Lisbon, 13-16 Octubre 2016: „Improving women’s journeys through abortion“

  • 09:00-
    • Christian Fiala, AT
    • Ann Furedi, GB
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      Early and very early medical abortion

      Philippe Faucher
      Hôpital Trousseau, Paris, France

      Early medical abortion will be defined in this presentation by termination of pregnancies with Mifepristone/Misoprostol when no visible gestational sac is visible on ultrasound. Very early medical abortion will be defined by termination of pregnancies before the date of expected menstruation. Providers are reluctant to provide medical abortion so early mainly because of the fear of a missed diagnosis of ectopic pregnancy. Consequences for women are not negligible: repeated consultations, repeated ultrasound, repeated HCG could delay the termination of the pregnancy and induce problems of costs, confidentiality or emotional distress. Arguments will be presented to reassure providers about the possibility to provide early medical abortion safely. A protocol for follow up of early medical abortion will be presented based on correct information given to the women (especially symptoms that must induce a visit to the emergency service) and serum HCG testing seven days after the medical abortion. The second argument is the possibility of a reduced efficacy of medical abortion in the early period of pregnancy which was suggested in one study. Published data on this fact will be presented. Finally very early medical abortion will also be considered in this presentation on the basis of recent studies.

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      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.

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      Strengthening autonomy: Mobile technology and self-assessment for medical abortion

      Deborah Constant1, Jane Harries1, Caitlin Gertz2
      1University of Cape Town, Cape Town, South Africa, 2Ibis Reproductive Health, San Francisco, USA

      Shortages of providers of surgical abortion methods are a significant barrier to safe abortion care across diverse settings where abortion is legal. Early medical abortion using mifepristone and misoprostol requires less provider involvement, is highly effective and can largely be managed by women themselves. Medical methods are highly acceptable to women and can increase women’s autonomy.
      Self-determination of gestational age eligibility, self-administration of misoprostol and management of abortion symptoms, self-assessment of abortion outcome and selection of postabortion contraception can be strengthened using mobile phone technology (mhealth). Reliable networks, adequate connectivity, phone ownership and phone privacy are necessary for mhealth to effectively facilitate safe abortion care. These conditions exist in developed but also in many developing countries.
      In South Africa studies have shown most women with gestations within 70 days can recall their last menstrual period with sufficient accuracy and use an online gestational age calculator to determine eligibility for medical abortion. Supportive text messages including reminders and information on complications over 14 days following mifepristone significantly improved preparedness and provided effective emotional support during the abortion. Self-assessment using a text questionnaire was feasible, but not accurate, and a low sensitivity pregnancy test was necessary to better detect ongoing pregnancies. Twenty-three percent of women correctly recalled information from the messages on contraceptive methods 4-6 weeks after they had received them. In Colombia a low sensitivity pregnancy test together with text questions for self-assessment was a safe and feasible alternative to in-facility care.
      Mhealth, using text messages, shows promise for strengthening women's roles and control with respect to medical abortion. Other approaches include telemedicine consultations, automated text checklists on incomplete abortion symptoms, digital images to verify pregnancy test results and online resources with contraceptive advice. The increasing familiarity with digital technology provides a powerful opportunity to strengthen women’s reproductive autonomy.

  • 10:30-
  • 11:00-
    Concurrent session 06: Stigma workshop
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      Abortion Stigma: What are we talking about?

      Anu Kumar
      Ipas, Chapel Hill, NC, USA

      This workshop will discuss the concept of stigma and its application to abortion.  The concept of stigma has been used in areas such as mental illness and sexual identity.  Research and action on the topic of abortion stigma is growing with the aim of reducing stigma so that women can access safe abortion care without shame.  Abortion stigma is defined as a negative attribute, ascribed to women who seek to terminate a pregnancy and anyone related to abortion that ‘marks' them as inferior.   Abortion stigma, however, can also affect providers, facilities and those close to women who have had an abortion.  The various levels in which abortion stigma operates will be discussed using an ecological model.  A key aspect of research has been the development of the Stigmatising Attitudes, Beliefs and Actions Scale (SABAS) to measure abortion stigma at the community level.  Research on stigma among abortion providers will also be presented.  Programmematic strategies to reduce abortion stigma developed by Ipas and others will be shared.  Finally, participants will learn more about inroads, The International Network for the Reduction of Abortion Stigma and Discrimination.  The network is an online resource for information, ideas and contacts on the topic.

    Concurrent session 07: SFP - Unintended pregnancy
    • Susan Higginbotham, US
    • John Sciarra, US
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      Measurement of unintended pregnancy and its importance for predicting negative life impacts.

      Abigail Aiken1 ,2
      1University of Texas at Austin, Austin, TX, USA, 2Princeton University, Princeton, NJ, USA

      Unintended pregnancy is a key public health metric for gauging efforts to improve women’s reproductive health. Research has demonstrated complexity in women’s intentions, desires and emotional orientations towards pregnancy, as well as the propensity of each to change over relatively short periods of time. Yet current approaches to preventing unintended pregnancy and improving pregnancy outcomes are narrowly focused on the ideal that all women must form timing-based intentions regarding whether/when to have a(nother) child and then specifically plan either to achieve or to avoid pregnancy. In reality, many women hold ambivalent, indifferent or incongruent attitudes towards pregnancy, while others do not find planning meaningful in the context of their lives or may be unable to attain normative ideals regarding readiness for pregnancy and parenthood. Moreover, the main public health and clinical rationale behind preventing unintended pregnancy is that it necessarily results in adverse health and social outcomes. The evidence for such negative outcomes, however, is mixed and many studies suffer from serious methodological limitations. We review cutting-edge research examining pregnancy intentions, feelings and desires from women’s perspectives, as well as the evidence linking intentions to both negative and positive life impacts. We conclude by examining how shifting our emphasis from preventing unintended pregnancies to preventing truly undesired pregnancies could advance reproductive justice and result in more woman-centreed policy and practice.

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      Beyond unmet need: desired versus actual use of contraception

      James Trussell
      Princeton University, Princeton NJ, USA

      Two studies have examined what method of contraception women were using and what method they preferred to use. One was among postpartum women in Texas and the other was among women attending an antenatal clinic or an abortion clinic in Hull, England. In Texas, 800 postpartum women who wanted to delay childbearing for at least two years were followed prospectively.  At 6 months postpartum, 13% of women were using an IUD or implant, and 17% were sterilised or had a partner who had had a vasectomy. Twenty-four percent used hormonal methods and 43% relied on less effective methods such as condoms and withdrawal. However, 78% reported that they would like to be using either a long-acting reversible contraceptive method (LARC) or sterilisation. In Hull 76% and 6% of pregnancies among women in the abortion and antenatal clinics were unplanned, respectively. In this group, among those not using contraception, 31% were unable to obtain the method they wanted. Among those using a method 33% stated it was not the method they wanted; of these 75% would have preferred sterilisation, the implant, injectable or intrauterine contraceptive.

    Concurrent session 08: Gynuity – Innovations in Medical Abortion Service Delivery
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      Simplified medical abortion screening

      Rodica Comendant1, Mark Hathaway2, Ginger Gillespie3, Elizabeth Raymond4
      1Reproductive Health Training Centre, Clinical Hospital #1, Chisinau, Moldova, Republic of Moldova, 2carafem, Washington, DC, USA, 3Institute for Family Health, New York, NY, USA, 4Gynuity Health Projects, New York, NY, USA

      Introduction: Currently, most providers perform an ultrasound or pelvic examination before medical abortion to assess the duration and location of the pregnancy. These evaluations are expensive, time-consuming and uncomfortable and they must be done by a skilled clinician in a medical setting. Our pilot study is designed to assess the safety and acceptability of offering medical abortion to selected women without either procedure.
      Methods: We will recruit women requesting medical abortion in Moldova, the United States, and Mexico. To be eligible, a woman must be certain that her last menstrual period started within the prior 56 days, not have recently been using hormonal contraceptives, have no risk factors for or symptoms of ectopic pregnancy and not have had an ultrasound or examination in this pregnancy. Some sites exclude women with evidence of uterine enlargement on abdominal palpation. Each subject is treated with a standard regimen of mifepristone and misoprostol and followed until the abortion is complete.
      Results: Up until May 2016 182 women had been enrolled at three sites. In Moldova 76% of all women having medical abortion at the study site have joined the study. In the United States the proportion is much lower; many abortion clients were ineligible because of irregular menses or contraceptive history and some prefer to have an ultrasound. Of the 175 subjects, with complete follow-up to date, 94% had complete pregnancy termination without additional treatment, 2% had surgical aspiration and 3% had extra misoprostol. No serious complications have occurred related to the absence of initial ultrasound and examination. Most subjects (89%) were pleased with omitting the screening ultrasound and pelvic examination. We will present updated data at the meeting.
      Conclusion: Simplifying the screening procedures for medical abortion appears safe and could substantially increase access to this service.

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      Multi-level pregnancy test for medical abortion follow-up: what do we know so far?

      Elizabeth Raymond, Tara Shochet, Jennifer Blum, Wendy Sheldon, Beverly Winikoff
      Gynuity Health Projects, New York, NY, USA

      Objectives: To summarise data on the effectiveness and feasibility of a strategy involving serial use of an urine multi-level pregnancy test (MLPT) for at-home follow-up after early medical abortion.
      Methods: We included data from five published studies involving a total of 1,848 women who received treatment at ≤63 days of gestation. In all five studies, an MLPT with five hCG ranges was used for assessing medical abortion outcomes. A baseline test was administered just prior to mifepristone and a follow-up test was administered 1-2 weeks later. Declining hCG concentrations in successive tests were interpreted as indication of abortion success, while stable or increasing hCG concentrations were interpreted as indication of possible continuing pregnancy. The MLPT results were then compared with results from standard clinical assessment.
      Result: A total of 93.8% (1487/1585) of those with successful abortion outcomes (no ongoing pregnancy) observed declining hCG concentrations in successive tests. All those with continuing pregnancies (21/21) observed stable or increasing hCG concentrations. The predictive value of the MLPT strategy for identifying continuing pregnancy was thus 100%. In addition, 94.0% (1496/1591) of women reported that the MLPT was either very easy or easy to use.
      Conclusions: The MLPT strategy is highly successful at identifying continuing pregnancies as well as absence of continuing pregnancy. Use of this strategy is both feasible and effective and would reduce the need for clinic follow-up after medical abortion for the majority of women.

