Nantes, 14-15 Septiembre 2018: „Liberating women - Removing barriers and increasing access to safe abortion care“

  • 09:00-
    10:30
    Opening session
  • 10:30-
    11:30
  • 11:30-
    12:30
    Abortion Laws and policies
    Presidente de la Sesión:
    • Rebecca Gomperts, NL
    • Antonella Lavelanet
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      WHO strives for a world where all women’s and men’s rights to enjoy sexual and reproductive health are promoted and protected, and all women and men, including adolescents and those who are underserved or marginalized, have access to sexual and reproductive health information and services. Access expressed through laws, policies, and guidelines is a key component of the enabling environment for safe abortion. However, abortion laws and policies can be punitive or protective;  specific or non-specific; confusing and even contradictory at times, all of which may exacerbate a chilling effect on those who seek, provide or advocate for access to services.
      Launched in June 2017, the Global Abortion Policies Database (GAPD) contains abortion laws, policies, standards and guidelines for UN and WHO Member States designed to strengthen global efforts to eliminate unsafe abortion by facilitating comparative analyses of countries’ abortion laws and policies. The abortion laws, policies, and guidelines within the GAPD are juxtaposed to information and recommendations from WHO safe abortion guidance, national sexual and reproductive health indicators, and UN human rights bodies’ guidance to countries on abortion. 
      This presentation provides a brief overview of the GAPD, an analysis of selected countries, and demonstrates the vagueness and complexities that exist in laws and policies.

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      This presentation interrogates the idea of ‘need’ in abortion law and explores how we assess claims of necessity under international human rights law. Using examples from the Global Abortion Policies Database, the presentation highlights the arbitrariness, overbreadth and dysfunction that characterize much abortion law worldwide, including many liberal regimes. These laws do not achieve the ends they purport to serve, and often undermine ends of public health, safety, and morality. The presentation focuses on the harms of unnecessary abortion law including: public health impacts of dysfunctional laws, access inequalities of overbroad laws and abuses of arbitrary laws. Particular attention is given to the harms by which abortion law becomes normative or even prescriptive of our lives. How law comes to shape the very ways we understand, experience and practice abortion. For example, how law and its institutional controls were traditionally used to define abortion safety, and the impact today on how we regulate self-managed abortion. We have given law much imaginative power over our field. For too long, we built norms of abortion practice in the image of the law, rather than having law serve aims of health and human rights. Today still, we carry over many falsehoods of abortion law into research, practice and policy, such as when health regulations carry on the gatekeeping and punitive work of criminal law. The presentation thus concludes with the idea of ‘freedom from law,’ an open and imaginative outlook that steers us away from the classic terms, binaries, and frames of abortion law that have patterned our field (e.g. risk and harm, time boundaries, set indications, protections and limits). The presentation extends an invitation to think ourselves away from the routines of abortion law and to ask: What do we need or want from law?

  • 12:30-
    14:00
  • 13:00-
    14:00
    Lunch session 1: RCOG session. "Women's access to abortion is at crisis point" - what can be done to fix the system? Perspectives from the UK and South Africa
    Presidente de la Sesión:
    • Patricia Lohr, GB
    • Valerie Truby, ZA
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      Despite South Africa having one of the most progressive abortion laws in the world, unsafe and illegal abortions remain a significant public health problem. Multiple barriers to abortion care provision exist including provider conscientious objection, stigma, healthcare provider shortages, lack of trained providers, and a lack of designated facilities providing abortion services.
      In partnership with the Western Cape Department of Health (WCDOH), the RCOG Leading Safe Choices (LSC) programme seeks to improve access to abortion services within the Western Cape by increasing the number of providers willing and able to provide Comprehensive Abortion Care (CAC) services; improving the quality of post abortion family planning counselling and provision; and raising the standing of abortion care professionals. The programme trains and mentors mid-level health care providers (HCPs) in CAC.
      Early on in the LSC programme it became clear that although training interventions can make a localised impact in relation to increasing skilled providers and improving quality of abortion care, the overall impact was being hindered by the prevalence of conscientious objection at senior management levels; the failure of the WCDOH to hold designated facilities accountable if they failed to provide CAC services; blockages in the referral pathway of patients and a lack of understanding of  multi-disciplinary teams to provide CAC services as women’s rights enshrined in the Choice on Termination of Pregnancy Act and the constitution of South Africa.
      In partnership with the WCDOH and using lessons learnt during the programme, a CAC Optimization Strategy was implemented to tackle systems barriers and to improve abortion care services. Following its implementation uptake of CAC training has tripled and 11 new CAC sites have been established in the Western Cape.
      This presentation will present the different elements of the Western Cape CAC Optimization Strategy and its vital role in improving CAC services within province.
       

