questionnaire. 59% used EHC for the first time. The major reasons for EHC request were problems with condoms (69%) and non-compliance with hormonal contraception (13%). Before sexual contact only 55% knew about availability of EHC without prescription through pharmacies. Alternatively women would have contacted a physician (55%) or a hospital (27%), but 11% would have waited without action. In 91% of all requests EHC was supplied. General satisfaction with pharmaceutical care was rated best (on a 4 point scale) by 86% of the women. Deficits concerned counselling about future contraception and risk of sexually transmitted diseases.
Conclusions: EHC through pharmacies could successfully be implemented. The structured counselling protocol was well used and is likely to support good counselling.
To monitor problems and changes in the quality of pharmaceutical care and in emergency contraception behaviour a larger study should follow this pilot study.
Development of a post-termination of pregnancy
Sripotchanart, W1; Chunuan, S1; Lawantrakul, J1;
Pongpaiboon, P1; Lawantrakul, J2; Kosalwat, S1;
Kritcharoen, S1; Buranasiri, L2
1 Prince of Songkla University, Thailand; 2 Hatyai Hospital, Thailand
This participatory action research (PAR) was aimed to (i) develop
the post-termination of pregnancy (TOP) care model for women
after a TOP and (ii) examine the obstacles in implementing the
developed model for women after a TOP.
The research processes were divided into four steps based on
the PAR model: (i) assessing the existing care model and planning
to develop the initial model; (ii) developing and implementing the
developed model; (iii) revising the initial model to meet the needs
of women after a TOP; and (iv) evaluating the results. The sample
consisted of 12 nurses at a hospital in Southern Thailand and 60
women after a TOP. Open-ended questions were used to collect
data among these women. In-depth interviews, focus group
discussion, and participant observations, were also used. Personal
data and qualitative data were analysed by using descriptive
statistics and content analysis, respectively. It revealed that the
post-TOP care model for women after a TOP was a holistic care
model comprising building an impressive relationship, having
positive attitudes, giving advice and counselling and providing
continuous care to meet the needs of women after a TOP. The
identiﬁed obstacles of the model implementation were the nurses’
overwork, stress, and weariness.
In conclusion, in this participatory action research led nurses to
recognise the importance of holistic care, have better attitudes
towards women after a TOP and improve their service of giving
advice and counselling by using the instructional media.
Wattana Sripotchanart, Sopen Chunuan, Jitsai Lawantrakul, Pranee Pongpaiboon, Jitti Lawantrakul,
Sureeporn kritcharoen, Sirirat Kosulwat,. et al., Thailand
Unsafe Abortion is a major public health problem and society .Each year, Thailand has a woman problem of unsafe abortion around 300,000 people. Complications resulting from unsafe abortion are an important cause of maternal deaths.Hospitals are tertiary places. But with the health care system that is limited. Task of making more women after an abortion care were not taken care coverage.This participatory action research have the following purposes:
1) to study and develop models of care women after abortion.
2) to study the satisfaction of women receiving post-abortion care model developed later.
3) to study the obstacles in developing models of care women after abortion.Participant consisted of 12 nurses who work in units of one hospital and 60 women after abortion.
Before and after the development of models of care of 60 people the tools used to collect information line is open-end questions. And satisfaction survey of women after abortion. Value equal to 0.97 poise storage to a depth interviews. Group discussions and questionnaires.
General data analysis using descriptive statistics. Qualitative data analysis with content analysis. Comparative satisfaction of women after abortion in the quality of hospital care before and after the development of quality care using statistics Independent-Sample t-test at the end of the research. Model of care women after abortion care is holistic, including building relationships that impressed. Having a positive attitude. Advising and counseling. And to maintain continuous compliance with the needs of women after abortion. The satisfaction of women after abortion before and after the development patterns of care differ statistically significant (p =. 05) obstacles in the development patterns found that the burden of care is more leisurely.
Summary of development patterns of care by women after abortion, research that focuses on practical involvement of nurses. Allow nurses are aware of more holistic care. Have better attitudes to women after abortion. The brochures created financial advice and counseling. To women after abortion has led to comply.
The ultrasound simulator system- a novell training system in ultrasound examination
Staboulidou I., Fiala C., Wüstemann M., Scharf A.