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      The Telabourtion Study: Evaluation of a Direct-to-Patient Telemedicine Abortion Service

      Erica Chong, Elizabeth Raymond, Philicia Castillo, Beverly Winikoff
      Gynuity Health Projects, New York, NY, USA

      Objectives: Given the difficulties women face in obtaining clinic-based abortion in many parts of the US, provision of medical abortion by telemedicine to women in their homes could be highly beneficial for increasing access. We developed a pilot study to obtain preliminary data on the safety, acceptability and feasibility of direct-to-patient telemedicine abortion.
      Methods: This case-series study of 50 women is being conducted in selected US states with no legal restrictions on telemedicine abortion. Women may learn about the study from staff at the collabourating study sites, from referring providers or from the study website. Each woman who is interested in the study will consult with a study investigator by videoconference and then will obtain screening tests at local facilities. If the results indicate that she is eligible, the investigator will send the abortion medications to her by mail. The participant will obtain tests at local facilities to confirm abortion completion and will have a follow-up consultation with the investigator by phone or videoconference. Data will be collected about interest in, and satisfaction with, the service, abortion complications and difficulties encountered by patients and providers in completing the protocol requirements.
      Results: We will review key legal issues that impact this model and challenges in designing the service to conform to expected standards of care for clinic-based abortion. We will also present data obtained in the project to date.
      Conclusions: In states with no legal restrictions, direct-to-consumer telemedicine abortion has great potential to increase women's access to abortion care in a safe and acceptable manner.

    Concurrent session 09: Free communication
    • Mirjam Denteneer, NL
    • Helena Kopp Kallner, SE
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      Use of effective contraception six months after emergency contraception with a copper intrauterine device or ulipristal acetate - a prospective observational cohort study

      Niklas Envall1 ,2, Helena Kopp Kallner2 ,3, Nina Groes Kofoed3
      1The RFSU Clinic, Stockholm, Sweden, 2The Karolinska Institutet, Solna, Sweden, 3Danderyds Hospital, Danderyd, Sweden

      Introduction: Emergency contraception must be followed by the use of an effective method for contraception in order to reduce future risk of unintended pregnancy. Provision of long acting reversible contraception (LARC) such as the copper intrauterine device (Cu-IUD) is highly effective in preventing unintended pregnancy.
      Objectives: to compare use of an effective method of contraception 6 months following insertion of a Cu-IUD or intake of ulipristal acetate (UPA) for emergency contraception (EC).
      Method: Women (n=79) presenting with need for EC at an outpatient midwifery clinic chose either Cu-IUD or UPA according to preference. Follow up was three and six months later through telephone interviews. Primary outcome was use of an effective contraceptive method at the six month follow up. Secondary outcomes included use of an effective contraceptive method at three months follow-up and acceptability of Cu-IUD.
      Results: A total of 30/36 (83.3%) of women who opted for Cu-IUD had an effective contraceptive method 6 months after their first visit compared to 18/31 (58.1%) of the woman who used UPA (p=0.03). In the Cu-IUD group 28/36 (77.8%) where still using Cu-IUD at six months and 31/36 (86%) stated that they would recommend the Cu-IUD to others as an EC method.
      Conclusion: Significantly more women who chose Cu-IUD for EC used an effective method for contraception at the six month follow up. The results of this study support increased use of Cu-IUDs for EC.

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      Evaluation of two low sensitivity urine pregnancy tests (1000 IU) used for self assessment following early medical abortion

      Sarah Millar, Sharon Cameron
      Chalmers Centre, Edinburgh, UK

      Introduction: The majority of women who have early medical abortion (EMA) at our service choose to confirm the success of the procedure by “self assessment” (a self-performed low sensitivity urinary pregnancy (LSUP) test at home two weeks after EMA). Women contact the abortion service if they have an invalid or positive result or symptoms of ongoing pregnancy. In 2014 we changed from a double cassette LSUP (Babyduo) to a single window LSUP (Check4) (both Quadratech diagnostics, UK). We predicted the Check4 test would be easier for women to use and interpret.
      Aims: To determine if the Check4 test improves the detection of ongoing pregnancies when compared with Babyduo and if there are any differences in reported invalid or positive results between the two tests.
      Methods: A retrospective database review identified women who had EMA “self assessment” in the 10 months before and 10 months after the introduction of the Check4 test. Fishers exact test and descriptive statistics were used for data analysis.
      Results: 1047 women were identified (n=492 Babyduo group and n=555 Check4 group). There were 2 ongoing pregnancies in the Babyduo group and 3 in the Check4 group. Significantly more invalid tests were reported in the Babyduo (n=18, 3.6%) than the Check4 group (n=6, 1.1%) (p=0.0064). Significantly more positive tests tests were reported in the Check4 (n=19, 3.4%) than the Babyduo group (6, 1.2%) (p=0.0244).
      Conclusion: The introduction of the Check4 LSUP has not altered the detection rates, or time to detection, of ongoing pregnancies. It has, however, been associated with fewer attendances for ‘invalid’ results and more for positive results. These findings may reflect that the single window Check4 test gives less margin for error in interpretation than the former double window test. We will continue to use the Check4 LSUP for EMA “self assessment” for this reason.

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      Analysis of cervical resistance during continuous controllable balloon dilatation

      Petar Arsenijevic, Slobodan Arsenijevic, Aleksandar Zivanovic, Slavica Djukic Dejanovic
      Faculty of medical sciences, Kragujevac, Serbia

      Background: Hydraulic dilatation is a novel method of cervical dilatation that is based on continuous and controllable dilatation by the pumping of fluid into the balloon extension of the system for continuous and controllable balloon dilatation (CCBD). The main advantage of this procedure is that it allows control and insight into the process of cervical dilatation.
      Methods: For the purposes of our research, we created a new and upgraded system for continuous and controllable balloon dilatation (CCBD), which consists of a programmed hydrostatic pump connected to a balloon extension. With regards to our aim to precisely measure and determine the location of the cervical resistance, we placed two pressure-measuring films on the top and on the bottom of the balloon extension. This study included 42 women in whom cervical resistance was measured prior to the suction curettage.
      Results: Cervical dilatation and measurement of cervical resistance were successful in all women. The analysis of the pressure-measuring films showed that the points of highest resistance are located in the zone of the internal cervical os and that these values are much higher than those in the zone of the external cervical os (0.402 versus 0.264 MPa at the upper pressure-sensitive film; 0.387 versus 0.243 MPa at the lower pressure-sensitive film). This study also showed that an increase in cervical resistance in the zone of the internal cervical os was followed by an increase in cervical resistance in the zone of the external cervical os.
      During continuous controllable balloon dilatation, the internal cervical os is the centre of cervical resistance, and the values do not decline with the number of miscarriages or the number of previous births.

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      Paracervical block (PCB) as pain treatment during second-trimester medical termination of pregnancy - a randomised controlled trial with bupivacaine versus sodium chloride.

      Inga-Maj Andersson, Lina Benson, Kyllike Christensson, Kristina Gemzell-Danielsson
      Södersjukhuset AB, Stockholm, Sweden

      The most common side effect of misoprostol is pain, however there are sparse studies of pain and pain treatment during MToP, especially in second-trimester abortion. Pain reported in second-trimester medical abortion is often intense, and peaks when the  expulsion occurs.
      Objectives: The aim of the present study was to determine if PCB administered before the onset of pain could decrease women´s pain experience during second-trimester MToP.
      Method: A double-blinded randomised controlled trial, with 113 participants included, was performed during May 2012 until April 2015.  Women who consented to participate were randomly allocated to receive a PCB with either 20 ml local anaesthesia (bupivacaine 2.5 mg/ml) or 20 ml sodium chloride 9mg/ml. The PCB was applied one hour after the first dose of misoprostol as a 2 to 4 millimetre deep paracervical injection into the mucosa at two sites (2 and 8 o´clock). The experience of pain was measured by visual analogue scale (VAS) at the time of administration of the first dose of misoprostol (baseline) and thereafter repeated every half hour during the abortion until the  expulsion. The main outcome was the highest pain intensity recorded on the VAS scale. Secondary outcomes were the induction-to-abortion interval measured from the start of misoprostol to  expulsion, the total morphine consumption, safety and side effects.
      Results: No statistically significant differences were observed between the two groups with regard to the highest and lowest pain intensity and morphine consumption. There was no difference in efficacy between the groups, neither in induction-to-abortion interval and time to placental expulsion nor in the rates of surgical intervention or the need for any additional treatment.
      Conclusion: It can be concluded that prophylactic PCB did not lead to a clinically significant reduction in maximal pain scores and the need for additional opiates during second-trimester MToP.

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      Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial

      Marie Klingberg-Allvin1 ,5, Amanda Cleeve1 ,2, Susan Atuhairwe3 ,4, Nazarius Mbona Tumwesigye3, Elisabeth Faxelid1, Josaphat Byamugisha3 ,4, Kristina Gemzell-Danielsson1 ,2
      1Karolinska Institutet, Stockholm, Sweden, 2Karolinska University Hopsital, Stockholm, Sweden, 3Makerere University, Kampala, Uganda, 4Mulago Hospital, Kampala, Uganda, 5Dalarna University, Dalarna, Sweden

      Objectives: We investigated the effectiveness and safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians.
      Methods: We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda. Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with first-trimester incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete abortion not needing surgical intervention within 14–28 days after initial treatment. The study was not masked. Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed effects model.  The trial was registered at, number NCT01844024.
      Findings: From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife versus physician group was –0·8% (95% CI –2·9 to 1·4), falling within the predefined equivalence range (–4% to 4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse events were recorded.
      Conclusion: Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and effective as when provided by physicians, in a low-resource setting. Scaling up midwives’ involvement in treatment of incomplete abortion with misoprostol would increase access to safe postabortion care.