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

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

    Lunch session 2: abortion progress in several parts of the world
    Presidente de la Sesión:
    • Sharon Cameron, GB
    • Mary Favier, IE
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      Progress in medical abortion in Thailand
      Kamheang Chaturachinda, WHRRF, Thailand
      Prior to 2002 Misoprostol was freely available over- the- counter in Thailand at a cost of US 40 cents each. In 2002 the Ministry of Health had the first ever female Minister. She was from an ultra- conservative religious right political party (Palang Dhama Party). This party viewed abortion as immoral and sinful. Misoprostol was therefore put on the restricted drug list that needed to be prescribed only in hospital by a physician. The cost of the tablet in the market rocketed from 13 Bahts (40 US cents) up to 2,500 Bahts (70 USD ) and  even to 5,000 Bahts (160 USD ) per tablet. A combination of Mifepristone 200 mg and Misoprostol 800 microgram package (commercial name MEDABON) was introduced in to Thailand in 2009 by the Concept Foundation. This was first introduced in to 3 leading medical schools in Bangkok(and later in to Provincial medical schools) as a research project. The second phase research of the efficacy and effectiveness of MEDABON was launched by WHO and our Foundation (WHRRF) at Ramathibodi hospital in Bangkok in 2010. After the publication of this study, we vigorously   pushed for the registration of the drugs in Thailand  as well as listing  in  the essential drug list (EDL). Listing in   EDL allows the National Health Security Office (NHSO) to obtain the drugs for use   in the Women’s Reproductive  Health  Entitlement Package at a reduced price. Registration was successful in 2014 . And  listing in EDL in 2016. Medabon is now bought by the NHSO at a reduced price  for distribution and use in the Women’s Reproductive Health Entitlement Package free of charge (market price 500 B./package: NHSO price 230 B./package). Even though Medabon is registered for use to terminate pregnancy, Safe Abortion is still not universal available to women in Thailand. The main reason for inaccessibility of women in Thailand to medical termination of pregnancy is the negative attitude of the healthcare providers. WHRRF together with the Royal Thai College of Obstetricians and Gynaecologists are trying to overcome this obstacle by education and training.

      Progress in medical abortion in Thailand

      Kamheang Chaturachinda, WHRRF, Thailand

      Prior to 2002 Misoprostol was freely available over- the- counter in Thailand at a cost of US 40 cents each. In 2002 the Ministry of Health had the first ever female Minister. She was from an ultra- conservative religious right political party (Palang Dhama Party). This party viewed abortion as immoral and sinful. Misoprostol was therefore put on the restricted drug list that needed to be prescribed only in hospital by a physician. The cost of the tablet in the market rocketed from 13 Bahts (40 US cents) up to 2,500 Bahts (70 USD ) and  even to 5,000 Bahts (160 USD ) per tablet. A combination of Mifepristone 200 mg and Misoprostol 800 microgram package (commercial name MEDABON) was introduced in to Thailand in 2009 by the Concept Foundation. This was first introduced in to 3 leading medical schools in Bangkok(and later in to Provincial medical schools) as a research project. The second phase research of the efficacy and effectiveness of MEDABON was launched by WHO and our Foundation (WHRRF) at Ramathibodi hospital in Bangkok in 2010. After the publication of this study, we vigorously   pushed for the registration of the drugs in Thailand  as well as listing  in  the essential drug list (EDL). Listing in   EDL allows the National Health Security Office (NHSO) to obtain the drugs for use   in the Women’s Reproductive  Health  Entitlement Package at a reduced price. Registration was successful in 2014 . And  listing in EDL in 2016. Medabon is now bought by the NHSO at a reduced price  for distribution and use in the Women’s Reproductive Health Entitlement Package free of charge (market price 500 B./package: NHSO price 230 B./package). Even though Medabon is registered for use to terminate pregnancy, Safe Abortion is still not universal available to women in Thailand. The main reason for inaccessibility of women in Thailand to medical termination of pregnancy is the negative attitude of the healthcare providers. WHRRF together with the Royal Thai College of Obstetricians and Gynaecologists are trying to overcome this obstacle by education and training.

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      Ireland has one of the most restrictive abortion laws in the world: abortion is only permitted to save the life of the mother. That is about to change. In May 2018, by a referendum, the Irish people voted by a landslide majority to repeal the constitutional provision—the 8th amendment—that banned abortion and to empower the legislature to provide for abortion care in Ireland.


      In 2017, a Citizen’s Assembly, 99 “Citizens” chosen by a random selection process to provide a geographical, gender, age balance, overseen by a senior judge, was convened to hear evidence from a wide variety of sources – medical, legal, activists on both sides of the issue.
      The very liberal legislative model recommended by the Assembly inspired a subsequent parliamentary committee—which in its turn heard form medical and legal voices—to also recommend legislation to permit abortion on broad grounds. This led the government to call a referendum to repeal the 8th amendment.
      The presentation will focus in particular on the ways in which health expertise, international best practice and public health evidence became tools of human rights advocacy. It will discuss the role of the Irish Family Planning Association in developing and using these tools, and, critically, in building the capacity and creating a community of healthcare practitioners who would become key advocates in the campaign to repeal the 8th amendment.
      The presentation will also outline the new legal framework being proposed by the government, potential barriers to access and inequities in the system proposed. Finally, the presentation will discuss the challenges that now present us as we finally become committed, rights-based providers of abortion care.
       

