Selma Hajri

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    First trimester abortion in the Arabic world

    Selma Hajri NGO, TUNIS, Tunisia -

    According to a WHO report, 100,000 abortions are performed per year, and 160 to 260 women die each year from unsafe abortions in the North / Middle East region. Unintended pregnancies remain high and the number of abortion seems very important although there is no reliable data. In most Muslim countries abortion, even in cases permitted by law, seems unacceptable to many. Illegal abortion is punishable by imprisonment. In some countries abortion is tolerated in the private sector and abortions are available in private clinics in many Arab countries, in good conditions for the well-off. But given the difficulty of their situation, many women, the poorest, use unsafe and risky methods of abortion.

    Only Tunisia in 1973 (14 weeks LMP) and Turkey (1981 until 10 weeks LMP) have legalized abortion in the first trimester without restrictions. The majority of countries in the MENA region, that have the most restrictive laws in the world, have not evolved since independence. Policy changes and growing influence of conservatives are leading to maintenance of negative attitudes among providers and denial by most physicians and state institutions. Moreover, the latest changes with the “Arab spring“ have not improved the situation. Even where abortion is legal it is now increasingly inaccessible. Recently in Turkey the government reduced access to abortion in the public health service. After the revolution, in Tunisia where abortion is free and available in all clinics of ONFP (Family Planning) and public hospitals since 40 years, many family planning clinics and hospital units are stopping providing abortion. When they still provide abortions, new restrictions are appearing on access to abortion with a change in attitude of providers, concerns and "self-censorship", coupled with greater hostility of the medical and paramedical personnel against abortion.

Gabriele Halder

Profession: Specialist in Obstetrics and Gynaecology
Affiliation: Familienplanungszentrum Berlin (FPZ), Berlin

Gabriele Halder ist Fachärztin für Gynäkologie und Geburtshilfe, Stellvertretende Vorstandsvorsitzende → Familienplanungszentrum Berlin (FPZ) - BALANCE Berlin e.V. und Leiterin des medizinischen Instituts des FPZ. Sie ist Mitglied der Ärztekammer Berlin.

Sie war massgeblich an der Organisation des letzten FIAPAC-Kongresses in Berlin beteiligt.

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    Medical abortion in the private practice,

    Gabriele Halder

    Specialist in OB/Gyne

    Working in private practice

    Head of the Family Planning Centre Berlin


    This presentation gives you an overview and in depth analysis about induced medical abortion with the abortion pill Mifegyne© ( Mifepristone ) and the Prostaglandin Cytotec© ( Misoprostol) in practical experience  as a practicing gynaecologist.

    The description of the problems in Germany in terms of having to deal with the german federal law and the regulations about the specific distribution channels of the abortion pill is considered as well as the increased requirements in the fields of care and consulting service for the female patients.

    The complexity in practice and the fact that in Germany the existence of prohibition for advertisment of induced abortions in general is another hurdle for the application of Mifegyne©. This is one section of the many reasons why last year 2003 only a percentage of 6,12 % of all induced abortions in Germany were done the non -surgical way.

Kai Haldre

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    Majority of research about the protective and risk factors of repeated teenage pregnancy has been carried out in the US. Worldwide, there is more information available about subsequent adolescent deliveries than abortions. The main reason here is that the availability and quality of abortion statistics vary largely in countries. In many countries with restrictive laws abortion statistics hardly exist. Estonia is considered to be a country with liberal legislation and complete abortion data since 1992. From the same period, after regaining independence from Soviet occupation in 1991, Estonia has undergone major socio-economic changes including profound educational and health care reforms. According to the World Bank Analytical Classification of countries Estonia has turned from upper/lower income country in 1990-ies to high-income country since 2006.
    The objective of this presentation is to analyze trends in adolescent pregnancies in Estonia from 1992 until 2017 and the proportion of repeated pregnancies from 1996 until 2017.
    Methods. Data on abortions were obtained from the Estonian Medical Statistical Bureau (1992–1995) and the Estonian Abortion Registry (EAR, 1996–2017).

    The completion and return of an anonymous record card to the EAR for each abortion is obligatory for every institution licensed to perform pregnancy terminations. Data about births were obtained from the Estonian Medical Birth Registry, which was established in 1992. The number of women in the 15–19-year age group was obtained from the Statistical Office of Estonia.
    Results. The percentage of teenage mothers from all parturients was 14.6% in 1992 and 2.0% in 2017, the proportion of adolescents from all women terminating pregnancy was 11.4% in 1992 and 7.2% in 2017. During the same period teenage abortion and fertility rates have decreased 81.7% and 79.8% respectively. In 1996–2017 the average proportion of teenage abortion patients with repeat abortion has been 18%, over the years no clear increasing or decreasing trend can be observed (lowest 15.8% in 2005 and highest 22.3% in 1996), the same is true concerning delivery before the index abortion (average 16.1%, lowest 13.0% in 2015 and highest 20.4% in 1996).  In average, 8.4% of teenagers were multipara during 1996–2017 (lowest proportion - 6.0% - in 2005 and highest in 2015 - 11.8%).
    Conclusions. During the period of remarkable changes in the Estonian society and economic growth teenage fertility and abortion rates have decreased substantially and become a rather rare event. During the study period a little less than one fifth of teenage abortion patients have experienced previous delivery or abortion, around one tenth of teenage parturients are multipara. Thus the proportion of repeated pregnancies among adolescents has remained the same.

