Ljubljana, 2-5 octobre 2014: „Task sharing in Abortion Care“

  • 08:00-
  • 09:00-
    • Kristina Gemzell-Danielsson, SE
    • Andreja Štolfa Gruntar , SI
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      Safe abortion – a moral obligation: why is it so difficult to follow the evidence?

      Ann Furedi bpas, London, UK - ann.furedi@bpas.org

      We are used to the anti-choice movement adopting the moral high ground on abortion. Latterly, they have moved on from morals to make false claims that abortion damages women. We note that, increasingly, our opponents adopt what they perceive to be claims that appeal to feminists. Abortion, they say, damages women's reproductive health by triggering breast cancer and causing infertility. Abortion when a woman is pregnant after rape , is they say, a second violation. They assert that abortion is responsible for a wide range of mental illnesses. While we consider abortion to be a benefit to society, and especially to public health, our opponents claim the contrary arguing that abortion results in the brutalisation and coarsening of communities. In a world that increasingly looks to base its values on ‘evidence', it should be relatively straightforward to rebut these claims. The facts are on our side. Yet it remains difficult to convince people that: - in a legal, safe environment abortion does no harm - providing, and being provided with abortion, can be morally driven - support for reproductive choice must be a core principle for a world that believes in individual freedom. These principles will not be resolved solely by a battle of evidence - we need to win hearts as well as minds.

  • 09:45-
    • Bojana Pinter, SI
    • Sam Rowlands, GB
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      Non-physician providers’ roles in access to safe abortion care: an overview of evidence

      Bela Ganatra WHO, Geneva, Switzerland - ganatrab@who.int

      Unsafe abortion continues to constitute a major mortality and morbidity burden especially in the developing world (21.6 million unsafe abortions; 13% of maternal deaths). Access to safe abortion is limited by numerous barriers but one of the most critical is the lack of trained providers. Many countries limit abortion service provision to specialist doctors. However, most developing country regions suffer from a critical short supply of OBGYNs , generalist doctors and even midwives. Areas with a critical shortage of health service providers also have the highest burden of unsafe abortion-related deaths. Expanding the provider base to include a range of other health workers is a recognized strategy to expand access to health services and scale up implementation of interventions of public health significance including for safe abortion care. Medical abortion as an effective and recommended technology has made it even more relevant to expand health workers' roles in provision of safe abortion care and to look at self-assessment as ways of reducing the need for health worker time and resources. There is a growing body of research evidence on the issue. Additionally, in several countries use of some cadres of non-physician providers is already part of practice (though often not of policy). The Department of Reproductive Health and Research at the WHO is currently reviewing and synthesizing evidence related to task shifting and task sharing in the provision of safe abortion and postabortion care with the aim of developing specific recommendations on the issue. The evidence base includes comparative studies, qualitative data and country case studies to synthesize programmatic experience form countries where non-physician providers have already been providing such care. The presentation will give a broad overview of the evidence on this topic and the process of the guidelines development.

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      From hospital to community

      Sharon Cameron1,2 1NHS Lothian, Edinburgh, UK, 2University of Edinburgh, Edinburgh, UK - sharon.cameron@ed.ac.uk

      There is growing recognition that termination of pregnancy (TOP) services should be able to offer both high quality contraceptive advice and provide women with the most effective methods of long-acting reversible of contraception (LARC), to start immediately after the TOP. Women who choose to start LARC immediately post TOP have a significantly reduced risk of having another TOP than counterparts choosing less effective methods. In many countries, TOP services are traditionally delivered from hospital departments of obstetrics and gynaecology where staffing of the labour ward usually takes priority. Junior medical staff delegated to undertake the consultations of women requesting a TOP may be disinterested in TOP care and may lack specialist contraceptive knowledge and training to insert the most effective LARC methods. In contrast, staff working in specialist contraceptive services (family planning/ sexual and reproductive health) in the community possess the knowledge and skills to offer the most effective methods of contraception. Furthermore, early TOP can clearly be delivered from the community setting. This raises the question of whether higher LARC uptake rates and as a consequence, fewer subsequent TOPs could be achieved if more TOP care was delivered from the community specialist contraceptive setting.