    Lunch session 3: Abortion stigma discussion panel
    Presidente de la Sesión:
    • Audrey Brown, GB
    • Sam Rowlands, GB
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      This paper reflects on findings from several recent studies on abortion in Scotland. These have examined experiences of earlier/later abortion, more than one abortion, and of working in abortion provision. Together they constitute a rich body of data illustrating manifestations of abortion stigma; feelings which abortion may evoke (such as shame, disgust), and ways in which stigma is resisted/rejected. Qualitative secondary analysis of these data highlights that negative attitudes toward abortion continue to prevail - and to shape experiences of those seeking and providing it – but that positive accounts also emerge and merit further attention. Foregrounding positive accounts contributes to understanding of abortion stigma, and of what alternative orientations to abortion might look like, in a way that is grounded in women’s lived experiences. Our analysis also suggests that, even in a context where it has been safely, legally provided for 50 years, women who have undergone abortion nevertheless find it difficult to escape cultural narratives which position it as highly negative and taboo. Our findings point to the need to further address abortion stigma and negativity head-on, and to collaboratively shift the narrative towards abortion positivity.
       

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      Objectives: In societies with oppressive anti-abortion norms, such as Northern Ireland, little is known about how these norms are resisted by the adult population. This paper explores how resistance to religious and patriarchal norms can be fostered through adult community abortion education; and considers how such knowledge can inform engagement with those seeking and providing abortions. 
      Methods: Participants (n=17) of a community-based abortion education programme were interviewed to explore their views on abortion utilising semi-structured interviews.  

      This paper focuses on a thematic analysis of the interview data, with a particular focus on how women resisted oppressive norms and the stigmatised positioning of abortion. 
      Results: The findings indicate that this resistance is multi-faceted and bolstered by a lived experience discourse, which does not necessarily involve eschewing religious notions held within society. 
      Conclusions: Meanings of abortion in society are constructed within socio-historical and gendered spaces and manifested through myriad discourses that impact on the perception and treatment of the issue in that society. The paper concludes that adult abortion education in community settings offers the possibility of creating dialogical spaces for people to reflect on and resist oppressive norms regarding reproduction and abortion, and in so doing can challenge stigma more broadly.  (drawn from article Bloomer, O"Dowd, Macloed, 2014)
       

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      This presentation seeks to generate understandings not only about how women may internalise abortion stigma; but also about how that internalisation may be resisted and rejected. It does this by drawing on a qualitative secondary analysis of young women's narratives in two abortion studies in England. The analysis showed that whilst most women did internalise abortion stigma, many resisted this stigmatisation, and some rejected it. Individually-held moral views interacted with socio-cultural norms around reproduction and motherhood, and shaped women's responses to their abortion. Stigma management strategies were grounded on rejecting notions of blame, and or feelings of shame. Those women who were morally confident about their exercise of bodily autonomy were least likely to struggle with their decision-making or to experience negative post-abortion emotions. The analysis showed that abortion-related stigma is neither universal nor inevitable, and indicates that attempts to normalise abortion may help women avoid internalising abortion stigma.

    Lunch session 4: Meeting with ‘Arts and theatre’
  • 14:00-
    15:30
    Concurrent session 1: Free communications
    Presidente de la Sesión:
    • Deborah Bateson, AU
    • Sam Rowlands, GB
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      Objectives: We examined experiences of women who travel from the Republic of Ireland to the UK for abortion care. Irish women’s experiences are poorly understood. Publically shared stories tend to highlight cases of tragic circumstances (e.g., foetal anomalies, minors), eclipsing more ordinary circumstances for seeking abortion. We collected data about experiences of the latter group by using a systematic qualitative research approach. 
      Methods: Qualitative data were collected using In-Depth Interviews (IDIs) with 25 Irish women who traveled to Liverpool and London for abortion care between February and June 2017. Participants were Irish citizens or permanent residents and received surgical or medical abortion. We excluded minors and foetal anomaly cases. Participants’ age ranged from 19 to 43 years old; 18 of 25 participants were in their 20s. Their reported gestational age was between 6 and 19 weeks. IDIs followed a 13-item Interview Guide with semistructured probes. Topics included: arranging travel, challenges, support network, delays, and privacy.
      Results: Data reveal significant hardships in women’s experiences traveling abroad for abortion care, including difficulties arranging travel in an “environment of secrecy” despite readily available information online, maintaining privacy in social and professional circles while waiting to travel, financial constraints, getting time off work, and securing overnight childcare. Financial barriers may lead women to intentionally schedule later appointments to allow time to organize money. Women who borrowed money reported getting bank loans of 900-1500 Euro. Additionally, the use and location tracking capabilities of social media (Facebook, Snapchat, etc.) may generate added stress about retaining privacy in abortion travel.
      Conclusion: Irish women who travel for abortion care to the UK overcome significant financial, social, and employment difficulties in a burdensome environment of secrecy in order to pursue abortion services abroad. This study highlights the need to liberalize access to abortion care in Ireland.