Peter Hall

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    Medabon introduced by Concept Foundation

    Peter Hall, Chief Executive Officer, Concept Foundation, Bangkok, Thailand and Geneva, Switzerland

    In order to make medical abortion more widely available, Concept Foundation, a not-for-profit organization based in Bangkok, Thailand, has been working to get a product available of assured quality at an affordable cost. It has been responsible, though a public-private partnership between WHO, Concept Foundation and industry, for the development of Medabon®, a co-packaged product containing 200mg mifepristone and 800µg misoprostol. The issue of abortion is often highly controversial, sensitive, emotive and with significant socio-cultural and moral dynamics and thus the introduction and use of products for medical abortion products requires careful planning. It is necessary to develop and implement an appropriately designed introductory process, which takes a systematic and incremental approach; ensures coordination and collaboration between the public health system and all key stakeholders; and utilizes a supportive health system. This has been undertaken with Medabon® in Cambodia, Nepal and Zambia. 

Kristina Hänel-Groh

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    Post abortion abstinence – is there any benefit?
    Kristina Hänel, MD, Giessen, Germany

    “The evidence of recommendations regarding sexual intercourse, tampons, bath and swim
    after abortion has not been proven. We have to discuss this topic and to develop new
    standards.” Since 2002, when I ended my lecture in Amsterdam with these words, we
    never discussed this topic again.
    Usually abortion providers - even me four years after Amsterdam - give recommendations
    as follows: not to put anything into the vagina, especially not to have vaginal intercourse,
    use tampons, take a bath or swim for 2 –3 weeks after the abortion. These
    recommendations are given for hygiene reasons and are based on the fear of an
    increased risk of infection. This fear is explained by the following arguments:
    The cervix is opened 

    The uterus is a wound
    The penis is responsible for infection-rate
    Furthermore there are some known factors for an increased risk of postabortional
    Manipulation in the uterus (surgical abortion),
    Pre-existing subclinical genital tract infections
    Rretained products of conception
    However the evidence is lacking whether abstaining from intercourse, bath, tampons etc
    actually reduces the risk of postabortion. On the other hand, there are potential benefits of
    sexual intercourse after abortion which should not be neglected like: emotional and
    psychological aspects, cognitive aspects e.g. the feeling to be „normal“, assisting uterus
    contraction, pain reduction through relaxation of the genital organs after orgasm.

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    Waiting period: Do women need it?


    Kristina Hänel-Groh, MD, has 10 years of experience as a sex therapist and abortion doctor in a Family Planning Centre.  Is the owner of an abortion clinic and is the author of the book: “Die Hölle der Löwin. Geschichten einer Abtreibungsärztin”.


    In several countries exists a prescription by law which demands from women a waiting time between the counselling and the abortion itself. This time is in Germany 4 days up to seven days in other countries.

    This lecture is based of interviews from women which at one hand had an abortion and on the other hand from persons which are working as counsellors.


    The following questions had been given to the women:

    -   At what time the pregnancy was noticed

    -   When did they do the decision for an abortion

    -   Is the prescribed waiting time helpful for the decision


    The following questions had been given to the counsellors:

    -   How many women had already done their decision, when the came to the counselling

    -   Is counselling in general helful for the women

    -   Is the demanded waiting time itself helpful


    Purpose of this lecture is to ask, if the prescribed waiting time is useful or if it’s more a medical risk because the abortion could be done later then.

Dharani Hapangama

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    Acceptability and compliance with contraceptives


    Dharani Hapangama , Clinical Lecturer / Dep. Of Gynaecology, University of Liverpool,UK


    According to the best guess of demographers, at least 2.5 billion women will require contraception by the year 2025. Since we are in the era of the largest cohort of reproductive aged population in history, consequences of even a small difference in unwanted fertility will be catastrophic.Although the steroid hormonal regimens dominated the female methods of reversible contraceptives over the last 40 years, side effects have severely affected their acceptability (consent to receive / approval). This provides the incentive for the pursuit of novel alternative methods of contraception.


    In 1995 Rosenburg and colleagues estimated $2.6 billion as the cost associated with unintended pregnancies that occurred due to poor compliance with the oral contraceptive pill. Non-adherence to a contraceptive method interferes with its efficacy and disrupts the evaluation of results in a research setting. Although compliance is a fundamental prerequisite for achieving the full potential efficacy of contraceptives, there is a dearth of information available on patient non-compliance with the use of different contraceptive methods. If at all, very little progress is made in either accurately detecting, or predicting non-compliance. We sought to obtain insight into the adherence behaviour of women taking part in a contraceptive trial assessing the feasibility of administering once a month mifepristone. The results demonstrate that we as clinicians and as clinical researchers have no other option but to work towards forming a true therapeutic alliance with our volunteers; and to come to an agreement with our patients rather than to impose a prescription or a protocol upon them.

Annarella Hardiman

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    Unplanned pregnancy and abortion decision making – a report on the circumstances and experiences of contemporary Australian women

    Annarella Hardiman, manager of the “Pregnancy Advisory Service”, at the Royal Women’s Hospital in Melbourne, Australia.

    Investigators: Annarella Hardiman, Maggie Kirkman, Heather Rowe, Shelley Mallet, Doreen Rosenthal

    Topic: This paper presents the results of a two part project on abortion: an audit of records of around 5500 women contacting the Pregnancy Advisory Service at the Royal Women’s Hospital in Victoria, Australia, and in depth interviews with 60 women who had contemplated or undergone abortion in Victoria.