Medizinischen Hochschule Hannover
Although ultrasound examination became almost indispensable in prenatal diagnostics as well as in gynecologycal examination, there are still a lot of short comings concerning the quality of sonographic education in OB/GYN.
At the Departement of Gynecology and Obstetrics of the Medizinische Hochschule Hannover (MHH) a multitude of normal and pathologica 3 D l volume cases were scanned and projected into a simulation object to be used for teaching and training purposes.
The ultrasound simulation system makes it possible to simulate a complete real time 2 D ultrasound examination. The system is able to simulate all imaginable kinds of ultrasound examination. It offers a novel opportunity of structured ultrasound training including the option to define various levels of difficulty. Thus it can also be used as a training tool to assess the competence of the sonographer.
Choosing induced abortion: an existential event?
Maria Liljas Stålhandske (Sweden)
Centre for the Study of Religion and Society, Faculty of Theology, Box 511, 751 20 Uppsala, Sweden
How do Swedish women cope with early induced abortion as a life event? This paper raises the issue of women’s existential needs in relation to abortion. Material from an ongoing empirical study, including interviews with women who have had an early abortion and personnel working in abortion care, will be presented. The study works out of a feministic perspective and aims at bringing a partly tabooed question connected to female reproductivity into the scholarly discussion. The aim is not to question the liberal abortion legislation in Sweden, which the author endorses.
To make an induced abortion is to make a crucial decision. Current Swedish abortion research shows that the decision often comprises strong and conflicting emotions. For many women it means to go through a period where feelings of pride, desperation, relief, grief and emptiness succeed each other. At the same time abortion is not included among those life events that people normally share and manifest through religious and/or social rituals and traditions. The consequences of this for women’s existential wellbeing have not yet been studied in international research.
The preliminary results of the study indicate that the need of existential and/or ritual processing is dependent upon the degree to which the woman experienced the abortion decision as difficult or ambivalent. When ritualizations of the event occur, they also seem to take different forms depending on how the woman relates to the aborted fetus.
Abortion is allowed up to 14 weeks of amenorrhoea.
A session of counselling must take place at least 3 days before the procedure.
A woman who is doing an abortion abroad, without prior counselling risks a
Minors need parental consent from their parents for an abortion. The Courts
can oppose abortions for minors.
Establishments performing abortions are under the jurisdiction of the regional
government. The price of an abortion is reimbursed by the state in most cases,
depending on the income of the women.
All publicity concerning abortion is forbidden.
Women’s preference for medical or surgical
method of termination of pregnancy at 9–12 weeks
Dewart, H1; Johnstone, A2; Cameron, S2
1 Royal Inﬁrmary of Edinburgh, UK; 2 Chalmers Sexual and
Reproductive Health Service, UK
Background and methods: Medical termination of pregnancy
(TOP) at less than 9 weeks of gestation and in the second
trimester, using mifepristone and misoprostol is well established
in Scotland. Although there is good evidence to support the
efﬁcacy, safety and acceptability of medical TOP in the late ﬁrst
trimester (9–12 weeks), it is not widely available. The TOP service
in Edinburgh, Scotland, UK currently offers only a surgical
method at this gestation band. A survey of women presenting to
this service at 9–12 weeks of gestation was conducted to
determine whether these women would choose a medical method
if this were available.
Results: Questionnaires were completed by a convenience sample
of 77 women over 5 months, representing 49% of all women at
this gestation during the study period. Women were of mean age
24.7 years (range 15–42). Most women (n = 51; 66%) stated that
they would choose a medical TOP if able to do so and a further
10 (13%) were unsure about preference of method. Most women
(n = 43; 56%) stated that they would still choose the medical
method, if they had to travel to another hospital (40 km away) to
have this. The commonest responses (out of 46 given) for
preferring a medical method was a perception that it was safer
(37%), easier (30%) and less invasive (28%).
Discussion and conclusions: Most women in our survey at 9–
12 weeks of gestation would in theory choose a medical method
of TOP, if this were available. Consideration should now be given
to offering this method to women as an alternative to surgery.
Recent developments in Spain
Recent events and the legal, police, political
and social developments that have taken place
in Spain in recent years are part of a global and
conservative campaign and have generated in the
new political context of this country vast concern
for the rights of women regarding equality and
sexual and reproductive health.
