Patricia Lohr


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    Gender-biased sex selection

    Lena Luyckfasseel IPPF European Network, Brussels, Belgium -

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

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

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

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    Very early surgical abortion

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

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

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

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

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

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    Identifying and managing on-going pregnancy after medical abortion

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

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

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    Methods of surgical abortion in the second trimester

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

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