    The project was funded by grants from the Australian Research Council and the Victorian Health Promotion Foundation, and the audit and the research was approved by the Hospital’s Research and Ethics Committee.

    Problem: In the context of little recent Australian research on women’s experiences of abortion or their demographic and social circumstances, Australia’s largest public hospital provider of abortion, in partnership with the University of Melbourne’s Key Centre for Women’s Health in Society, undertook to contribute to the knowledge in relation to this issue. Abortion research in Australia has lacked a coordinated national approach, for instance 7 separate States and Territories provide abortion services within their individual criminal laws (abortion is still located in the criminal laws of 5 states/territories) and health laws.

    Theoretical approach and method:A quantitative audit of 5462 (de-identified) electronic records of women

    who had contacted the Royal Women’s Hospital regarding their unplanned and/or unwanted  pregnancy during a 12 month period, in order to analyse and describe their  demographic and psycho-social circumstances.

    - In-depth qualitative interviews with 60 women regarding the circumstances of their pregnancy and their decision making and experience of abortion or continuing the pregnancy (the majority had chosen abortion.)

    Results: The audit demonstrated the variety of socio-demographic and personal circumstances of Australian women seeking abortion, and assists in challenging the negative stereotypes about the many Australian women who have unintended pregnancies and contributes to societal understanding and acceptance of this fundamental women’s health issue.

    The interviews revealed rich information about women’s complex lives within which they made decisions about abortion. Each woman’s story is different, yet women have much in common. In considering their own needs, desires, and capacities, the well-being of potential children, and their responsibility for children and adults already in their lives, these women were making considered decisions to terminate or continue their pregnancies, based on multiple and contingent factors.

    Together they provide evidence to inform policymaking, service provision, further research, and public debate. For instance, since the Victorian legislation had recently removed abortion law from the criminal law and formally acknowledged abortion as part of women’s health care, the findings and recommendations of this research will assist the health system to recognise service needs, identify gaps, and ensure the equitable provision of timely and affordable services across the state.

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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.

Danielle Hassoun

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    Feasibility of a self-performed urinary test for the follow-up of medical abortion: the Betina study

    Danielle Hassoun1, Ines Perin2 1Private Practice Office, Paris, France, 2Gynaecology Department, Delafontaine Hospital, Saint Denis, France -

    Background: Medical Termination of Pregnancy (MToP) implies a follow-up visit (14 to 21 days after mifepristone intake) to verify the effectiveness of the abortion procedure and the absence of any complication. Studies have shown that a level of hCG in the serum less than 1000 IU, two weeks after the intake of the mifepristone means the success of the method in 90% of the case. Objectives and method: We set up an observational study among French specialized centres either private practice offices, academic hospital centres or family planning facilities. The objectives were to assess the benefit of a self-performed urinary semi-quantitative test in the follow-up of MToP, assessing the feasibility, acceptability and user-friendliness of the test as well as the women’s capacity to interpret it correctly. Concordance between qualitative results from the test and quantitative values from the blood hCG measurement was also assessed. Results: 322 women were included by 17 centres (47% private practice, 35% hospital practice, 18% family planning centers) from May to October 2013. The mean age was 28.1 ± 6.4 years. 82% (N=264) of patients attended the follow-up visit and 13% (N=42) of patients were lost to follow-up. 69% (N=183) patients had performed the two tests on the same day ± 1 day. Concordance between urinary test and hCG blood measurement was 94.5% [90.2%; 97.4%]. A large majority of women (90%, N=198)) read the urinary test correctly whatever the levels of hCG. Performing the test at home was found reassuring for 40% (N=71) of them, and satisfactory for 26% (N=46) of them but 3% (N=5) considered it to be alarming and 12% (N=46) unsettling. Conclusion: The semi-quantitative urinary test shows good concordance with plasma level. Proposing a urinary test for the women to control the success of the procedure appears to be relevant, efficient and safe.

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    Is ultrasound necessary
    Danielle Hassoun, MD, Paris, France 
    The question remains whether Ultrasound (US) is a mandatory requirement for performing
    medical abortion. In fact, it is very useful in diagnosing early pregnancy, in allowing early
    diagnosis of ectopic pregnancy and finally in confirming success or failure of the method.
    However, not having access to US technology should not be considered as a barrier to
    introducing medical abortion.
    To diagnose very early pregnancy requires very good equipment and highly trained
    providers. Without a vaginal probe, the diagnosis of a pregnancy less than 6 weeks
    remains nearly impossible.
    At the follow up visit, the use of US can confirm the success or failure of the method and
    especially the reassurance there is no on going pregnancy but it can also be responsible
    for unnecessary interventions because of faulty interpretations of the images.
    In high resource settings, where the equipment is readily available and the providers are
    highly trained, the possible risk is that US may be used as a replacement for clinical exam,
    resulting in a potential loss of clinical skills.
    In low resource settings, where the equipment is possibly inadequate and providers not
    sufficiently trained to use it, relying on their very good clinical skill
    can make them good medical abortion providers.
    Lessons learned after almost 20 years of experience in this field show that US is not a
    requirement when clinical exam and BHCG (when accessible) are concordant with the
    condition that the providers maintain a good level of clinical skill.