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      Access to abortion in Australia: insights from health care professionals

      Angela Dawson1, Deborah Bateson2, Rachel Nicholls1, Anna Doab1, Jane Estoesta2, Elizabeth Sullivan1, Ann Brassil2
      1Faculty of Health, University of Technology Sydney, Sydney NSW, Australia, 2Family Planning New South Wales, Sydney NSW, Australia

      Objectives: Recent changes in Australia's national policy with the approval of mifepristone and misoprostol for medical termination of pregnancy (MTOP) have led to increased choices for Australian women. In New South Wales (NSW), the largest and most populous state, there is no statewide data on abortion and incomplete information on MTOP. Further, there is limited research concerning the practices of trained and credentialled abortion service providers. We undertook a qualitative research study to investigate health professional views, perceptions and practices concerning MTOP.
      Method: Eighty-one general practitioners (GPs), surgeons, gynaecologists, nurses and Aboriginal health workers in urban, rural and remote locations who do and do not provide abortion were interviewed. A deductive content analysis methodology was employed to analyse transcripts based upon a framework we developed to examine access to early abortion.
      Results: Private clinic abortion providers noted that they were busy and were mainly involved in surgical procedures with MTOP accounting for half of their work. Gynaecologists viewed abortion at the fringes of the speciality. GP and gynaecologist non-providers thought of abortion as stigmatised work that ‘others' do in private clinics and referred accordingly. Abortion was not seen as a priority for the public system and only provided at the will of interested doctors. MTOP provision was regarded by GPs as difficult due to the follow up required and most were not interested in provision. GP MTOP providers felt isolated and reported demand was low as was women's awareness. Nurses and Aboriginal health workers play an advocacy and facilitation role for mostly disadvantaged women.
      Conclusions: This study provides insight into access to abortion in the public sector and the low interest in provision from GPs who are at the forefront of primary care provision. Leadership from professional associations as well as the involvement of nurses may increase access for women.

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      Safety of medical abortion up to 10 weeks at home

      Iolanda Ferreira, Filipa Coutinho, Manuel Fonseca, Elsa Vasco, Teresa Bombas, Maria Céu Almeida, Paulo Moura
      Obstetrics Service A and B of Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

      Introduction: In Portugal, abortion by women's request is legal until 76 days of pregnancy. The rate of medical abortion is nearly 96% in the National Health System.
      Objectives: Evaluate the safety of medical abortion at home before and after 9 weeks of pregnancy.
      Methods: Retrospective evaluation of 6735 women (Group1-before 9 weeks; Group2-after 9 weeks), who attended our department between January 2007 and December 2015. For abortion the protocol used was mifepristone 200 mg and vaginal misoprostol 800 mcg after 48 hours. Statistical analysis was made using Independent T-test; Chi-Square and Mann-Whitney U test in SPSS 20.0.
      Results: Medical abortion was an option in 98.8% (n= 6650) of cases; 56 (0.8%) at hospital and 6594 (99.2%) at home. Regarding abortion at home, the mean age was higher in group 1 (28.9 vs 28.3; p= 0.05).
      According to national guidelines, an abortion is complete when there is no need for additional medical or surgical intervention. There was no difference in efficacy between groups (Group 1: 97.4% vs Group 2; 96.5%; p= 0.3). The most common side effect was pain, which was moderate (Group1: 34.3% vs Group2: 30.9%) intense (32.3% vs 38.2%) and maximal (11.6% vs 18.2%). Pain scores were significantly higher after 9 weeks of gestation (p= 0.04).
      There were no differences between groups regarding complication rate (Group1: 7.9% vs Group 9.9%; p= 0.2). The most common complication was retained abortion (6.1% vs 6.5%); method failure (1.2% vs 1.6%); endometritis (0.2% vs 0.8%) and severe blood loss (1% vs 1%). The rate of admission to hospital due to complications did not differ between groups (3.7% vs 4.4%; p= 0.5).
      Conclusion: Medical abortion is equally effective and was proven to be safe at home in both groups. The most common side effect was pain and it was significantly more intense after 9 weeks of gestation.

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      Preferred terminology amongst women seeking abortion : A  British survey

      Sharon Cameron1, Patricia Lohr2, Roger Ingham3
      1NHS LOTHIAN, Edinburgh, UK, 2BPAS, London, UK, 3University of Southampton, Southampton, UK

      Objectives: Some controversy exists as to whether or not women find the term ‘abortion’ distressing and would prefer alternatives such as ‘termination of pregnancy’.  There is a lack of evidence to substantiate any change in terminology. We conducted a study to determine views of women seeking abortion on terminology used.
      Methods: A cross-sectional study of the views of 2,259 women presenting for abortion in Britain was conducted over four months in 2015.  Self-administered anonymous questionnaires were distributed at 57 abortion services in Scotland, England and Wales. The questionnaire asked for women’s views on preferred terminology and collected basic demographic data.
      Results: The mean age of respondents was 27 years (range 13-51), 51% had children and 36% had previously undergone abortion. Most women did not find the words ‘abortion’ or ‘termination of pregnancy’ distressing. 35% (n=738) indicated that they found 'abortion' distressing vs 18% (n=399) who felt 'termination of pregnancy' was distressing (p<0.000). Significantly more respondents stated a preference for 'termination of pregnancy' than 'abortion' (n= 1009; 45% vs n=263; 12% respectively p<0.0001). This preference was not affected by demographic characteristics (e.g. age, reproductive history, residence).
      Conclusions: Most women do not find either ‘abortion’ or ‘termination’ to be distressing. However, a relative majority might favour 'termination of pregnancy' and abortion care providers should be sensitive to this when communicating with women.

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      Contraceptive use among immigrant and non-immigrant women seeking abortion care in Stockholm County

      Karin Emtell Iwarsson1, Elin Larsson1, Kristina Gemzell-Danielsson1, Birgitta Essen2, Marie Klingberg-Allvin1
      1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden

      Background: Globally, immigrant women encounter more challenges in reproductive healthcare than non-immigrants. A previous Swedish study showed being foreign-born was a risk factor for induced abortion and immigrant women had less experience of contraceptive use compared to non-immigrants. In order to ensure equitable care, it is important to investigate if this pattern still exists.
      Aim: To compare the contraceptive use ever in life, at conception and planned use after an induced abortion, including type of methods, between immigrant and non-immigrant women seeking abortion care in Stockholm County.
      Method: A cross-sectional study using an interview-based questionnaire, conducted at six abortion clinics. In total 637 women responded.
      Results: In the study 425 were non-immigrants and 212 immigrants. A significant difference was observed within the immigrant group, therefore it was divided into foreign-born (148) and 2nd generation migrants (64). For all women, 96% reported they had used contraception ever in life. A significant difference was seen where non-immigrants had used pills and withdrawal to a higher extent, and foreign-born women had used copper IUD. At time of conception, 34% had used contraception. There was no significance between the different methods. Planned future use of contraception was 93%. Copper IUD was significantly more common among foreign-born women, implant among 2nd generation migrants and vaginal ring among non-immigrants. 52% of all women planned to use long acting reversible contraception (LARC = IUD’s and implants) after the abortion.
      Conclusion: Immigrant women seem to have less experience of contraceptive use ever in life, at conception and as planned future method compare to non-immigrants. A significance was seen between non-immigrants, foreign-born women and 2nd generation migrants for different types of contraceptive methods ever in life and as planned future method. Efforts are needed to improve access to contraceptives among immigrants and to increase the use of LARC among all groups.

    Concurrent session 10: RCOG & Leading safe choices project
    • Alison Fiander, GB
    • Anna Glasier, GB
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      Royal College of Obstetricians and Gynaecologists Leading Safe Choices Project: An overview

      Anna Glasier1, Alison Glasier2
      1University of Edinburgh, Edinburgh, UK, 2Royal College of Obstericians and Gynaecologists, London, UK

      Obstetricians, gynaecologists and allied healthcare workers are in an ideal position to improve the provision of family planning and abortion services, but sadly these services are often regarded as low priority. The Royal College of Obstetricians and Gynaecologists (RCOG), with 14,000 members worldwide, is in an ideal position to influence both clinical practice and the attitudes of the profession. The RCOG Leading Safe Choices (LSC) initiative aims to put the evidence into practice by strengthening the competence and raising the standing of family planning and abortion care professionals. In collabouration, initially with colleagues in South Africa and Tanzania, the initiative aims to promote best practices in postpartum contraception and comprehensive abortion care (CAC) in South Africa, and comprehensive postabortion care (CPAC) in Tanzania. A three-pronged approach is being taken.

      1. Evidence based, practical Best Practice Papers on postpartum family planning and comprehensive, and postabortion care have been developed and disseminated.
      2. Short, intensive theoretical and skill training courses have been developed based on the best practice papers, with subsequent ‘on-the-job' training and supportive supervision.
      3. The initiative aims to support professionalisation of family planning and CAC/CPAC services through certification and accreditation.

      The Leading Safe Choices Initiative is now well underway in South Africa and the outcomes of the programme are being monitored and evaluated to determine impact. Development of training materials continues as lessons are learnt along the way. Progress is being made in establishing the initiative in Tanzania. Barriers to successful implementation are being addressed with enthusiasm for the initiative but remain a challenge. Leading Safe Choices has stimulated the RCOG to look closely at both postpartum contraception and the delivery of abortion services in the UK.