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      Women on Web

      Rebecca Gomperts Women on Waves, Amsterdam, The Netherlands - gomperts@womenonwaves.org

      Women on Web is a telemedical abortion service for women with an unwanted pregnancy up to 9 weeks living in countries without safe abortion care. Three studies looked at the outcome and factors influencing the surgical intervention rate after the medical abortion provided to women through telemedicine. One retrospective study analyzed information from 484 women who received a medical abortion at their home addresses in 2006 and 2007. Sixteen of the 265 (6.0%) women who provided follow-up information reported that they did not use the medication. Of the remaining 249 women who did the medical abortion at home, 13.6% reported having a surgical intervention afterwards and 1.6% reported a continuing pregnancy. After the follow-up rate increased from 54.8% to 77.6% of the cases, 12.6% of the women reported they did not take the medication and only 6.8% of the women having the medical abortion at home underwent a surgical intervention afterwards. Another study analyzed the influence of geographical location on the outcome of the 2323 women. High rates were found in Eastern Europe (14.8%), Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%; p=0.000). The third study evaluated the data from women living in Brazil.. Of the 370 women who used the medicines, 307 women provided follow-up information about the outcome of the medical abortion. Of this group, 207 (67.4%) of the women were up to 9 weeks pregnant, 71 (23.1%) were 10, 11 or 12 weeks pregnant, and 29 (9.5%) of the women were at least 13 weeks pregnant. There was a significant difference in surgical intervention rates after the medical abortion at the different gestations (19.3% at <9 weeks, 15.5% at 10-12 weeks and 44.8% at >13 weeks, p=0.06). However, 42.2% of the women who had received a surgical intervention afterwards did not have any symptoms of a complication. This research shows that medical abortion can be safely and effectively provided to women themselves through telemedicine. Surgical intervention rates after the medical abortion provided via telemedicine reflect local medical practices. The risk of surgical intervention and ongoing pregnancy after home medical abortion only tends to increase after 12 weeks of pregnancy.

  • 10:45-
  • 11:15-
    • Mirella Parachini, IT
    • Allan Templeton, GB
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      Characteristics of women who obtain legal abortions across countries

      Gilda Sedgh, Akinrinola Bankole, Susheela Singh, Anna Popinchalk Guttmacher Institute, New York, NY, USA - gsedgh@guttmacher.org

      Context: Abortion levels may differ between subgroups of women because of variations in the level of unintended pregnancy and in the likelihood that women will choose to terminate their pregnancies if they become pregnant unintentionally. Understanding differentials in levels of abortion according to women's characteristics can shed light on the circumstances surrounding the reasons leading to abortion. Methods: Data from government statistics on characteristics of women who obtain legal abortions were obtained from countries where legal abortion is generally available and reliable abortion statistics are compiled. We compute the percentage distributions of abortions and abortion rates by selected characteristics of women, particularly age, marital status and parity. For a few countries, we present the proportion of abortions that are obtained by immigrants from other countries. Since the adolescent years are a particularly vulnerable period for many females, we highlight adolescent abortion rates and the proportion of pregnancies among adolescents that end in abortion across countries. Results: In general, abortion rates are higher among 20-24 year olds than any other age group. In most countries with reliable evidence, married women obtain a larger proportion of abortions than unmarried women. More than half of abortions are obtained by women with at least one child. Although adolescents account for a high proportion of abortions in some countries, they do not obtain a disproportionate share of procedures. The proportion of teen pregnancies that end in abortion varies widely across countries, even among countries with liberal abortion laws. Conclusions: Abortion rates vary across socio-demographic subgroups of women. However, within all subgroups examined here, some women will obtain an abortion when faced with an unintended pregnancy.

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      Abortion in Spain: recent developments

      Alberto Stolzenburg ACAI, Spain

      The current 2010 Law on Sexual and Reproductive Health and Voluntary Termination of Pregnancy recognizes for the first time abortion as a fundamental women's right. It clearly sets the health dimension of this right and provides legal certainty as well. Women have access for free to abortion on demand up to 14 weeks, in case of maternal and fetal pathology up to 22 weeks and beyond 22 weeks for very severe and incurable diseases. When the majority of Spanish society has gone in the last years through democratic values regarding abortion, the Government strives to change the current law even though 80% of the population reject the draft law and 68% of their own voters believe that women should decide themselves. Meanwhile the abortion rate in Spain keeps stable and is similar to other countries of Western Europe. The preliminary draft of Justice Minister Gallardón specifies these and other realities and seeks to placate the most reactionary wing of the Spanish right. In this way, abortion will be allowed only under two conditions: rape and serious maternal diseases, eliminating fetal deformations as a reason. At the same time, it establishes a medical and legal journey of such magnitude, that in practice it makes abortion impossible even for the legal reasons mentioned. In addition, this law penalizes severely health professionals, deepening the stigma and the legal uncertainty that have marked them. The draft law is pending approval by the Council of Ministers. An approval that has been awaited by the strong social and political opposition and internal contestation among the Executive and the ranks of the Popular Party. If finally the Parliament approves the draft this year, Spain would have in 2015 the most restrictive law of the democratic era.