The various recent historical stages are
discussed, from the Second Republic (1936-
1939) and the military dictatorship of Franco
(1939-1975) to democracy (1975-2012)
in relation to the legislation and practice of
induced abortion, in particular highlighting the
achievements and shortcomings of the Abortion
Law of 1985 and the current Law on Sexual and
Reproductive Health and Voluntary Termination of
Pregnancy, in force since July 2010.
The current political situation is described, with a
Conservative Government and absolute majority
in Parliament, and the statements of its main
representatives regarding the change of the current
law until end of year. Furthermore, we also present
the upcoming trial of professionals from an abortion
clinic in Barcelona and the attempt by retrograde
sectors and anti-choice groups to use this case to
put pressure on the Government and public opinion
in favour of a radical restriction of the right to abortion.
Reasons for the use of medical versus surgical abortion in Europe
Clínica Ginecentre, Málaga, Spain
Although most countries in Europe have similar abortion laws and belong to the most advanced category in the world, the implementing regulations can in practice facilitate or hinder access to abortion care. In the same way, since the legalisation of Mifepristone in France in 1988, the use of specific drugs in the abortion practice has spread in Europe unevenly but there are still significant differences from one country to another.
We classify the countries as follows:
The main reasons affecting the use of medical versus surgical abortion are:
This paper reviews the impact of these factors in different European countries and regions.
Proposals are presented to improve the availability of the most appropiate method for each woman, according to their special circumstances.
Our top priorities: medical safety and free method choice for the women
Abortion in Spain: recent developments
Alberto Stolzenburg ACAI, Spain
The current 2010 Law on Sexual and Reproductive Health and Voluntary Termination of Pregnancy recognizes for the first time abortion as a fundamental women's right. It clearly sets the health dimension of this right and provides legal certainty as well. Women have access for free to abortion on demand up to 14 weeks, in case of maternal and fetal pathology up to 22 weeks and beyond 22 weeks for very severe and incurable diseases. When the majority of Spanish society has gone in the last years through democratic values regarding abortion, the Government strives to change the current law even though 80% of the population reject the draft law and 68% of their own voters believe that women should decide themselves. Meanwhile the abortion rate in Spain keeps stable and is similar to other countries of Western Europe. The preliminary draft of Justice Minister Gallardón specifies these and other realities and seeks to placate the most reactionary wing of the Spanish right. In this way, abortion will be allowed only under two conditions: rape and serious maternal diseases, eliminating fetal deformations as a reason. At the same time, it establishes a medical and legal journey of such magnitude, that in practice it makes abortion impossible even for the legal reasons mentioned. In addition, this law penalizes severely health professionals, deepening the stigma and the legal uncertainty that have marked them. The draft law is pending approval by the Council of Ministers. An approval that has been awaited by the strong social and political opposition and internal contestation among the Executive and the ranks of the Popular Party. If finally the Parliament approves the draft this year, Spain would have in 2015 the most restrictive law of the democratic era.
Early, liberal provision of intrauterine contraception after first trimester abortion is not associated with an increased risk of postabortal adverse events or complications
Elina Pohjoranta, Maarit Mentula, Satu Suhonen, Oskari Heikinheimo Helsinki University Central Hospital, Helsinki, Finland - email@example.com
Objectives: We carried out a randomized prospective study to assess the effects of early provision of intrauterine contraception (either LNG-IUS or Cu-IUD) vs. routine practice of starting contraception following first trimester induced abortion. This is a secondary analysis comparing early (i.e. within 3 months) adverse events/complications in the two groups. Method: Altogether 756 women undergoing an induced abortion were randomized into two groups (378 in the intervention and 372 in the control group). In the intervention group, 70 (19%) women chose surgical abortion; 68 (97%) of them received an IUS/IUD at the time of abortion. Of the 308 women choosing medical abortion, 290 (83%) received the IUS/IUD at the follow-up visit 2-3 weeks after abortion, the remaining 61 (17%) later. The women in the intervention group had an appointment with the study nurse at 3 months after the abortion. For the control group, a follow-up and future contraceptive counselling was scheduled in primary health care, which is the normal practice. All women were advised to contact the hospital should complications arise. The hospital charts were reviewed for postabortal complications (i.e. bleeding, residual tissue, ongoing pregnancy or infection requiring treatment) within 3 months. Results: 58 (15%) women in the intervention group and 45 (12%) women in the control group were treated for an adverse event (p=0.196). The rate of complications among all women choosing medical abortion was 82 (13%) and 21 (15%) among those choosing surgical abortion. In the intervention group, 24 (41%) patients' complications were detected before the follow-up, 31 (53%) at the follow-up visit, and 3 (5%) at 3 months. Altogether 20 (5.3%) IUS/IUD expulsions occurred by 3 months, 7 (35%) of which were before 2-3 weeks. Conclusions: The early insertion of an IUD after first trimester abortion does not increase the overall risk of adverse events/complications nor cause extra visits to the clinic.