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      RCOG Leading Safe Choices: Training abortion providers in South Africa

      Alison Fiander3, Judith Kluge1 ,2
      1University of Stellenbosch, Western Cape Province, South Africa, 2Tygerberg Hospital, Western Cape Province, South Africa, 3Royal College of Obstetricians and Gynaecologists, London, UK

      The Choice-on-Termination-of-Pregnancy ACT of 1996 changed laws in South Africa from highly restrictive to more liberal laws for abortion provision. It legalised abortion-on-demand for women in the first trimester and allowed abortion provision for socio-economic reasons, amongst others, up to 20 weeks gestation. The law also allowed trained registered nurses to provide both surgical and medical abortions in the first trimester. In the ensuing years, non-governmental organisations such as Marie Stopes and IPAS assisted the Department of Health with training of nursing staff. Following withdrawal from South Africa by some NGO's a void was left in comprehensive abortion care training. Additionally, other ongoing challenges to ensuring designated TOP facilities had trained staff to provide abortion services continued. In 2011 only 57% of designated abortion facilities were providing abortion services. A persistent high proportion of abortions are performed in the second trimester. Forty present of women who had a second trimester abortion had initially presented to a health facility in the first trimester but had the procedure delayed at the facility or by a requirement to refer to other health facilities. Women still have unsafe abortions, accessing illegal abortion providers. Unsafe abortions also occur in legal facilities due to lack of training and services failing to meet minimum standards.
      The RCOG Leading Safe Choices initiative aims to improve the competence and standing of abortion care providers. It has recently been implemented in Western Cape Province, South Africa with the training of master trainers in December 2015. Subsequent Comprehensive Abortion Care training was initiated in March 2016. The Best Practice paper on Comprehensive Abortion Care was included in the Western Cape Province Department of Health Abortion Policy in 2016. Progress regarding this initiative in South Africa will be presented.

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      Leading safe choices in Tanzania

      Pendo Mlay1, Alison Fiander2, Emma Simpson2, Nia Shepherd2
      1KCMC, Kilimanjaro, Tanzania, 2RCOG, London, UK

      Introduction: Disproportionately, maternal and neonatal morbidity and mortality in sub-Saharan Africa is significantly higher compared to the rest of the world. In Tanzania the estimated number of unsafe abortion is 36 per 1000 women of reproductive age and the National CPR is <34%, while 25% of married women have unmet need for family planning. Provision of effective family planning and postabortal care represents an important strategy to mitigate this maternal health burden. LSC initiative aims at improving access to effective family planning and Comprehensive Postabortion Care. Methods: The programme has three primary goals: first is the promotion of best practice in postpartum family planning (PPFP) and comprehensive postabortion care (CPAC) through development and distribution of Best Practice Papers (BPP); secondly, increasing professional competency in PPFP and CPAC through training and supervision of providers; thirdly, promoting professional respect for providers working in reproductive sexual health through accreditation and certification. A team of local and RCOG experts worked on developing a curriculum using country policy and guidelines, which will be piloted in 4 health facilities in Kilimanjaro and Dar es Salaam regions.
      Expected outcome: LSC intends to influence policy makers and health care providers to set up a regional framework that will meet contraceptive needs for women during the postpartum and postabortal period. Overall expectation of this initiative is to increase awareness and uptake of effective family planning.
      LSC Progress in Tanzania: March 2016, MOHSW and PPFP stakeholders convened in Dar-es-salaam to discuss PPFP issues and agreed to have a harmonisation meeting early May 2016. This was held in Bagamoyo to harmonise LSC and MOHSW curriculums and as a result, one document will be used to train all HCW in Tanzania with Master training set for July 2016.  Further progress will be presented.

    Concurrent session 11: Variation in abortion care in Europe
    • Raïna Brethouwer, NL
    • Dimitar Cvetkoff, BG
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      The situation of minors under the new abortion law in Spain

      Carolina Rivas
      ACAI, Sevilla, Spain

      In 2010 the socialist Government passed a new law, which allows abortion on request up to 14 weeks and by maternal or foetal causes up to 22 weeks. In very special situations, the minors between 16 and 18 years could decide without the consent of the legal representatives.
      Sociological data (which were not included in the mandatory notification form) of 36718 women were collected from July 2010 to October 2011 to analyse the situation of the minors.
      In 2015 the conservative Government partially amended the Abortion Act, requiring in all cases the consent of the legal representatives of the young women of age 16 and 17.
      From May to August 2016 data of women who had a TOP have been collected to determine the changes in the situation of the minors following the reform of 2015.
      In the first study it was found that:

      • Out of 36718 women (100%), 1186 were age 16 and 17 (3.23%).
      • Out of 1186 minors (100%) only 151 (13%) failed to inform their parents.
      • These 151 minors represent 0.41% of all women (36718).
      • 87% of the minors age 16 and 17 reported their representatives and were mostly accompanied by them.

      The reasons given by the 151 minors for failing to inform their parents correspond to those cited in the law itself: serious family conflicts, domestic violence, ill-treatment, anti-abortion attitudes in the family, disabling or psychiatric diseases etc.
      Although details of the second phase are still picking up, the experience accumulated since September 2015 allows us to verify that the minors without the consent of their parents face restrictive interpretations of the law (e.g. in the Madrid Region, where the presence of both is required) or delays in the processing of the necessary judicial authorisation, potentially exposing them to unsafe abortion.

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      Reasons for the use of medical versus surgical abortion in Europe

      Alberto Stolzenburg
      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:

      • Countries with high prevalence of medical abortion
      • Countries with prevalence of medical over surgical abortion
      • Countries where both methods are used with similar frequency
      • Countries with a predominance of surgical over medical abortion
      • Countries with high prevalence of surgical abortion 

      The main reasons affecting the use of medical versus surgical abortion are:

      • Legislation, administrative and health regulations
      • Legalisation of Mifepristone
      • Legal and off-label use of prostaglandins (Misoprostol)
      • Where (type of health care facility, inpatient and outpatient care)
      • Public or private institution
      • Who performs abortions (gynaecologists, general practitioners, nurses, midwives)
      • Conscientious objection
      • Preference for usual practice ("culture") by health professionals and also the women
      • Access to continuing vocational training, dissemination of knowledge (medical guidelines: WHO, RCOG, IPPF, NAF etc.)
      • Scientific research, especially use of drugs in abortion care
      • Political factors (conservative or liberal governments)
      • Economic factors
      • Cultural and religious factors

      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

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      Indications for mid-trimester abortion throughout Europe

      Mirella Parachini
      San Filippo Neri Hospital, Roma, Italy

      Laws regulating mid-trimester abortions in Europe are more restrictive than first trimester in most countries. European countries can be classified into various categories indicating the circumstances under which a woman can legally obtain mid-trimester abortion. The indications range from countries that prohibit abortion altogether or permit it only to save the life of a woman to countries with additional grounds such as: to preserve the physical and mental health of the woman; in case of pregnancy resulting from rape or incest; in case of risk of foetal impairment. These differences lead to the persistence of the so-called abortion tourism but it has also to be considered that there are legal differences in the access to abortion services for foreign women in various European countries. It is very important for the abortion providers working in countries with restricted access to mid-trimester abortion to be updated about these different legal frameworks. Nowadays, women have access to the internet, giving them authoritative and reliable information. This presentation will provide an overview of the indications for mid-trimester abortion throughout Europe.

  • 12:30-
  • 13:00-
    mid trimester workshop
    • Inga-Maj Andersson, SE
    • Annette Aronsson, SE
    • Cecilia Berger, SE
    • Kristina Gemzell-Danielsson, SE
    • Monica Johansson et al. , SE
    • Helena Kopp Kallner, SE
    • Ingrid Sääv , SE
    • Eneli Salomonsson, SE
  • 13:00-
    Lunch session 05 – Free communications
    • Philippe Faucher, FR
    • Matthew Reeves , US
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      An evaluation of postplacental insertion of intrauterine contraception (PPIUC) at elective caesarean section in the UK

      Rebecca Heller2, Anne Johnstone2, Sharon Cameron1 ,2
      1NHS Lothian, Edinburgh, UK, 2University of Edinburgh, Edinburgh, UK

      Objectives: Sexual health policy recognises that increased uptake of the most effective methods of contraception immediately postpartum could prevent unintended pregnancies and short interpregnancy intervals. Our objective was to evaluate uptake, complications and acceptability of postpartum intra-uterine contraception (PPIUC) inserted at elective caesarean section.
      Methods: All women scheduled for elective caesarean section in NHS Lothian, Scotland were given written information on postpartum contraceptive methods antenatally, indicating that intrauterine contraception could be inserted at caesarean section. This included the offer of a thread check at six weeks by a gynaecologist with an ultrasound scan if threads were not visible. At this visit women were asked about their satisfaction with PPIUC.
      Results: To date (July 2015 – March 2016) 787 women were scheduled for elective section and sent information about postpartum contraception. 142 of 787 women (18%) chose PPIUC, which was performed in 136 cases.  6 were unable to be inserted, 2 of these women returned for insertion subsequently. 120 women (88%) still have the device in situ. There have been 10 expulsions, in 6 cases women have had a second device inserted.  6 devices have been removed. There have been no cases of pelvic inflammatory disease. Of 88 women who have thus far attended for a 6 week check, threads were visible in 47% of cases (n=41). Ultrasound confirmed IUC in situ in all cases of missing threads apart from1, this woman awaits an abdominal x-ray to exclude perforation. Of women attending the 6 week check, 78 (89%) stated that they were happy or very happy with IUC insertion at caesarean section.
      Conclusion: PPIUC at elective caesarean section appears to be a popular option, for women, that is safe and highly acceptable.  This could be an important strategy to prevent short interpregnancy intervals and unintended pregnancies in the UK.

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      Why have abortions decreased in the USA?