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      Background: The failures of medical termination of pregnancy (MToP) can have serious consequences such as exceeding the legal age of abortion and the occurrence of fetal malformations related to the teratogenic action of misoprostol.


      Objective: To study the correlation between a low-sensitivity urine pregnancy (LSUP) test associated to a self-performed questionnaire and the standard patient follow-up after MToP, consisting of a clinical examination, a blood hCG test and ultrasonography when needed. Methods: Prospective cohort study included women who came to their post abortion visit after MToP from March to August 2017. They performed a LSUP test and a self-performed questionnaire to assess their opinion on the completion of the abortion. Then a standard follow up was done by a doctor. A successful MToP was defined as a complete uterine abortion, with no the need for surgical intervention or for new abortive medication. Results: 133 women have been included in this study. The rate of successful MToP was 94.0%. Regarding failures there were two ongoing pregnancies (1.5%) and six retained products of conception (4.5%) treated either by a surgical procedure or with a new oral administration of misoprostol. Sensitivity of the womens opinion combined to the LSUP test was 100%, specificity was 89.6%, positive predictive value 38.1%, negative predictive value 100%, a Youden index of 0.89 and a kappa coefficient of 0.51. Conclusion: Given the extremely high efficacy of MToP, most women do not need a clinical follow-up to confirm pregnancy termination. Our data show that most women can ascertain their abortion outcome using a simple self-administrated questionnaire and a LSUP test.

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      Objectives: Existing data suggest that European women from countries with relatively liberal abortion laws travel to other European countries for abortion care, yet, few studies have described this unique experience. Methods: We analysed preliminary data from a five-year mixed method study conducted in the UK and the Netherlands. We examined characteristics of women travelling for abortion services from France, Italy, Germany, and other EU countries. We present results from 127 self-administered surveys collected in the UK (n=41) and in the Netherlands (n=86). From our data we identify main barriers to abortion care, estimate the costs incurred, and describe delays women experienced in the process. We contextualize these findings using data from in-depth interviews. Results will be updated based on the most up-to-date data. Results: Patients incurred large out-of-pocket costs. Only 5% of respondents in the Netherlands and 2.5% in the UK had the costs of the abortion procedure fully or partially covered by insurance and all clients incurred additional travel costs. The majority of participants were in their second trimester of pregnancy. On average, clients had considered an abortion over a month before their scheduled procedure, and almost all wanted to access abortion earlier in their pregnancy, but were delayed because they did not know they were pregnant and/or there were no abortion services near their residence. The main barriers to abortion services included surpassing the gestational age limit in their country of residence or not meeting the legal requirements. On average, clients travelled 3-6 hours to access services in the UK and the Netherlands. Conclusion: Women throughout Europe experience legal, social, and procedural barriers to abortion services in their countries of residence that cause them to have to travel for abortion services abroad. Women incur high costs in travelling for abortion services and in many cases are delayed in accessing wanted abortion services

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      In Poland, abortion is legally restricted. Yet there are underground abortion providers and many who have an unwanted pregnancy receive abortion pills through telemedicine services. Those who advocate abortion face threats and harassment by anti-abortion thugs and by the government, yet throngs of people have filled the streets. In the USA, abortion is legal but increasingly inaccessible to many, although there is at least one clinic in every state. There are networks of community-based providers and evidence that increasing numbers of people are choosing to manage their abortions with pills obtained through a range of sources, but 18 women have been arrested. In both countries, there are activists working to put abortion pills in womens hands and de-stigmatize the practice of self-management and the language around home use of abortion pills. On this panel, a member of the Polish Abortion Dream Team, the Director of Women Help Women and a member of the USA project SASS (Self-Managed Abortion, Safe and Supported) will discuss the parallels and lessons learned in their work, both from advocacy and security and activism perspective, that may be relevant for the pro-choice movement at large.

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      Context: The method of abortion has rapidly changed from surgical to medical termination of pregnancy (MToP) in several countries; today 95% of abortions are MToP in Finland. 
      Objective: Intensity of pain, need of analgesics, evaluation the adequacy of ibuprofein and paracetamol, and patient satisfaction. Comparison of teenagers vs. adult women. These are the results of an interim analysis of the first 97 patients of the study. 
      Methods: This prospective study evaluates pain during MToP in early pregnancy (<64 days of gestation). Altogether 120 primigravid women are being recruited. The ratio of teenagers (15-19 year-olds) and adult women (25-35 year-olds) is 1:1. 
      MToP was carried out according to the Finnish national guideline. The medication consists of 200mg of mifepristone administered at the outpatient policlinic followed by 0,8mg of misoprostol vaginally or orally at 24-72 hours primarily at home. Ibuprofein (600mg) and paracetamol (1g), both up to three times/day were used for pain management. First doses are taken simultaneously with misoprostol and thereafter whenever needed. Pain is measured by visual analogue scale (VAS), which is reported in a diary each time patient needs analgesics. 
      Results: The highest pain reported by VAS was 78±18 (mean±SD) among teenagers and 66±27 among adult women (p=0,005, VAS 70-100mm); 48% vs. 19% of the patients reported severe pain. Nevertheless 77% of teenagers and 65% of adults evaluated the analgesia as adequate and the overall satisfaction with the care received was high in both groups (VAS 85±12 vs. 85±15; p=0,311).