Martine Hatchuel

Oskari Heikinheimo

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    Abortion in women with cardiac disease

    Oskari Heikinheimo
    Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland

    The presentation will cover:
    Presentation of cardiac conditions and their treatment in which continuation of pregnancy predisposes the woman to high-risk of cardiac or obstetric complications. These include conditions such as history of cardiomyopathy (especially with comprised cardiac function), pulmonary hypertension and/or conditions in which cardiac disease or its treatment requires anticoagulation or treatment with teratogenic medication(s);
    Management of abortion (either medical or surgical) in women with cardiac disease, especially as concerns management of haemodynamics, and current recommendations concerning anticoagulation and possible antibiotic prophylaxis;
    Recommendations concerning multidisciplinary treatment of women with underlying cardiac disease faced with unwanted pregnancy and situations where continuation of pregnancy is considered contraindicated.

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    Challenges in post-abortion contraception

    Oskari Heikinheimo (Finland)

    Department of Obstetrics and Gynecology, Helsinki University Central Hospital, POBox 140, 00029-HUS, Helsinki, Finland

    The influence of contraceptive use and counseling on the risk of repeated abortion is unclear. In a recent prospective study, specialist counseling and provision of contraceptives did not have an effect on the rate of repeated abortion (Schunmann and Glasier, Human Reproduction, 2006). However, in randomized clinical trials the use of intrauterine contraception, initiated at the time of surgical abortion, has been effective in reducing further unintended pregnancies (Pakarinen et al., Contraception, 2003).

    We analyzed recently risk factors for repeat abortion among a cohort of 1269 women undergoing medical abortion between August 2000 and December 2002 (Heikinheimo et al., Contraception, 2008). Contraceptive use was assessed at the time of follow-up performed at 2-3 weeks following the abortion; intrauterine contraception was initiated at the clinic at the time of follow-up, or within 2 months. The subjects were followed prospectively via the Finnish Registry of Induced Abortions until December 2005, the follow-up time (mean ± SD) being 49.2 ± 8.0 months.

    In comparison with combined oral contraceptives, use of intrauterine contraception was most efficacious in reducing the risk of another pregnancy termination. In multivariate analyses the hazard ratios (95% Cl) of repeat abortion were 0.33 (0.16 to 0.70) among Cu-IUD users and 0.39 (0.18 to 0.83) among LNG-IUS users when compared to users of combined oral contraceptives. The incidence of repeat abortion was highest among women the postponing initiation of contraceptive use.

    Contraceptive choices made at the time of abortion have an important effect on the rate of re-abortion. Use of intrauterine contraceptives for post-abortal contraception is most efficacious in decreasing the risk of repeat abortion.

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    One-and two day mifepristone-misoprostol intervals are both effective in medical termination of second trimester pregnancy

    Oskari Heikinheimo, Satu Suhonen and Maija Haukkamaa, Department of Ob&Gyn, Helsinki University Central Hospital, Finland


    Termination of pregnancy because of fetal anomaly requires the utmost clinical sensitivity and individualized patient care. We compared the efficacy of a one-day mifepristone and misoprostol  –interval in medical termination of second trimester pregnancy performed because of fetal anomaly with that of the standard two-day interval among the first 100 women in each group. A 200 mg dose of mifepristone was used; 0.4 mg of misoprostol was administered vaginally at three-hour intervals until abortion occurred.


    When calculated from ingestion of mifepristone, the time to abortion was 28:25 h (23:10 – 50:40 h) (median (range)) and 52:43 h (45:55 – 83:15 h) (p<0.0001) in the one- and two-day MIFE-MISO groups, respectively. However, following initiation of misoprostol administration the time to abortion (7:25 h (1:00 – 23:15 h)) was longer (p<0.05) in the one-day interval group than in the two-day interval group (6:20 h (0:45 – 36:30 h); by 12 h 82 and 87% (n.s.), respectively, of the subjects had aborted. The proportions of cases undergoing surgical evacuation of the uterus were 64 and 45% (p<0.001), in the one- and two-day interval groups, respectively. 


    Thus both one- and two-day mifepristone-misoprostol intervals are both valuable in termination of second trimester pregnancy.

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    Risk factors for repeated abortion
    Oskari Heikinheimo, MK, Prof., Department of Ob&Gyn, Helsinki University Central
    Hospital, Helsinki, Finland
    The frequency of repeated abortion varies in different countries and depends greatly on
    the overall abortion incidence. In Finland the annual abortion incidence is ~9/1000 fertile
    aged women; the proportion of repeated abortion has been ~30% of all abortions for
    several years. Low socioeconomic status, parity and older age have emerged as risk
    factors for repeat abortion in previous studies.
    In order to further characterize the risk factors for repeated abortion we have initiated two
    large scale cohort studies employing the national abortion register, where 99% of all
    abortions performed in Finland are being reported. Woman’s age, previous pregnancies,
    duration of pregnancy, method of pregnancy termination as well as planned future
    contraception are reported to the national register.
    Helsinki study comprises of ~1400 women chosing medical abortion at our institute
    between 2000-2002. At 2-3 weeks following abortion, all women attended the clinic for a
    control visit, where the outcome, as well as compliance and initiation of contraception was
    assessed. Detailed demographic, life-style and abortion related data of the subjects have
    been collected. Also, the contraceptive method and the date when contraception was
    initiated have been recorded. The first assessment of repeat abortion until the end of year
    2005, and it’s risk factors is being performed. However, the study will continue until 2012. 