      Philip Darney
      University of California, San Francisco, USA

      Background: The rate and number of abortions in the USA increased rapidly after legalisation in 1973 to nearly 1.5 million by 1990.  But by 2009 the total was less than 1 million.  What accounted for a 50% decline in less than 20 years?  Those opposed to abortion rights argue that various restrictive laws in more than half the states have encouraged women to give birth rather than abort.   Advocates of family planning assert that increased use of effective contraceptives has decreased the need for abortion in the USA.
      Methods: State and US National data are reviewed in light of legislative changes to examine the relationships among contraceptive prevalence, method mix, age specific fertility, employment, unintended pregnancy and abortion rates.  Specific states, eg, California and Texas, are compared and contrasted.
      Results: Several factors explain the steep decrease in abortion rates and numbers in the USA, but legislative restrictions and declining numbers of providers account for only a small proportion of state-specific variance.  Changes in age-specific fertility rates, particularly a rapid decline in teen pregnancies, increased use of more effective contraceptives and rising employment rates among women provide, along with other demographic factors, powerful explanations for fewer abortions.
      Implications: Fewer abortions require fewer providers which could further decrease access to family planning for poor women living in medically underserved areas.  Less access in already impoverished regions, where restrictive abortion laws are most likely, increases teen and premature births, poverty rates and local health care costs leading to a cycle of declining reproductive health services and increasing poverty and social disruption.

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      Self-Administered lidocaine gel for pain control with first trimester surgical abortion: a randomised trial (SALSA)

      Jennifer Conti, Klaira Lerma, Kate Shaw, Paul Blumenthal
      Stanford University School of Medicine Department of Obstetrics and Gynecology Division of Family Planning Services and Research, Palo Alto, California, USA

      Objective: To assess pain control during first trimester surgical abortion using a locally applied, patient-administered lidocaine gel compared to traditional lidocaine paracervical block.
      Methods: We conducted a randomised controlled trial of women undergoing surgical abortion at less than 12 weeks gestation in an outpatient clinic setting. Participants were randomised to receive 12ml of a 1% lidocaine paracervical block (PCB) or 20ml of a self-administered, 2% lidocaine gel 20-30 minutes before procedure initiation. In addition, all patients received sedation as per institutional standard. A 100mm visual analogue scale (VAS) was administered to measure anticipated pain, baseline pain, pain with speculum and tenaculum placement, pain with cervical dilatation (primary outcome), pain after suction aspiration and pain 30-45 minutes post-operatively.
      Results: 142 women were enrolled: 68 in the PCB group, 69 in the gel group. Two and three subjects were not analysed due to protocol deviations or drop-out, respectively. Socio-demographic characteristics and VAS scores at all time points, except for tenaculum placement, were similar between groups. Mean and median pain scores for the primary outcome (pain score immediately following cervical dilatation) did not differ between groups. This was also true when nulliparous and parous subjects were analysed separately. The median pain score with cervical dilatation was 65mm in the PCB group and 68mm in the gel group (p=.45). Likewise, there was no statistically significant difference between mean pain scores at any of the other time points measured (speculum placement (p=0.39), tenaculum placement (p=0.07), cervical dilatation (p=0.31), speculum removal (p=0.19) and post-procedure (p=.75).
      Conclusion: There were no statistically significant differences concerning pain control between self-administered lidocaine gel and a traditional paracervical lidocaine block. Lidocaine gel should be considered as an alternative, non-invasive approach to pain control for first trimester surgical abortion.

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      Are women with a foreign background more likely to have an induced abortion as compared to nonimmigrant women? A study conducted in Stockholm, Sweden

      Elin Larsson1 ,2, Karin Emtell-Iwarsson1, Kristina Gemzell-Danielsson1, Birgitta Essén2, Marie Klingberg-Allvin1 ,3
      1Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden, 22Department of Women’s and Children’s health/ IMCH, Uppsala University, Uppsala, Sweden, 33School of Education, Health and Social Studies, Dalarna University, Falun, Sweden

      Objectives: To examine if women with a foreign background were more likely to have an induced abortion as compared to nonimmigrant women.
      Methods: A cross sectional study conducted in eight abortion clinics in Stockholm County during January to April 2015. The eight clinics conduct more than 90% of all abortions in Stockholm County. Inclusion criteria were all pregnant women 18 years old or above, seeking for induced abortion. Exclusion criteria were individuals under 18, not decided about having an abortion and women who had travelled to Sweden only to have an abortion. Midwives at the clinics interviewed the women in the end of the first visit, using a standardised questionnaire that they filled in. When needed a professional interpreter was used.
      Results: A total of 787 women were included in the study, 67% of the participants were nonimmigrants, 23% were foreign born and 10% were second-generation immigrants. These proportions were significantly different from the general population. There was a significant higher incidence of abortion among second-generation immigrants. Immigrant women were older as compared to non-immigrant women. However, immigrant status was not a significant predictor for having a subsequent abortion. However, immigrant women from certain countries were over represented among the women seeking abortion care and did not correspond to the proportion in the general population. In addition, contraceptive use ever in life, and at time of conception was lower among immigrant women as compared to non-immigrant women.
      Conclusions: Contrary to previous European research immigrants were less likely to have an induced abortion as compared to non immigrants, but the study suggests that second generation immigrants are presenting for induced abortion in higher numbers. More research is needed to understand the reasons for this and why access to contraceptives is lower among immigrant women.

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      The Zika Virus: highlighting the impact of abortion restrictions on the lives of women in Latin America

      Kelly Blanchard1, Kinga Jelinska2, Susan Yanow2, Cecilia Vieira da Costa2
      1Ibis Reproductive Health, Cambridge MA, USA, 2Women Help Women, Amsterdam, The Netherlands

      The emergence of the Zika virus in Latin America and the Caribbean (LAC) has coincided with increased reports of infants born with microcephaly, and has prompted some governments in the region to issue blanket warnings against pregnancy.  However, the LAC region has some of the most restrictive abortion laws in the world. Government recommendations that women avoid pregnancy without provision of information, education, contraceptives or access to safe abortion care does not address women’s needs or promote their rights and has the potential to increase the incidence of unsafe abortion in the region, particularly among young and low income women who are most at risk of Zika exposure.  This panel will provide an overview of the issues linking Zika and reproductive rights, and will share preliminary results of qualitative research on Zika and pregnancy decision-making among women in Puerto Rico and Brazil.  Additionally, the perspectives of women from LAC seeking information about safe home-abortion from an online service will be shared.  Strategies for potentially avoiding a surge in unsafe abortions will be highlighted.
      Attendees will learn about the current legal framework in LAC for accessing abortion and the impact of the Zika virus in mobilising new strategies for expanding access to safe abortion.  We will also invite participants to engage in a discussion of how to support regional activists in their long-term goals of increasing access to safe and decriminalised abortion and identify lessons learned for efforts to expand access to safe abortion care in other restricted settings.

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      Supporting and promoting the provision of MTOP in Victoria, Australia

      Annarella Hardiman1, Paddy Moore1, Kylie Stephens2, Susie Allanson3
      1Royal Women's Hospital, Melbourne Victoria, Australia, 2Centre for Excellence in Rural Sexual Health, University of Melbourne, Melbourne Victoria, Australia, 3Fertility Control Clinic, Melbourne Victoria, Australia

      The Royal Women's Hospital ("the Women's") located in Victoria, Australia, is a specialist women's public hospital which has provided abortion for around 45 years. However because abortion is not provided in a strategic, equitably accessible way within the public health system across Victoria, the Women's cannot meet the high number of requests for abortion received. Victoria's reform of the abortion law in 2008 resulted in a decriminalised and progressive abortion law. Contemporary medications for MTOP also become available in Australia around this time as a result of social and policy reform. This was considered to be an opportunity for further development and provision of abortion services across this large geographical area. However since then, there have not been any strategic or policy initiatives addressing the gaps. In recognition of this, the Women's sought to prioritise a strategy of professional development, training, networking, mentoring and health promotion via a collabourative public / private partnership of academics, abortion providers and health promotion advocates. The Women's, Family Planning Victoria, Fertility Control Clinic and Centre for Excellence in Rural Health partnered to develop a strategy to increase the involvement of interested regional health professionals in the provision of abortion. The provision of MTOP was considered a suitable vehicle to encourage and support health professionals outside hospitals to contribute to the accessibility and choice of abortion for women across Victoria. The partnership delivered a number of free regionally based sessions for around 100 remote and rural health professionals in their own communities to receive professional development, networking and mentoring opportunities. Policies and guidelines developed by the Women's were made available to support the development of new services by new providers. This resulted in an increasing uptake of the provision of MTOP by general practitioners, health centres and others sites, which have developed local cooperative partnerships.

  • 13:30-
    Lunch session 04 - The discovery and development of mifepristone
    • André Ulmann, FR
  • 14:00-
    Concurrent session 12: Whats topical in Europe
    • Catherine Chéry, LU
    • Gabriele Halder, DE
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      Coping with UK Abortion Law

      Allan Templeton
      University of Aberdeen, Scotland, UK

      When the 1967 Abortion Act came into practice in England, Scotland and Wales, it was seen as a major step forward in Women’s Health. Now almost fifty years later, the Act’s evident limitations inhibit best practice in several respects. Abortion in the UK is illegal unless the conditions of the 1967 Act are met and confirmed by two doctors. In the majority of cases a woman requests an abortion and an abortion is justified because it is safer than having a baby, condition c states “that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated”. This may not be what the Act intended and is certainly not what the GMC now advises in recognising a person’s right to make decisions about her own healthcare.
      Furthermore the advent of medical abortion particularly has highlighted the inadequacies of the current Act with regard to safe and effective service provision. Nurses are prohibited from sanctioning and performing abortions. The obverse interpretation of the Act which requires both mifepristone and misoprostol to be given in clinics makes abortion at home (the preferred option of the majority of eligible women) both more inconvenient and uncomfortable than necessary.  Within the UK, abortion has now been devolved to Scotland, and although it has been made clear there will be no early attempt to amend current legislation, changes which improve service provision will be considered. This highlights the dilemma of those wishing to improve matters, namely whether to campaign to strike out the laws which make abortion illegal and so recognise a woman’s right to abortion, or whether to interpret and amend current laws to improve service provision, as was very nearly achieved in 2008.