      Altogether 88% vs. 93% would choose MToP again. 
      Conclusions: Women and especially teenagers undergoing MToP experience strong pain already in early pregnancy. Even though teenagers experience more pain they more often estimate that the combination of ibuprofein and paracetamol is adequate.

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      Aim: To explore women’s experiences of returning for subsequent abortions and the experiences of staff who provide abortions.
      Background: While overall abortion rates are decreasing in the UK, the percentage of women undergoing more than one abortion has increased.  Between 2006-2016 there was a 6% increase in the number of women requesting repeat abortions, rising from 32% to 38% despite historical improvements in medical interventions for contraceptive technology.  Previous quantitative research has focussed on what is different about women who request multiple abortions and how to get them to uptake and adhere to long acting reversible contraception.  Rather than their personal experiences.
      Methodology: Qualitative semi structured interviews with 10 women who have had multiple abortions and 12 semi structured interviews with staff who work in an abortion service.  All interviews were transcribed verbatim.  Interviews were analysed using thematic analysis.
      Results: Four overarching themes emerged which were guilt, shame, coping and perfect contraception.  Women experience guilt at multiple levels from the legal framework, to service and individual level; whereas staff struggle with their own guilt regarding provision of services.  Stigma is expressed in the language used, by both women and staff, surrounding abortion and by the issue of woman returning for multiple procedures.  Coping describes the different ways that women coped with their abortions and how they coped differently with each one, examining how patterns of behaviour may emerge.  Accounts evidence a sense of deep shame around returning for abortions which links closely with guilt where both women and staff apportion and internalise blame. 
      Conclusions: Abortion is a stigmatised medical procedure for both women and the staff who provide them. Women and staff use a variety of mechanisms to reduce that stigma some of which may fail to address ongoing problems with contraception.  However, women who return for multiple abortions are diverse and so are their experiences, procedural and service issues may need to re-examine implicit attitudes to abortion.

       

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      Objective: To analyze long-term satisfaction to intrauterine contraception after medical induced abortion.


      Minimizing delay from medical abortion procedure to insertion of intrauterine contraception is a new approach to increase intrauterine contraception uptake and reduce subsequent unplanned pregnancies. Effect of this immediate insertion on womens satisfaction and quality of life is unknown. Materials and methods: Subanalysis of a randomized controlled trial. Total of 267 women were randomized to receive levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena, Bayer, Turku, Finland) immediately (?3 days) or later (2-4 weeks) after medical induced abortion during January, 2013 December, 2014 in Helsinki University Hospital, Finland. Selected demographic factors were collected. Women answered questionnaires concerning satisfaction and quality of life at follow-up visits three months and one year after LNG-IUS insertion. Results: Following three post-randomization exclusions, there were 264 participants. Of the immediate-insertion group 98/133 (73.7%) and the delayed-insertion group 78/131 (59.5%) women returned to the 3-month follow-up, and 89 (66.9%) and 63 (48.1%) to the 1-year follow-up. Median age was 27.8 (IQR 23.033.1) vs. 27.3 years (22.532.1), p=0.54. At 3-month visit the immediate-insertion group was more often satisfied or very satisfied with their contraception compared to the delayed-insertion group (89 [89.9%] vs. 61 [79.2], p=0.048). We found no difference at 1-year (71 [79.8%] vs. 47 [74.6%], p=0.45). Womens experienced health, as measured by visual analogical scale (0100 mm), at 3-month visit was 84 mm (median, IQR 77 91) vs. 87 mm (7795), p=0.19, and at 1-year visit 85 mm (7493) vs. 86 mm (7492), p=0.75. Conclusion: Immediate LNG-IUS insertion following medical abortion did not have a long-term effect on womens satisfaction with intrauterine contraception or experienced health. Loss-to-follow-up rate was high and may have produced a selection bias. However, these results endorse the feasibility of immediate initiation of intrauterine contraception following medial abortion.

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      Objectives: In Bangladesh, women undergoing menstrual regulation (MR) (an approved procedure to regulate menstruation in women at risk of pregnancy) are a key group to target with contraceptive services. We used a randomised controlled trial to evaluate an intervention delivered by mobile phone which was designed to promote contraceptive use among MR clients in Bangladesh.

      Methods: In 2015/2016, we recruited 972 women after their MR procedure from 41 facilities, and randomised them to intervention or control groups. The intervention group were sent 11 automated, interactive voice messages with optional call centre counselling over 4-months post-MR. The primary outcome was self-reported LARC (long acting reversible contraceptive) use at four months post-MR; secondary outcomes were use of any effective modern method, subsequent pregnancy or MR and intimate partner violence (IPV).