    Similarly, a nationwide study employing the national abortion register has been initiated. In
    the nationwide study cohorts of ~23.500 women choosing medical abortion and 65.000
    women choosing surgical abortion between 2000-2005 are being followed. The first
    assessement of repeat abortion will be performed until the end of year 2005. Among other
    things, the study allows estimation of the true risk for repeat abortion following different
    methods of pregnancy termination.
    It is hoped that these register based strategies will be valuable in identifying the incidence
    and risk factors for repeat abortion. In addition, true efficacy and cost-benefit ratio of
    various contraceptive methods can be assessed. These data are valuable when
    developing and designing family planning services aiming to shift from abortion to effective

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    Use of levonorgestrel-releasing IUS (Mirena®) following medical termination of pregnancy


    Oskari Heikinheimo and Satu Suhonen  MD, Department of Ob&Gyn, Helsinki University Central Hospital, Finland


    Immediate insertion of levonorgestrel-releasing IUS (Mirena®) following first trimester surgical abortion is safe and effective.


    We evaluated the post-abortal contraceptive practices among 417 women who chose medical termination of pregnancy (MTP) during the first year of use of MTP in our hospital between August 2000 and 2001. MTP was offered to women with unwanted pregnancy with duration of up to 56 days, and it was carried out by administration of 200 mg of mifepristone on day 0 (visit I) followed by 0.4 mg of misoprostol administrered vaginally on day 2 (visit II). A 3rd visit was scheduled at 3 weeks to control the outcome of MTP.


    Future contraception was planned during visit I. 61% of women chose combined oral contraceptive (COC, whereas 29% of women chose intrauterine contraception. A total of 65 women opted for Mirena® (i.e. 16%) and 53 women (i.e. 13%) for Cu-IUD.  Of the IUD’s 55% (66% of the Cu-IUDs and 46% of the Mirena® IUSs) were inserted on visit III, and 25% at a later occasion at the clinic.  The insertions were uneventul, and no complications requiring removal of the IUD occurred.


    We conclude that similarly as following surgical abortion, Mirena® is a safe contraceptive option also following medical abortion. Despite the slight bleeding, Mirena®  can be inserted at the time of control visit at approximately 3 weeks following MTP.

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    Self-assessment of urine hCG – a novel option in the follow-up after induced abortion?


    Oskari Heikinheimo

    Helsinki University Central Hospital and University of Helsinki, Department of Obstetrics and Gynecology, Helsinki, Finland -

    There is controversy concerning the need for routine follow-up after an uncomplicated abortion. This is also reflected in the various guidelines on induced abortion. The WHO guideline states that following safe, induced abortion, post abortion care may not require follow-up visit, whereas according the Royal College of Obstetricians & Gynaecologists guideline there is no need for routine follow-up after surgical or medical abortion if successful abortion has been confirmed at the time of the procedure. The Finnish guideline states that ‘the follow-up is important’. This controversy is also reflected in women’s compliance with a follow-up: in research studies, up to 50% of the women do not attend the scheduled follow-up visit. Ideally, during follow-up, completeness of the abortion can be verified, possible complications excluded and the use of post-abortion contraception encouraged. In addition, counseling and psychological support could be provided. The completeness of the abortion can be ascertained in several ways. The value of pelvic examination or ultrasonography have been questioned, whereas the use of serum or urine hCG to exclude ongoing pregnancy has been advocated. Recent studies have focused on development of semi-quantitative urine hCG tests as possible self-assessment tools to verify the completeness of an abortion. We have recently completed a randomized multicenter study to compare self-assessment at home using a two-step urinary hCG tests vs. assessment at the clinic following early medical abortion (Oppegaard et al., accepted for publication). The results show that the rate of complete abortion (94% vs. 95%) or the need for surgical evacuation of the uterus did not differ between the groups. Nine in ten of the women found the urine hCG test easy to use, and significantly higher proportion of the women (82% vs. 59%) would prefer the self-assessment should they undergo an other abortion. It is concluded that self-assessment by means of urinary hCG test performed at home might be an important option for many women to verify the completeness of an induced abortion.

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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.

Carry J. Hekket

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    Carry J. Hekket, RN, Bloemenhovekliniek, Heemstede, The Netherlands
    Through a short personal impression, and by using material from Sherman de Jesus´
    (Memphis films NL) acclaimed documentary about the ´Bloemenhovekliniek´, this
    presentation will give an insight in to the dilemmas faced by staff working in a specialised
    second-trimester clinic in their day to day work.

Cornelia Helfferich

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    Immigrant women and contraception: Meeting the challenges

    Cornelia Helfferich (Germany)

    Evangelische Fachhochschule Freiburg, Bugginger Strasse 38, 79114 Freiburg i. Br., Germany

    Migration to Germany is often a linked to the family history of migrant women: as marriage migration of young women or migration together with husband, children (and parents). Thus migration implies different realities and different needs for family planning.

    In a study on behalf of the Federal Centre for Health Education, 300 immigrant women (20 to 44 years) from Turkey and Eastern European Countries were included. The results show that patterns of use of contraception are similar to those in the country of origin, but there is the problem of access to information and methods in Germany. Both immigrant groups have a high rate of abortion. Turkish immigrant women tend to limit family size by abortion, but a substantial proportion of abortions are carried out after marriage (which is linked to migration) to postpone the birth of the first child. For women from Easteuropean countries, especially for late repatriates, migration is linked to postponing birth (of the first child or further children) in the period after migration, mostly due to involvement in further education, by using contraception or abortion.