Perception of pain during misoprostol-induced medical abortion
Marja Tikka, Satu Suhonen, Timo Kauppila, Seppo Kivinen (Finland)
Helsinki University Central Hospital, Finland
Counselling, information about the process of medical abortion as well as sufficient pain relief are important factors when a woman chooses medical abortion. Menstrual pain, parity and woman’s age may influence pain perception and satisfaction with the chosen method of abortion. Medical abortion can be performed with misoprostol administered in home. How painful the abortion experience is, and can this pain be predicted would be useful to know when medical abortion is chosen and especially when home-use of misoprostol is planned.
Fifty-six women who had chosen medical abortion were allocated in this study. Their mean age was 26.2 years (SD 6.2, range 15-43). On the day the medical abortion was started, the median length of pregnancy evaluated by transvaginal ultrasound was 47 days (range 32-63). This was the first pregnancy for 4 women. Altogether 29 women (51.7 %) were nulliparous.
The women were asked to describe their menstrual pain by describing how intense (sensory discriminative component of pain) and unpleasant (affective-motivational component) the pain was. Visual analogue scale (VAS) and a pain drawing of the body area where the pain was felt were applied. When the participants were at the ward after receiving misoprostol, they were asked to describe similarly the pain they felt during the abortion. Afterwards, the type of pain at home, its duration and need for painkillers were recorded, too. At the control visit after medical abortion, their willingness to have gone through the abortion at home was also asked.
The intensity of menstrual pain correlated significantly with the intensity of pain perceived during medical abortion. Both intensity and unpleasantness of menstrual pain correlated with the affective-motivational component of pain perception during medical abortion, too. Older and parous women reported less pain. In these women the area where pain was felt was also smaller. At the time of control visit, 55 % women were willing to choose home administration of misoprostol as a method of choice for abortion. Their VAS scores for pain during abortion were lower than in women who would not prefer home administration of misoprostol (12 vs 68 mm, median). Most of the women who were willing for home-administration were parous. However, neither the length of pregnancy at the time of abortion nor the age of the woman had an influence on her view.
In nulliparous women, dysmenorrhea predicts the pain perceived during medical misoprostol-induced abortion. Sufficient pain relief is important to all women, but especially if home-administration of misoprostol is planned during medical abortion.
Contraceptive failure - unprotected sex or failure
in use of the chosen contraceptive method or use
of an ineffective method - leads to unintended
pregnancy. Most women choose abortion in this
situation. Avoiding the same incident in future, that is
reducing the risk of repeat abortion, is in the interest
of the woman and also the society both medically,
psychologically, socially and economically. Including
contraceptive counselling in post-abortion care is
important and emphasized also in recent guidelines
(WHO, RCOG). However, counselling itself has not
been shown to have a beneficial long-term effect on
contraceptive use and risk of repeat abortion.
Recovery of ovarian function after abortion is
rapid, ovulation occurs within the first month after
abortion in most women. Thus contraception
should be started as early as possible after
abortion. Immediate start of both hormonal
(pill, patch, ring) and also long-acting reversible
(LARC) methods (implant, injection, intrauterine
contraception) is recommended in the above
mentioned guidelines. After medical abortion
LARC using implants, injections can be started on
the day of abortion, intrauterine contraception as
soon as an on-going pregnancy is excluded. There
is evidence that if after abortion a LARC method
is chosen, the risk of repeat abortion is reduced.
Well-functioning, easy-access contraceptive
services are important in the follow-up.