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      EBCOG and setting standards of care in Europe

      Tahir Mahmood1 ,2, Jacky Nizard1 ,3
      1European Board & College of Obstetrics and Gynaecology, Brussels, Belgium, 2Victoria Hospital, Kirkcaldy, Scotland, UK, 3APHP - Hôpital Universitaire Pitié-Salpêtrière, Paris, France

      There is considerable diversity within EU and EEA countries how women's health services are delivered.  While there are significant economic variants within these countries, outcomes data suggests that within some countries, women are even denied access to basic human rights which have been recognised in the UN Charter.
      There are huge variations in the outcomes in both obstetrics and gynaecology, from maternal morbidity and mortality rates down to access to women's right and access to methods for family spacing.
      EBCOG being a representative body of 37 countries in Europe have developed two documents  to define uniform standards of care in all areas of women's health services to provide support to health care planners. These documents were launched at the EU Parliament in 2014. They have also been translated in Russian language with the help of UNFPA - Eastern Europe and Central Asia Region. They are accessible at our website (

      This presentation will describe our novel approach to address these issues around health services delivery were developed and will call for an action by all stake holders.

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      Refusal to treat is not ‘Conscientious Objection’

      Christian Fiala
      Gynmed Clinic, Vienna, Austria

      Health Care Professional’s (HCP) refusal to treat or serve patients in Reproductive Health based on personal or religious reasons is frequently and misleadingly called ‘Conscientious Objection’ (‘CO’). In many countries ‘CO’ is lawful but almost always unregulated. HCP invoking ‘CO’ are misusing their position of power and trust but expecting to keep their job and salary, even if they deceive their patients and refuse to comply with part of their professional duty. ‘CO’ is mainly a phenomenon in public health services because private institutions rarely engage, pay and keep employees who do not fulfil all their professional duties. Consequently ‘CO’ is abuse of the public service and taxpayers money. The significant negative impact on women’s basic healthcare and human rights is well known and has been published repeatedly. The impact is strong especially in those countries where abortion and contraception are mainly provided by public institutions, whereas it is negligible in countries:
      -       with a predominantly private health care
      -       where the law obliges all hospitals to provide abortion or
      -       where ‘CO’ is not tolerated (Sweden, Finland, Iceland).

      The debate around  ‘CO’ is characterized by
      -       one side defending an eminence based position with faith based arguments giving HCP the right to refuse patients versus
      -       the other side arguing for an evidence based position with arguments based on facts and in favour of giving patients the right to a legal treatment for which they pay either directly or indirectly via a health care insurance.
      No country has regulated ‘CO’ in a way that would satisfy women and their need for basic medical care as well as HCP’s personal or religious beliefs. What is misleadingly called ‘CO’ is a remnant of a patriarchal social model and incompatible with evidence based medicine as well as current human rights standards.

    Concurrent session 13: FIGO Prevention of Unsafe Abortion
    • Teresa Bombas, PT
    • Paul Van Look, CH
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      Barriers to expansion of post abortion contraception within the FIGO Initiative on Prevention of Unsafe Abortion in Africa

      Guyo Jaldesa
      University of Nairobi, Nairobi, Kenya

      An estimated 22 million abortions continue to be performed unsafely each year, resulting in the death of an estimated 47,000 women and disabilities for an additional five million women. Almost every one of these deaths and disabilities could have been prevented through sexuality education, family planning and the provision of safe, legal induced abortion and care for complications of abortion. Further abortions could be reduced through provision of effective postabortion contraception. Though postabortion contraception is an official strategy this is rarely implemented in African countries resulting in very few women leaving hospital with a method, especially long acting reversal contraception (LARC), following treatment for incomplete abortion. The following barriers were identified for poor utilisation of postabortion contraception: lack of awareness of the methods; fear of side effects; ignorance (at times they think they can't conceive immediately after an abortion); lack of partner support/culture; and religious beliefs. Lack of provider knowledge and stock are two of the barriers to postabortion contraception utilisation.

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      The FIGO initiative - How providers are making a difference

      Anibal Faúndes
      State University of Campinas, Sao Paulo, Brazil

      The FIGO Initiative on Prevention of Unsafe abortion was created in 2007, under the leadership of Dorothy Shaw, with the purpose of reducing the burden of unsafe abortion for women, particularly in countries with restrictive abortion laws. Because abortion is often stigmatised, it was a subject mostly ignored by the obstetric and gynecology societies in those countries and the first task of the FIGO initiative was to bring unsafe abortion and its consequences to the fore and propose strategies for prevention. The obstetrics and gynecology societies and an increasing proportion of their members have become involved in the implementation of these strategies. Of particular relevance is that eleven countries with abortion laws that are not totally restrictive where the law has never, or almost never, been applied started to provide safe abortion using the full extent of the law. In addition, four of the five obstetrics and gynecology societies from countries where abortion is not permitted in any circumstance are actively involved in promoting less restrictive abortion laws.
      One of the countries participating in the FIGO initiative (Uruguay) succeeded in the approval of a law that now allows abortion without restrictions (with regard to the cause) with the very important participation of the obstetrics and gynecology society and its members. This activity of the Uruguayan colleagues started long before the FIGO initiative was created but FIGO helped to disseminate the application of the new law, facilitating access to safe abortion services in the whole country. The FIGO initiative has also contributed to committing many of our colleagues to become involved in replacing surgical curettage with manual vacum aspiration or misoprostol and in the installation or expansion of post abortion contraception services.

    Concurrent session 14: Provision of safe abortion and emergency contraception in humanitarian and emergency contexts
    • Philippe David, FR
    • Ronald Johnson, CH
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      Tragically lacking: safe abortion care in humanitarian emergencies

      Sandra Krause
      Women's Refugee Commission, New York, New York, USA

      Formed in 1995, and currently comprising a network of over 1700 individual members from 450 agencies, the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) is a broad-based, highly collabourative coalition committed to expanding and strengthening access to quality reproductive health (RH) services for persons affected by conflict and natural disaster. Among populations affected by humanitarian crises, the IAWG documents gaps, accomplishments and lessons learned; evaluates the state of RH in the field; establishes technical standards for the delivery of RH services; builds and disseminates evidence to policy makers, managers and practitioners; and advocates for the inclusion of crisis-affected persons in global development agendas.
      The IAWG undertook a global review of RH in crises from 2012-2014 a decade after its first review from 2002-2004. The 2014 evaluation aimed to identify existing RH services, quantify progress, document gaps and determine directions for future programmes, advocacy and funding.  The evaluation is based on seven complementary studies which explore research, institutional capacity to address RH, changes in funding, implementation of the standard minimum priority RH services in a humanitarian emergency, comprehensive RH services in select settings in three countries, and select RH indicators from the United Nation High Commissioner for Refugee’s Health Information System. The IAWG 2014 global review represents a snapshot of RH in humanitarian emergencies.
      Findings from the IAWG 2014 global review show a major gap in the availability of safe abortion care despite the increased risks for unwanted pregnancy due to increased risks of sexual violence and lack of access to birth control as a result of displacement and disrupted health systems, in humanitarian emergencies. This presentation will focus on the gap in safe abortion care identified in the global review, published reasons for the gap, and IAWG’s initiatives to address safe abortion care in humanitarian settings.

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      MSF: Addressing challenges to providing safe abortion in humanitarian emergencies

      Catrin Schulte-Hillen
      Medecins Sans Frontieres, Geneva, Switzerland

      MSF responds to needs for the termination of pregnancy, including on request (TPR); it is part of the organisation's work aimed at reducing maternal mortality and preventing unsafe abortions in the countries where we work. The presentation shares insights into MSF's experience over the past few years. A policy decision on safe abortion care was taken in 2004 - the fact that care did not expand rapidly came as a surprise. It also took time to recognise that specific efforts are required to understand and address key challenges that present barriers to the provision of safe abortion care.
      With policy, guidance, tools and training in place, humble progress has been made and some key lessons have emerged: the importance of making patient needs a priority over other considerations; acting accordingly requires organisation of services and other measures to mitigate potential risk for the patients and staff. There are undeniably strong social norms regarding abortion and they must be considered. An important knowledge gap remains, even among MSF staff. An open dialogue with staff, relevant medical actors and at community level is essential to address this and result in a change in attitude.

    Concurrent session 15: Medical methods
    • Antonia Costa, PT
    • Philippe Faucher, FR
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      Practical management of midtrimester abortion

      Linda Hunt
      Royal Infirmary, Edinburgh, UK

      This presentation will cover the practical aspects of managing mid trimester medical abortion as conducted by a nurse midwife.
      It will draw upon experience from a Scottish hospital setting in Edinburgh where all mid trimester abortions have been performed medically using mifepristone and misoprostol for more than 25 years (approximately 120 per year). The presentation will cover management of complicated cases including the scarred uterus and twin pregnancy. It will also give practical advice for how to manage pain relief and how long to wait before intervention for retained placenta.