Lotti Helström

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    Ethics and abortion


    Lotti Helström, MD, Karolinska University Hospital , Stockholm


    This lecture discusses attitudes towards induced abortion, held by members of medical staff involved. Most people have a morally and ethically defined opinion about induced abortions. Women in general, often regard induced abortions as something that other women may have. Should they, themselves consider induced abortion, it would be as an exception. Members of medical staff often express that induced abortions are requested by a special and “careless” kind of woman. Among members of medical staff, the free choice of induced abortions is often defended only by alternative dangerous, unsafe abortions, that women otherwise would expose themselves to. Such an attitude may reflect an attempt to avoid confrontation with the fact that induced abortions actually involve that the foetus is killed. The attitude helps the medical staff not to confront the eventual “moral advantage” of the anti-abortionists, who claim that they defend life. Members of medical staff need to carefully reflect on their own attitudes towards killing a foetus and also towards women who request abortions. It must be appreciated that the women who chose induced abortion, in fact are the same kind of woman as those who decide to carry out their pregnancies. With a reflective view, medical staff also has the best tool to help and advise a woman to avoid future abortions.

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    Should ultrasound be shown to the woman?
    Lotti Helström, MD, PhD, Department of Women’s Health, Stockholm South Hospital,
    There is an ongoing discussion whether to show the ultrasound screen or picture to the
    woman and/or her male partner at the pre abortion medical examination or not. It has been
    clamed that the picture might influence her in her decision and force her to feel guilt or
    shame of her wish to terminate her pregnancy. On the other hand the picture might help
    her to realize and clearly view her situation and thus help to the right choice. There is a
    point in regarding the woman as the only individual able to make the right choice and see
    the medical staff only as her servants, serving her with the information that she needs for
    making the complex decision about how to realize her maternity in this specific situation.
    Hers is the choice, to see or not, and to choose the information necessary.

Caitriona Henchion

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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.

Donald Henderson


Stanley Henshaw

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    Global trends in abortion and contraception


    Trends in abortion and contraception: Global overview

    Stanley K. Henshaw, USA

    The long-term worldwide trend toward liberalization of laws governing induced abortion has continued in recent years, though at a slow pace, with significant liberalization since 2005 in Colombia, Ethiopia, Mexi-co City, Niger, Portugal, Spain, Thailand and Togo, while new restrictions in a few countries had relatively little impact.  Nevertheless, about 37% of the world’s population lives in countries where restrictions make it difficult or impossible to obtain a legal abortion.

    The World Health Organization estimates that about 42 million induced abortions occur every year, almost half illegally.  Abortion rates are moderate to high in most developing countries, though a few countries with excellent family planning services or little interest in fertility control have low rates.

    Abortion rates have declined in recent years in a majority of industrialized countries with complete statis-tics, especially in Eastern and Central European countries where rates were relative-ly high. Abortion rates in most industrialized countries are in the range of 7 to 16 abortions per 1,000 women aged 15-44.  Rates would be lower in many developed countries if not for immigrants from developing areas that have relatively high abortion rates.

    Trends in abortion rates to a large extent reflect changes in contraceptive practice. The UN Population Division’s estimate of the proportion of married women of reproductive age using contraception increased from 58% in 1998 to 63% in 2009.  In the more developed regions, the proportion of users remained about the same but there was a shift from traditional methods in favor of IUD, condom and pill. In less developed regions, use of all methods increased except male sterilization.  Abortion rates have not necessarily fallen, however, because more couples are seeking to control their fertility.  Worldwide, the most popular methods are female steriliza-tion, IUD, and contraceptive pill, in that order.

    In the United States, a marked fall in the abortion rate of teenagers since 1995 accompanied greater use of hormonal methods, condoms, and dual methods. Increased contraceptive use and a shift from traditional to modern methods have contributed to declining abortion rates in formerly Soviet-bloc countries.

    In the United States, where half of unintended pregnancies result from imperfect use of contraceptives, increasing acceptance of the IUD promises to reduce the high rates of unintended pregnancy and abortion.

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    The Impact of Religion of Abortion Utilization
    Stanley K. Henshaw, The Guttmacher Institute, New York, USA,

    Three aspects of religion potentially influence abortion practice: religious structures and
    authorities, the effect of religious dogma on individual behavior, and religiosity (the
    intensity of religious belief).
    Religious structures and authorities often influence abortion laws and policies; examples
    are the Catholic Church in Latin America and Islamic authorities in Indonesia.
    Religious dogma can affect abortion utilization by reducing sexual activity outside of
    marriage, influencing the use of contraception, and causing women to continue unwanted
    pregnancies. In practice, however, religious affiliation appears to have little effect even
    when the religions differ in their positions on abortion. In the United States, Catholic
    teenagers are no less likely to be sexually active than are Protestant teenagers, and
    though Catholic women are slightly more likely than other women to use withdrawal or
    rhythm, their contraceptive use is similar in other respects. Similarly, a survey of abortion
    patients found that Catholics were about as likely as other women to have used a
    contraceptive method when they became pregnant, though they were more likely to have
    used withdrawal or periodic abstinence. The abortion rate among Catholic women is at
    least as high as that of Protestant women. Studies in Nigeria and India have found little
    relation between religious affiliation and abortion rates.
    Religiosity, on the other hand, is associated with negative attitudes toward abortion, almost
    without regard to the particular religion. In the United States, religiosity (being a “born-
    again” Christian or attending church frequently) is associated with lower rates of sexual
    activity among teenagers and lower abortion rates, though not with any particular pattern
    of contraceptive use. However, the personality characteristics that influence this religious
    behavior may also reduce the need and inclination to choose abortion.