       


      We used Logistic regression modelling to calculate odds ratios, allowing adjustment for baseline differences between the groups among pre-defined variables. In 2017, we conducted in-depth interviews (IDIs) with 30 trial participants to explore the intervention effects/non-effects.

      Results: We interviewed 773 participants (80%) at 4-months. Full details of the results from the trial and IDIs will be presented at the conference. Many IDI participants reported that they learnt more about contraception from the intervention however some women faced barriers to accessing the automated content due to low phone literacy. IDIs indicated a high frequency of phone sharing and that women’s phone use is sometimes monitored or controlled by others in the home. The majority of IDI participants had told their husbands about the study and their MR.

      Conclusions: These findings highlight the importance of considering familial contexts when designing interventions that reach into homes. The results of this trial will help us to understand whether this type of intervention can be successfully translated to the Bangladesh context.

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      Objective: To evaluate whether intrauterine instillation with Mepivacaine (Carbocain) before insertion of an intrauterine contraceptive device (IUD) decreases pain at insertion compared with placebo (NaCl). Design: Double-blind randomized controlled trial. Setting: Two outpatient clinics providing contraceptive services. Population: Women over 18 years of age opting for IUD for contraception. Methods: Women were randomized to intrauterine instillation of Mepivacaine (intervention) or placebo (placebo, NaCl) with a hydrosonography catheter before insertion of an IUD. During the procedure, women marked their pain on a 10-cm visual analogue scale (VAS). Data were analyzed by intention to treat, using descriptive and inferential statistics. Main outcome measures: Difference in pain score (VAS) at the time IUD insertion between intervention and placebo group. Results: A total of 86 women were randomized. Mean VAS-score was 4.63 in the intervention group (n=41, SD=2,21) compared to 5.67 in the placebo group (n=40, SD=2,62, P = 0.058). The intervention did not have a significant influence on pain but had a significant influence on the overall experience of the procedure (P = 0.003). Conclusions: Intrauterine instillation of Mepivacaine prior to IUD insertion did not significantly affect the pain score but had a significant influence on the overall experience of the procedure. Our findings support further studies with larger sample sizes.

    Concurrent session 2: Hot topics in abortion care
    Presidente de la Sesión:
    • Teresa Bombas, PT
    • Philippe David, FR
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      The quest for the optimal regimen for pain control for first trimester surgical abortion is ongoing. The desired characteristics of an optimal regimen include safety, efficacy, relatively inexpensive cost, and easy to administer.  Although paracervical blocks and nonsteroidal anti-inflammatory medication in combination with non-pharmacologic methods (heating pad, support person) fulfil these criteria - many women still experience significant levels of pain during their procedure.  To complicate matters, many clinicians have strong feelings that their pain regimen approach is best but as clinicians have been shown to underestimate the amount of pain women are experiencing, rigorous testing of these regimens are needed.  

      Finally, a woman’s perception of pain is complex with both physical and psychosocial elements that have been associated with higher levels of pain including parity, age, and anxiety levels. The current literature will be discussed as well as a brief review of the pathophysiology of abortion-related pain, patient characteristics associated with increased levels of pain, a practical approach to care and research gaps.

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      National guidelines on Rhesus (Rh) testing and treatment with Rh (anti-D) immune globulin (RhIg) for spontaneous and induced abortion vary between countries. Rh alloimmunization (also called isoimmunization) may harm subsequent pregnancies, but there is a lack of evidence that this occurs in early gestations. We should stop testing Rh status and administering RhIg to women having an induced or spontaneous abortion at early gestations if this is shown to be unnecessary, because this interferes with access to abortion and incurs extra cost. In the Netherlands, the policy is to not treat Rh-negative women having medication-induced or spontaneous abortions under 10 weeks’ gestation and surgical abortions under 7 weeks’, while in Canada all Rh- negative women are treated. We compared the clinically significant Rh alloimmunization rates in Canada and the Netherlands to determine whether the Dutch policy could be safely adopted by other countries. National guidelines from Canada and the Netherlands were obtained for the period of 2006 to 2015, and public databases were consulted to obtain national rates of abortions, births, Rh negativity, and the number of women with clinically significant perinatal antibodies. For Canada, the total fertility rate was 1.56, the abortion rate was 1.9%, and the Rh negativity rate was 13.0%. For the Netherlands, the total fertility rate was 1.66, the abortion rate was 1.2%, and the Rh negativity rate was 14.5%. In Canada, out of 573,206 samples tested in pregnant women, 0.0043% had clinically significant perinatal antibodies. In the Netherlands, out of 1,816,457 samples tested, 0.0040% had clinically significant perinatal antibodies.

       

       

       

      This provides evidence that the Dutch policy of not treating Rh-negative women having medication-induced or spontaneous abortions under 10 weeks’ gestation and surgical abortions under 7 weeks’ can be safely adopted by other countries.