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      Identifying and managing on-going pregnancy after medical abortion

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

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

    Concurrent session 16: Free communication
    • Oskari Heikinheimo, FI
    • Caroline Moreau, FR
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      Buccal versus sublingual misoprostol alone for early pregnancy termination in legally restricted Latin American settings: A randomised trial

      Wendy Sheldon1, Ilana Dzuba1, Heather Sayette2, Jill Durocher1, Beverly Winikoff1
      1Gynuity Health Projects, New York, NY, USA, 2PP Global, New York, NY, USA

      Objectives:  To examine the efficacy and acceptability of two misoprostol only regimens that are commonly used for medical abortion in legally restrictive settings; as well as the feasibility of a multi-level pregnancy test (MLPT) for at-home follow-up.
      Methods: This randomised open-label trial is ongoing at six clinics in two Latin American countries where abortion is highly restricted.* A total of 382 eligible, consenting women with gestations of ≤ 70 days who request medical abortion is required to show an expected difference of 8% in efficacy between the two study arms. Participants are randomised to three doses of buccal or sublingual administration of 800 mcg misoprostol every three hours. Study providers are blinded to group allocation. All women receive two MLPTs to administer and interpret abortion status: the first is taken in-clinic on the day of enrolment and the second at-home on the day of follow-up.
      Results: Data collection should be completed before October 2016. To date, the overall rate of successful, non-surgical abortion is 93.4% (183/196) and rate of ongoing pregnancy is 1.0% (2/196). Among those with no ongoing pregnancy, the MLPT successfully identified this outcome in 83.5% (162/194) of cases; it also identified need for follow-up among all those with ongoing pregnancy (2/2). More than 80% (160/195) of participants stated they would select medical abortion in the future and 87.6% (170/194) felt they could use an MLPT on their own.
      Conclusion: The efficacy of misoprostol alone is higher than expected based on published literature. Study findings will provide important evidence on the efficacy of a three-dose buccal misoprostol alone regimen. In addition, multi-level pregnancy tests appear to be a feasible and potentially useful tool for abortion service delivery in legally restrictive settings.
      *Note: To protect study providers and their clinics, we are not disclosing country locations at this time.

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      Analysis of induced abortion-related complications admitted to referral based medical facilities in Kinshasa, Democratic Republic of the Congo.

      Daniel Ishoso Katuashi1, Antoinette Tshefu Kitoto2, Yves Coppierters3
      1Kinshasa School of Public Health, Lemba, Kinshasa, The Democratic Congo, 2Kinshasa School of Public Health, Lemba, Kinshasa, The Democratic Congo, 3Université libre de Bruxelles, Bruxelles, Belgium

      Objectives: This study aims to analyse the extent of induced abortion-related complications at referral health facilities in Kinshasa and their characteristics, the length of hospitalisation, the proportion of deaths and their characteristics, as well as deaths that occurred after two days of hospitalisation.
      Methods: The cross-sectional study focused on 1541 gynaecological patients admitted as emergencies at 7 referral health facilities in Kinshasa, from 1 January to 31 December 2014, facilities that were selected representatively from the 5 types of districts of Kinshasa. Information was collected by reviewing patient files/records and analysed with SPSS20 and Epi-Info3.5.4.
      Results: There were 12.8% (11.2% to 14.6%) cases of induced abortion-related complications with a correlation to adolescence, celibacy, nulliparity, residence in semi-rural districts of Kinshasa and history of one or more abortions; 4.0% of deaths, including more than one third (1.8% to 4.0%) that are related to induced abortion-related complications, with a mortality of 13.6% and a significant increase in risk of death in the presence of a post abortive, pelvic peritonitis type complication. Half of these deaths occurred after two days of hospitalisation. Finally, the median length of hospitalisation was 10 days, higher in post abortive, pelvic peritonitis compared with patients with pelvic peritonitis due to Caesarean section/hysterectomy.
      Conclusion: This study demonstrates that induced abortion-related complications were a significant public health problem, because of their frequency in cases admitted as gynaecological emergencies at referral medical facilities in Kinshasa and their weight on hospital maternal deaths, and, furthermore, that supportive care in hospitals poses a serious problem. Accordingly, there is a need to understand the reason for the problem of hospital care in order to fulfil and provide a set of services that is appropriate for those medical facilities.

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      European transnational survey related to medical abortion in the first trimester of pregnancy

      Filipa Mendes Coutinho1, Teresa Bombas1 ,2, Paulo Moura1
      1Serviço de Obstetrícia A, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 2On behalf of Expert Group on abortion, European Society of Contraception and Reproductive Health (ESC), Coimbra, Portugal

      Background: Currently most European countries allow abortion upon women's request in the early weeks of pregnancy. Despite WHO's recommendations, the definitions and methods used in clinical practice are not well established. The knowledge of the different attitudes regarding abortion would be beneficial.
      Methods: We conducted a survey via mail involving 20 centres from 19 countries in which abortion is legal, to understand the differences in clinical practice regarding medical abortion. We performed a statistical analysis assessing a number of variables, including: number of abortions per year; rate of medical abortion; availability of national guidelines; methods of follow-up; among others.
      Results: Nineteen centres responded (95%) and most of these (84%) perform medical abortion. A large number do not use it as a first-line method. Thus, from an estimated 21,925 abortions registered in the past year, only 39% were performed by medical protocol. In spite of the lack of guidelines all the institutions use a combination of mifepristone and misoprostol to terminate pregnancy. The differences lie in the dosage used as well as the route of administration. Concerning follow-up, 52% of the institutions agree on a two week interval and almost 65% perform an hCG blood level as well as an ultrasound scan after this period. Similar percentages (63%) repeat medical treatment in case of ongoing pregnancy after a first cycle of medication and 68% in case of incomplete abortion. When asked if having more precise definitions for success of medical/surgical abortion would be beneficial, nearly 77% responded affirmatively.
      Conclusions: In late years we have witnessed an increase in the number of medical abortions performed in European countries. Despite the WHO recommendations the access to abortion methods are quite different. The majority of the surveyed institutions agree this would be an important step towards improving management of the procedure.

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      Women's informal knowledge and understandings about IUC

      Victoria Newton1, Lesley Hoggart1, Susan Walker2, Mike Parker2
      1The Open University, Milton Keynes, UK, 2Anglia Ruskin University, Chelmsford and Cambridge, UK

      Objectives: The aim of the study was to explore the acceptability of intrauterine contraception (IUC) in a UK General Practice setting. There were four arms to the project comprising surveys and interviews with both practitioners and patients. Here we present data from the patient arm of the study.
      Methods: We used a mixed method QUAL/quant approach. We interviewed 30 women (aged 18-49), who had never used IUC, to gain insight into their beliefs about and attitudes towards IUC. Incorporating qualitative responses into a questionnaire, we subsequently surveyed 1195 never/ever users aged 18-49 years, about their beliefs and knowledge about IUC methods.
      Results: The qualitative interviews revealed four key themes: 1) women were concerned about the procedures for insertion and removal of IUC; 2) women were concerned about the long-term effect of IUC in their body and its impact on reproductive functions; 3) there was an emotional response of distaste for an internal device; 4) social networks were important in knowledge sharing and decision making about contraception.

      The quantitative survey confirmed these findings. Women expressed concerns about painful fitting (54.9%), unpleasant removal (55%), womb damage (33.1%), movement of the device inside the body (41.1%), and dislike of the thought of the device in the body (48.5%). Women who reported negative account from friends and family were significantly less likely to use either IUD or IUS (p<0.001).
      Conclusions: The beliefs and fears expressed by the women in the study constitute a significant potential barrier to the uptake of IUC. Clinician recognition and discussion of these aspects of women's beliefs about IUC have the potential to remove unnecessary barriers to IUC use, thus allowing women access to highly effective, long term methods of contraception.

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      Contraception before and after abortion: what do women seek? – experience of an abortion referral centrecentre in Lisboa, Portugal.

      Catarina Reis Carvalho, Joaquim Neves, Raquel Gonçalves, Carlos Calhaz-Jorge
      Hospital Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal

      Introdution: Abortion by women’s request is one of the most commonly performed procedures in the world. The objective of this study was therefore to assess the choice of contraceptive method after abortion and the factors that may determine this choice.
      Methods: This was a retrospective cohort study based on a medical record review at one hospital in Portugal. We included 613 women who had an abortion in January 2015- March 2016. We conducted associations between age, number of previous abortions, educational status and receipt of contraception at the time of abortion.
      Results: Among the women included, the average age was 28 years (13-47), 47.3% nulliparous and 10.2% unemployed. Concerning obstetric history, 41.4% had a previous, voluntary abortion (1-8) with18.6% within the last five years. Previous to the abortion, 20.1 % had no contraception, 1.8% used natural methods, 22.2% barrier methods and 36.4% oral contraceptives.  When asked, 76% knew why the previous method failed, identifying the main cause as forgetfulness in taking oral contraceptives followed by voluntary suspension of the method. After the abortion, 19.2 % had no review consultation or refused counselling, without getting contraception or adopting their previous method, 14.9% preferred oral contraceptives and the majority (51%) chose long-acting reversible contraceptives (LARC). Women with a previous history of abortions seem to adhere less to later contraception and prefer oral contraceptives while the others prefer LARC (p=0.003). We found no association between age and educational status and contraceptive choice (p=1.12, p=0,67).
      Conclusions: Despite high access to contraceptive services, subsequent voluntary abortions are a reality. Education on contraception is an essential element of high-quality abortion care. Choosing LARC was popular for these women. A major limitation of this study is the short follow-up of the women. More studies are needed.