Wye Yee Herbert

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    Our love affair with misoprostol over the last
    20 years
    Herbert, WY
    The Queen Elizabeth Hospital Pregnancy Advisory Centre, Australia
    TheQueen Elizabeth Hospital Pregnancy Advisory Centre in
    Adelaide, South Australia is agovernment-funded clinic established
    in 1992,providing over 2500 surgical terminations eachyear.
    Four papers published over the last 20 years document our
    implementation of misoprostol use, showing significant
    improvements in service delivery, as well as reduction in
    complication rates.
    Our first study published in 1999 showed that adding
    misoprostol to osmotic dilators at 17–20 weeks of gestation to
    increase passive dilatation of the cervix, markedly reduces the risk
    of perforation of the uterus.
    Our second study published in 2009 compared the outcomes
    of four different peri-operative misoprostol regimens for first
    trimester surgical terminations. Compared to no misoprostol
    regimen, the regimen of 200 lg of oral misoprostol 3 hours
    pre-operatively plus 200 lg of misoprostol vaginally at the end of
    the surgical procedure showed: 90% reduction in difficult cervical
    dilatations, 60% reduction in rate of D&C treatment of retained
    products of conception and 71% reduction in incidence of
    women requiring post-operative contact for concerns.
    In 2011, our third study demonstrated that adding 200 lg of
    oral misoprostol 3 hours before two tablets sublingually every
    half-hour for three doses at 13–16 weeks of gestation further
    reduced difficulty of the operation.
    In 2002, we adopted medical management with misoprostol,
    as first-line treatment for retained products following surgical
    termination. Our study published in 2009 showed that the
    regimen of 200 lg of misoprostol orally or sublingually three
    times a day for six doses was 93% effective, and reduced the
    D&C rate by 79.6% from 1.18% to 0.24%.

Leila Hessini


Ragnhild Hjertberg et al.

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    Women’s experience of home-abortion

    R. Hjertberg, M. Jahnson, M. Jarkander-Rolff, K. Lindelöw, I. Rosengren (Sweden)

    Octaviakliniken, Stockholm, Sweden

    Background. Medical abortion with the use of the antiprogestin mifeprostone combined with a prostaglandin has been approved in Sweden since 1992. Misoprostol has been shown to be the most optimal prostaglandin analogue and since 2006 it is possible to perform the abortion at home which is both safe and efficient. (Gemzell Danielsson et al). There has been an increasing demand from women to perform medical abortion at home.

    Objective.To evaluate women’s experience of home-abortion and also to evaluate if our routines with counselling, possibility of advice on the telephone met the women’s need of safety.

    Methods.100 questionnaires regarding given information, feeling of safety, acceptability, and complications, were given to women who chose to use misoprostol at home. Response rate was 56%.

    Results. Mean age 34 yrs (18-46). The information regarding the procedure given from doctor and nurse was sufficient (98%). 85 % felt very safe and 15% rather safe in the home-setting. 100% had enough time for questions before the abortion and 98 % were satisfied with the telephone-contact during the day. 83% had good and 8% had sufficient analgesics during the day. The procedure went as expected although 44% found it not as painful as anticipated.

    Conclusions. Home-abortion with the use of misoprostol presents a good alternative for many women. It is safe and has a high acceptability. However it demands enough time for detailed counselling and good routines at the clinic as well as written information to the women.

Pak Chung Ho


Benjamin-Immanuel Hoff


Lesley Hoggart

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    An in-depth study of abortion and repeat abortion: young women’s decision-making, experiences, feelings and post-abortion behaviour.

    Lesley Hoggart, Principal Research Fellow School of Health and Social Care, Univ. of Greenwich, UK

    This paper reports on a research project (Hoggart and Phillips 2010) that studied teenage abortion and repeat abortion in London, UK. This research set out to explore factors that might help explain what are currently viewed as disproportionately high rates of teenage abortion, and repeat abortion, in London. This required gathering data on sexual behaviour leading to unintended and unwanted teenage pregnancies; on teenage experiences of abortion; and on post-abortion sexual behaviour.

    Utilising a qualitative methodology, interviews were conducted with three groups of participants: focus groups with 14-16 year old girls in London schools; in depth interviews with sexual health practitioners; and in depth interviews with teenagers that had terminated pregnancies. The theoretical approach adopted was to examine how abortion decisions and experiences are mediated by value systems, and localised cultural and social norms (Harden and Ogden, 1999,  Henderson, 1999, Hoggart et al., 2006, Lee et al., 2005, Lie et al., 2008, Pearson et al., 1995).

    One of the key findings of the research was that the mindset of pregnant teenagers and the extent to which they make an abortion decision by and for themselves may influence their feelings and sexual behaviour following the abortion. Abortion is viewed as ‘immoral’ by many young women in the UK, and this view can make abortion decision-making difficult and stressful. Feeling that abortion is ‘immoral’ is likely to contribute towards any feelings of regret and/or guilt that young women may have following an abortion.

    The research also indicates that young women who are able to make their own decision for their own reasons are more likely to establish an effective contraceptive regime following an abortion, than young women who may have been reluctant to end their pregnancies and do not have any plans for their own futures. The research findings have important implications for post-abortion services. They suggest that complex issues would need to be explored around the time of the abortion in order to offer an appropriate individualised post-abortion service.