       

    Concurrent session 3: Novel ways of working
    Presidente de la Sesión:
    • Ingrid Sääv , SE
    • Allan Templeton, GB
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      Objectives: In the United States, many women struggle to obtain an abortion due to ever-increasing barriers to access. The TelAbortion Project provides medical abortion directly to women in their homes using telemedicine and mail, enabling them to receive services without going to a clinic. We will report on interim findings from the first two years of the project.
      Methods: TelAbortion is available in Hawaii, New York, Maine, Oregon, and Washington. Interested women contact implementing sites and interact with clinicians by videoconference. After obtaining screening tests at radiology and lab facilities close to them, eligible women are mailed packages containing mifepristone and misoprostol. Women take the medications at home, obtain follow-up tests and have another consultation with the clinician. 
      Results: Through June 2018, 200 women had received medication through the project. Of the 70% who were followed to completion, 5% had a surgical completion. The vast majority of packages were sent within two weeks after the initial study contact, and all women reported taking the mifepristone at gestational ages of 72 days LMP or less. No related serious adverse events were reported. All women reported being very satisfied or satisfied, and the most commonly reported best features of the service were the convenience and privacy.
      Conclusions: Direct-to-patient telemedicine abortion is feasible and can potentially increase access to abortion care in a safe and acceptable manner. Although telemedicine bans and other restrictions are on the rise, TelAbortion could plausibly be legally implemented in about half of the 50 states, where about 56% of the female reproductive-age population reside.

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    Concurrent session 4: Refusal to treat under 'Conscientious Objection': consequences, impact and how to secure the right for abortion
    Presidente de la Sesión:
    • Nausikaä Martens, BE
    • Mirella Parachini, IT
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      How will we be able to secure the right for abortion? Around the world, in a lot of countries where abortion is legal, women have great difficulties to have access to abortion. A few countries have regulations that state CO is not permitted for health care providers working in the field of reproductive health (Sweden, Finland, Iceland).
      Is this an actual solution for other countries? In most countries, individual CO is written in the abortion law and in medical law, and in Belgium, abortion providers agree to this.


      Which woman wants to be treated by a team that has a negative feelings towards abortion? Anti-choice health care workers obliged to work in the field of abortion could make it a traumatic experience!
      In countries where CO is permitted, our actual fight should focus on the following:
      The state should ensure that abortion services are available in each region (in hospitals or in outpatient facilities) and make sure women know where to go. Public hospitals should offer an abortion service if they want to keep their state funding. Public hospitals should not have the “right” of conscience. Objector status of doctors should be public and quick referral to an abortion service mandatory. Providers, who work in abortion services, should choose to do so (conscientious commitment) so that women are treated with respect and empathy. 
      Doctors performing abortions should not be discriminated and should be dismissed from other tasks who need to be taken over by conscientious objectors. Women’s rights movements should encourage feminists to become doctors and young doctors to perform abortion and be proud to do so.  We need to do a charm offensive to show that working in abortion care permits rich human encounters with women grateful to be able to decide about their future life.

    Concurrent session 5: Liberating women in Ireland
    Presidente de la Sesión:
    • Sharon Cameron, GB
    • James Trussell, US
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      The Irish abortion referendum represented an historic moment for reproductive rights in Ireland. Strikingly, the overwhelming “Yes” vote from Irish voters was echoed and supported by a broad spectrum of Irish politicians. This presentation will describe the critical role played by scientific evidence in shaping the policy conversation and influencing the opinions of politicians. We will discuss both quantitative and qualitative findings about how women in Ireland access abortion and their experiences both traveling abroad to clinics and self-managing using online telemedicine. Looking ahead, we will also examine elements of the new legislation Irish politicians are drafting to grant access to abortion up to 12 weeks gestation. Finally, since the political spotlight has now turned to Northern Ireland, where abortion laws remain among the strictest in the world, we will preview new research examining women in Northern Ireland’s decision-making and experiences around abortion and discuss strategies for how this research might help support change. 

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      Objectives: This paper considers recent developments in abortion law and policy in Northern Ireland and analyses their impact on access and future direction. Specifically, the paper considers: the investigation carried out by Committee on the Elimination of All Forms of Discrimination against Women (CEDAW); the implementation of the Centralised Booking System for those travelling to England; the implications of the Irish Referendum; political debates in the UK parliament and the recent Supreme Court Judgement.  

      Methods: the paper reviews research studies, political debates, policy documents, legal cases and considers the views of stakeholders (senior civil servants, health professional bodies, politicians, activists, trade unionists and academics).
      Results: The restrictive legal context in Northern Ireland has resulted in only 16 abortions carried out by the NHS in the last reported year.In contrast 919 abortions were carried out in England to those with Northern Ireland addresses.  Others self-abort at home, risking criminality in doing so.  There is also evidence that abortion is a workplace issue – that women are unable to get sick leave, returning to work too soon and are uncertain who they can access support from.The CEDAW inquiry established that restricted access resulted in grave and systematic violation of human rights, including the chilling effect on clinicians of unclear law and policy, no referral pathway for post abortion care for those that travelled and no pathways for return of foetal remains. 
      Conclusions: the culmination of the CEDAW investigation and court judgements have identified human rights violations as a result of highly restricted access to abortion.  This can only be overcome by decisive legislative action to address inadequacies, until then, for many needing an abortion, travelling to England or self-aborting at home, will remain a harsh reality.