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      Mifepristone and misoprostol for cervical ripening in surgical abortion between 12 and 14 weeks of gestation: a randomised controlled trial

      Alexandra Ohannessian1, Karine Baumstarck2, Julia Maruani1, Emmanuelle Cohen-Solal1, Pascal Auquier2, Aubert Agostini1
      1Department of Gynecology and Obstetrics, La Conception Hospital, Marseille, France, 2Department of Public Health, Self-perceived Health Assessment Research Unit, Aix-Marseille University, Marseille, France

      Objective: Misoprostol and mifepristone are the two substances recommended for cervical preparation during first-trimester surgical abortions to decrease intraoperative bleeding and complications. The objective of the study was to evaluate whether the combination of mifepristone and misoprostol for cervical preparation in an elective surgical abortion between 12 and 14 weeks of gestation can reduce blood loss in comparison to misoprostol or mifepristone alone.
      Method: A randomised controlled trial was performed in Marseille, France between May 2013 and May 2014. Women requesting a surgical abortion under general anesthesia between 12 and 14 weeks of gestation numbered 198, randomised into three groups: one group received 400 mcg oral misoprostol three hours before surgery; one 200 mg oral mifepristone 36 hours before surgery; and the other both treatments. The main outcome was the quantity of intraoperative bleeding. Secondary outcomes were duration of intervention, ease of dilatation and complications.
      Results:  The quantity of intraoperative bleeding differed significantly between the groups (p=0.001): 222 mL+/-64 in the combination group, 329 mL+/-129 in the misoprostol group, and 276 mL+/-119 in the mifepristone group. The combination was associated with a shorter operative duration (p=0.001): 5 minutes +/-2 in the combination group, 7+/-5 in the misoprostol group, 7+/-3 in the mifepristone group. A hemorrhage was observed for 5 of 55 women (9%) in the combination group, 13 of 51 (25%) in the misoprostol group, and 9 of 56 (16%) in the mifepristone group (p=0.08). No cervical laceration or uterine perforation was reported.
      Conclusion: The combination of mifepristone and misoprostol in cervical preparation for elective surgical abortions between 12 and 14 weeks of gestation significantly reduced blood loss in comparison to misoprostol or mifepristone alone.

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      Therapeutic abortion for maternal indications or how to reduce them?

      Ben Amor Anissa1 ,2, Dimassi Kaouther1 ,2, Ben Aissia Nizar1 ,2, Triki Amen1 ,2
      1Mongi Slim Hospital, La Marsa, Tunis, Tunisia, 2University Tunis El Manar, Faculty of Medicine of Tunis, Tunis, Tunisia

      Background: Maternal medical conditions are an important reason for therapeutic abortions. Indeed several medical diseases may deteriorate or even develop during pregnancy.
      Aim : The purpose of the study was to assess the reasons for therapeutic abortion for maternal indications in our department and to determine how to reduce them.
      Methods: We conducted a retrospective study in the Mongi Slim Gynecology and Obstetrics department, La Marsa, Tunisia from 2005 to 2015. All cases of therapeutic abortion were included.
      Results: There have been 127 therapeutic abortions done in 10 years, 32 of them were for maternal indications. The incidence was about 1 per 1000 births. The gestational age varied from 9 to 26 weeks' amenorrhoea. The causes were: obstetric diseases (12%), mainly severe preeclampsia (7%) and premature rupture of membranes (5%); maternal severe heart diseases (5%), mainly valvulopathies; maternal somatic diseases (2 cases : lupus and severe diabetic ketoacidosis); 8 cases (7%) of maternal cancer discovered while pregnant (5 cases of breast cancer, 1 of lung cancer and 2 of digestive cancer); and psychiatric conditions.
      Conclusions: A quarter of therapeutic abortions done in our department were for maternal indications. It seems that chronic diseases not adequately followed up or diagnosed while pregnant are a major cause of therapeutic abortion despite the high frequency of obstetric causes. It is very important to encourage preconception consultations to improve the screening of these diseases and plan the pregnancy care properly. However, pregnancy still constitutes the only opportunity to have a detailed full check-up and to diagnose many diseases.

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      Comparing 200 μg and 400 μg sublingual misoprostol before surgical abortion; a Dutch single centre clinical pilot.

      Sandra Kroeze
      Stimezo Zwolle and ASK Mildredhuis Arnhem, Zwolle / Arnhem, The Netherlands

      Study Question. To compare efficacy and side effects of 200 μg and 400 μg sublingual misoprostol for cervical priming prior to first trimester surgical abortion.
      Summary Answer. This study indicates 200 µg misoprostol can be used for cervical priming prior to surgical abortion as the results showed fewer side effects but no difference in cervical dilatation in comparison to 400 µg misoprostol.
      What Is Known Already. Administration of misoprostol prior to vacuum aspiration reduces complications and morbidity in first trimester pregnancies. As a result, the Dutch society of abortion physicians (NGVA) decided to adopt cervical priming with misoprostol in their standard operating procedure (SOP). However, the use of misoprostol is associated with various adverse effects such as abdominal pain, shivering and nausea. A study in the field of Prevention of Postpartum Hemorrhage have suggested that 200 µg misoprostol is just as effective as a 400 µg dose, but with a reduction of adverse effects. This could also be the case for cervical priming prior to surgical abortion.
      Study Design, Size and Duration. This pilot was performed in a Dutch abortion clinic. In regard to the upcoming new SOP for first trimester abortions, all women attending this clinic were assigned to receive either 200 μg or 400 μg sublingual misoprostol prior to surgical abortion. The primary outcome was the complexity of the procedure (an efficacy parameter ), scored as dilatation on a scale of 1 to 5 and the secondary outcome was the presence of side effects before, during and after treatment. Pain registration was performed by the standardised VAS score. The pilot took place between October 2014 and June 2015.
      Participants, Setting and Method. Women requesting a surgical abortion between 5 and 13 weeks of gestation were recruited for this pilot. Exclusion criteria were any contraindication for misoprostol or the administration of breastfeeding. Gestational age was established by ultrasound examination. The allocated dose of misoprostol (200 µg or 400 µg) was self-administered 1 hour prior to treatment. The women either received 1 tablet of 200 µg misoprostol or 2 tablets of 200 µg. Vacuum aspiration was performed under general or local anaesthesia according to clinical routine.
      Main results. In total, 280 women were enrolled in this pilot. These women were divided into two groups; a group receiving 200 µg of misoprostol (n=144) and a group receiving 400 µg of misoprostol (n=136) for cervical priming. Cervical dilatation was measured based on a scale from 1 (manual dilatation was still needed) to 5 (no manual dilatation was needed). There was no difference found between both groups regarding cervical dilatation. This indicates that a difference of misoprostol dosage, when used for cervical priming, does not alter the complexity of the procedure. For the second objective of this study, the prevalence of adverse effects was measured by a questionnaire prior to treatment. A total of 145 side effects were measured in the 200 µg group and a total of 162 in the 400 µg group. 32% of the women who received 200 µg misoprostol experienced no side effects, while this percentage was lower in the 400 µg group (21%). There was a higher prevalence of shivering in the 400 µg group (14%) compared to the 200 µg group (9%) and a greater percentage of women in the 400 µg misoprostol group experienced nausea as a side effect (11,7%) in comparison to the women receiving 200 µg Misoprostol (4.8%). There was no difference in the prevalence of abdominal pain and the dryness of the mouth.

  • 15:30-
  • 16:00-
    Strengthening health care providers
    • Sharon Cameron, GB
    • Nausikaä Martens, BE
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      Integrating abortion training in sexual and reproductive health care

      Johannes Bitzer
      University Hospital Basel, Basel, Switzerland

      Preventing unwanted pregnancies is a main objective of sexual and reproductive health care. This is achieved by women and men-friendly contraceptive services including patient centred counselling, availability of all methods, shared decision making, follow-up care etc. In reality, women are still very often confronted with unwanted pregnancies which they experience as a threat to their global health. These women need a high standard of abortion care including easy and rapid access to abortion services; non discriminative, empathic care; shared decision making about the available methods; safe and professional procedures by well trained professionals; qualified and appropriate follow up including postabortion contraception.
      These qualities should be provided by recognised abortion training for health care professionals in the field of sexual and reproductive health

      Abortion training: The training has to be based on 3 elements:

      a)    Knowledge: 
      - Knowledge about epidemiological data, early and late pregnancy development, endocrine and non endocrine factors involved in pregnancy development, diagnostic procedures to determine the pregnancy week, diagnosis of missed and threatened abortion
      - Knowledge about medical and non medical abortion techniques (dosages, timing, procedure) efficacy, risks, side effects, Standard operating procedures
      - Knowledge about postabortion contraception

      b)  Skills:
      - Case for medical abortion. Exact procedure
      - Technique of surgical abortion (simulation) assisting, performing under supervision, performing alone
      - IUD and implant insertion

      c)  Attitudes:
      Group discussion about ethical and psychosocial, sociocultural aspects of abortion and critical incident reporting

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      How can a Fellowship in Family Planning be established in Europe?

      Uta Landy
      Fellowship in Family Planning and Ryan Residency Training Programme, San Francisco, CA, USA

      Subspecialisation has expanded with the growth of evidence-based practice and complexity in medical care in the US. There are now 127 accredited subspecialties across all medical disciplines with four in Obstetrics and Gynecology: Reproductive Endocrinology and Infertility, Maternal Foetal Medicine, Oncology and, most recent, Female Pelvic and Reconstructive Surgery. The Family Planning Fellowship is exploring potential accreditation and certification.
      Why did we create a subspecialty in family planning? Historically, US medical schools gave clinical care, training, research and advocacy in abortion and contraception little attention. Since the demand for pregnancy termination was mostly met by freestanding clinics, few teaching hospitals offered or taught abortion or complex contraception.
      In response, we launched two national initiatives. The first, the Fellowship in Family Planning, was started at UCSF in 1990 and now counts 31 sites in leading academic ob-gyn departments. It has produced a new generation of leaders in the field who have advanced abortion and contraceptive research, clinical training, and advocacy. Our 300 graduates have helped launch 90 new academic training programmes through a parallel initiative, the Ryan Residency Training Programme.
      While the results of our model may serve as an inspiration to our European colleagues, our approach may not be replicable in the European context.  There are certain steps required to ensure fellowship success. Leaders in the field must be motivated to serve as champions of the effort, and professional organisations, e.g. ESC, must lend their official support. The service delivery system must allow for clinical training and sources of research funding must be identified. Advocacy for reproductive justice should become part of training.  Finally, the structure and settings, clinical care, teaching and research of the family planning fellowship must be substantial enough for academic centres and the service delivery community to recognise it as an essential component of reproductive health.

  • 17:00-
  • 17:45-