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    Marie Stopes International UK Abortion Study: "And then I fell pregnant with my second child". Young women's accounts of multiple unintended conceptions

    Lesley Hoggart, Victoria Newton The Open University, Milton Keynes, UK -

    Objectives: The overall aim of the study was to explore the behavioural, social and service related factors that are associated with one or more unintended and unwanted pregnancy amongst young women (under 25 years). The aim of this paper is to explore the contraceptive journeys and decision-making of young women who have had more than one pregnancy resulting in abortion and/or live birth. Methods: Data is drawn from a longitudinal investigation using in-depth qualitative interviews with 36 young women, 12 of whom had experienced more than one unintended pregnancy. Results: A number of factors contributed towards participants experiencing more than one unintended pregnancy. Of particular importance, was their difficulty in finding a method of contraception they were happy with. For many this was combined with unpredictable personal lives. Some spoke about their difficulty in addressing their ‘need' for contraception due to complex sexual relationships. For each pregnancy, they discussed their decision-making with regard to continuing or terminating the pregnancy based on individualised and situational circumstances. However, their accounts of becoming unintentionally pregnant on more than one occasion were characterised by feelings of shame. Abortion stigma was an integral part of the young women's reflections about their experiences, even when they believed that they had made the right choice. Many were left with feelings of guilt that they had been in the situation more than once. Conclusions: The difficulties that some women experience establishing a contraceptive regimen need to be recognised and respected. It would be helpful to work towards continuing flexible and individualised support, recognising that a contraceptive choice made at the time of abortion may be subject to change. Condoms should be routinely provided following an abortion, and women should also be channelled into their local contraceptive services. Abortion stigma remains an issue that needs to be addressed.

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    Marie Stopes International UK Abortion Study: "I didn't think it would happen to me". Young women's accounts of pre- and post- abortion contraceptive use.

    Lesley Hoggart, Victoria Newton The Open University, Milton Keynes, UK -

    Objectives: The overall aim of the study was to explore the behavioural, social and service related factors that are associated with one or more unintended and unwanted pregnancy amongst young women (under 25 years). In this paper we explore, qualitatively, the narratives of young women who - for a multitude of reasons - have experienced unwanted pregnancy. Methods: A longitudinal investigation using in-depth qualitative interviews with 36 young women who have had one or more abortion. The study is funded by, and being undertaken in collaboration with, Marie Stopes International. Results: Participant's accounts of unintended and unwanted pregnancy highlight the diverse situational and behavioural scenarios in which women become pregnant when they do not want to be. Most participants in the study had been actively attempting to avoid pregnancy but had experienced a contraceptive failure due to improper use or a misunderstanding about the method. Other participants were sure they had used their method correctly and were uncertain how and why they became pregnant. For those women who were aware they were at risk of an unintended pregnancy, most did not seek emergency contraception. These women recounted finding it difficult to access emergency hormonal contraception (EHC), or being worried about having to pay for it. There was a clear lack of knowledge about the emergency IUD. For the few women who had accessed EHC, there was very little evidence of advice regarding the emergency IUD being given by their provider. Conclusions: An advance supply of EHC would enable women to have it to hand should the need arise. General awareness about the IUD as a method of emergency contraception needs to be raised. Providers should discuss the emergency IUD with women seeking EHC, especially for those who are close to the EHC time limit.

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    ‘Trust me to be the awkward one’: young women’s
    experiences with the contraceptive implant
    Hoggart, L; Newton, V
    University of Greenwich, UK
    This paper will present the findings of a recently completed
    qualitative study examining ‘premature’ implant removal amongst
    young women (aged 16–24) in London. The paper will explore
    young women’s contraceptive journeys with the implant and
    examine how and why the implant was initially selected as a
    contraceptive of choice and then removed within one year or less
    of fitting. The focus of the paper is on the complex process of
    contraceptive decision-making, and how this may change as a
    result of bodily experiences subjectively associated with the
    implant. The paper will begin by discussing young women’s
    reasons for choosing the implant. We will then examine how
    individual and collective experiences of the method contribute to
    the decision to have the implant removed. These experiences
    include a range of perceived side effects, issues concerned with
    bodily control, and changes in sexual relationships, as well as
    service related factors. The research has shown that young women
    who have made a positive choice in favour of the implant will
    tolerate a considerable amount of discomfort before reaching a
    ‘tipping point’ at which they decide to have the implant removed.
    During this period they often feel unsupported and isolated, and
    even attach blame to themselves for the ‘failure’ of their body to
    accept the implant. We also suggest that negative experiences and
    a lack of support may contribute towards negative attitudes
    towards other long-acting reversible contraceptive methods.

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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.

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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.

Manuelle Hurwitz


T. Husson

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    Who should control the effectiveness of the procedure? I. BANGOU
    (Guadeloupe) maintained that it should be the specialist and the general
    practitioner who started the treatment.
    How should it be controlled? T. HUSSON (France) indicated that a good way of
    ensuring the success of the method is to measure hCG 10 days after
    misoprostol. It should be below 75% of the initial value before the abortion. An
    ultra-sound at follow-up is also an excellent method.

    During the discussion, C. GEMZELL reported that Sweden has excellent results using mifepristone 600 mg + gemeprost 1 mg, administered vaginally. Some
    centres perform 70% of their abortions in this way.

    Many speakers from the floor suggested that the method should be made
    easier, with the misoprostol being taken at home.