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      Objectives: This presentation is an intimate and sometimes stark look at the groups most negatively impacted by the abortion law and policy in Ireland and Northern Ireland using real life examples of those still struggling to access legal abortion and the hardships they are facing.
      Methods: The presentation is based on the experiences of clients who have contacted Abortion Support Network (ASN). As ASN’s primary function is to provide financial assistance, the case studies will be of those who are marginalised, at risk, or otherwise without the financial means and support networks required to access abortion services without assistance.
      Results: While those based in Northern Ireland are able to access free abortions if they travel to England, not all people are able to travel. In addition, ASN continues to be contacted by women who have no idea about the scheme allowing free abortions in England, which is obviously due to a lack of knowledge of the availability. Meanwhile, while the Republic of Ireland has repealed the 8th amendment, there has as of yet been no legislative change, and anyone who wants an abortion is still forced to take safe but illegal abortion pills or travel to another jurisdiction.
      Conclusions: as an abortion fund ASN won’t be drawing any conclusions until our phone stops ringing so often due to in country provision. For now, the only conclusion is the one we already know – that the criminalisation of abortion has always and will always most adversely impact the poor.

  • 15:30-
    16:00
  • 16:00-
    17:30
    Improving access to and simplifying early abortion
    Presidente de la Sesión:
    • Philippe Faucher, FR
    • Nathalie Kapp, FR
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      Women are seeking abortion at increasingly earlier gestations, with 41% of first trimester patients in the U.S. receiving an abortion at <6 weeks gestation.  The efficacy of medical abortion at <6 weeks gestation is not significantly different than at 6-7 weeks, however, seeking abortion very early in gestation increases the likelihood that providers will have difficulty visualizing the pregnancy on ultrasound, the current standard of care in many clinics. 
      The most serious risk of treating women with an undesired pregnancy with mifepristone and misoprostol without first confirming a diagnosis of intrauterine pregnancy is a missed diagnosis of ectopic pregnancy.  Studies suggest an incidence of ectopic pregnancy of 0.2-0.3% among women presenting for medical abortion. Data support the practice of providing mifepristone and misoprostol medical abortion in the setting of undesired pregnancy of unknown location (PUL) using serial serum hcg testing to simultaneously exclude ectopic pregnancy and determine the efficacy of the medical abortion.  Guidelines that enable provision of medical abortion in the setting of PUL, when the patient is asymptomatic, low-risk for ectopic and when combined with close follow up to exclude ectopic pregnancy exist to support this service development.
      This presentation will review the evidence for providing medical abortion at <6 weeks gestation including in the setting of PUL.

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

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      When planning post-abortal contraception it is important to note that women seeking trimester termination of pregnancy (TOP) have demonstrated their high fertility and are at risk of subsequent induced abortion.  The importance of the efficacy of the post-abortal contraceptive method has been increasingly recognized during the last decade. A safe and highly effective method with minimal dependency on the user compliance, i.e. long-acting reversible method of contraception (LARC) is clearly of value.  When compared to use of LARCs and especially intrauterine contraception (IUD), use of oral contraceptives or postponing initiation of contraception is associated with a significantly increased risk of subsequent TOP.
      Placement of an IUD immediately at the time of first trimester surgical abortion is the standard of care and it is also recommended in international guidelines. In comparison to delayed insertion, the expulsion rate is somewhat higher (5 vs. 3 %). following immediate insertion. However, the number of IUD users during the follow-up is increased when compared to delayed insertion (92 vs. 77 %).
      Increasing use of the medical TOP and home administration of misoprostol pose challenges to provision of post-abortal contraception. However, progestin implants can be safely inserted on the day of mifepristone administration. A recent RCT comparing fast-track insertion (≤3 days vs. 2-4 weeks after misoprostol administration) of the levonorgestrel-releasing intrauterine system (LNG-IUS) after first trimester TOP has shown that also rapid initiation of intrauterine contraception is feasible. Fast-track insertion is associated an increased risk of partial expulsion (12.5 vs. 2.3%).

      However, fast tract insertion was safe with similar rate of adverse events, and identical bleeding profile as that associated with later insertion. At one year of follow-up the user rate was higher and number of new pregnancies lower if the LNG-IUS had been inserted immediately.

      Thus, an effective, quickly-started long acting contraception should be the goal of treatment regardless of the method of TOP as long as a new pregnancy is not planned. To reach this contraceptive initiation should be an integral part of comprehensive patient friendly abortion care with low threshold and easy access. This will also reduce the need of additional visits, subsequent TOP, and allows initiation of an effective contraception, with all its added health benefits.

  • 17:30-
    18:30
    Symposium on the indications for uses, and practical applications of the Ipas Manual Vacuum Aspirator (MVA). Organised by WomanCare Global.
    Presidente de la Sesión:
    • Alison Edelman, US