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      Developments in legal regulation of abortion in Europe

      Adriana Lamackova Center for Reproductive Rights, New York, USA - ALamackova@reprorights.org

      While most European countries continue to provide abortion without restriction as to reason and/or on broad grounds, including socio-economic grounds, the past few years have seen a dramatic rise in legal proposals aiming at restricting abortion laws. One type of proposal seeks to eliminate legal grounds for abortion, while the other type of proposal seeks to impose procedural barriers on access to abortion such as mandatory waiting periods and biased counseling requirements. Refusals of care on the grounds of conscience are another procedural barrier significantly affecting women’s access to legal abortion services that has been on the increase in Europe. This presentation will provide an overview of these restrictions that have been adopted in some countries. It will also address standards developed by United Nations and regional human rights bodies, as well as by the World Health Organization with regard to access to abortion.

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      An update on unwanted pregnancy from Slovenia - with special focus on adolescents

      Bojana Pinter Division of Ob/Gyn, University Medical Centre, Ljubjana, Slovenia - bojana.pinter@guest.arnes.si

      Background: In Slovenia abortion has been permitted on request from 1977. The liberalization of the law was a consequence of improvements in vacuum aspiration technique in 1964 at the Dept. of Ob/Gyn in Ljubljana, Slovenia. This technique had been successfully presented to the world's professionals at IPPF conference in Santiago, Chile, in 1967 and evaluated in the American-Yugoslav joint project "Abortion study Ljubljana" in 1971−1973. Content: Abortion rates in Slovenia have decreased in the last thirty years: in 1980 the abortion rate was 40.3/1000 women aged 15−49 years, in 2012 8.7/1000. Among adolescents aged 15−19 years abortion rates decreased from 25.3/1000 in 1980 to 5.8/1000 in 2012. A decrease in unwanted pregnancies was evident in spite of an increase in sexual activity of adolescents. According to representative studies on sexual behaviour of Slovenian secondary-school students in the years 1996, 2004 and 2012 the percentage of sexually active students aged 17 years increased from 45% (male) and 44% (female) in 1996 to 53% (male) and 57% (female) in 2014. The decrease in abortion rates is in correlation with an increase in use of effective contraception (condom, hormonal contraception or double method): from 75% in 1996 to 85% in 2012, and a decrease in students using no contraception: from 19% in 1996 to 7% in 2012. In addition, contraception is widely accessible through outpatient Ob/Gyn services and fully covered by general health insurance. In the last twenty years the knowledge on contraception among providers has increased. In spite of the fact that sexuality education in schools is not mandatory, pupils and students get some information through special programmes held in schools. In addition, the media, on the subject of contraception, mostly work in collaboration with professionals. Conclusions: The decrease in abortion rates in Slovenia is the result of accessible services and increased knowledge of contraception among providers and users.

  • 12:45-
    Lunch Session: Sponsored Symposium: Exelgyn - Update in medical abortion
    • Elisabeth Aubény, FR
    • Allan Templeton, GB
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      25 years of mifepristone

      Kristina Gemzell Danielsson

      Karolinska Institutet/ Karolinska University Hospital, Dept of Woman and Child Health, Division of Obstetrics and Gynecology, Stockholm, Sweden - Kristina.Gemzell@ki.se

      Based on the combined regimen of a progesterone receptor modulator, RU 486, developed by Roussel Uclaf and the Nobel prize awarded discovery of prostaglandins, medical abortion with mifepristone and a prostaglandin analogue was developed into a safe and effective method for induced abortion in the 1980ies. A team of researchers led by Pr. Baulieu was critical in the development of mifepristone (RU486) as was the French Ministry of Health. Further researches from Pr. Bygdeman’s team in Sweden described the combined regimen with prostaglandin. Then the WHO and later the company Exelgyn further endorsed this method which provided women with an alternative to surgery. Since the 1980ies research has focused on improving the regimen and care of medical abortion. Today the prostaglandin analogue of choice is misoprostol and medical abortion is a safe option for termination of pregnancy at all gestational lengths. An increasing number of women worldwide benefit from this development. Besides even if there are still differences from country to country not only in access to medical abortions (legal situation, home use, gestational age) but also in the clinical routines of medical abortion care (protocol, reflection delay), Medical methods for termination of pregnancy tend to replace the surgical options in many countries. There is also an increasing recognition that medical abortion can improve access to safe abortion in countries with restrictive abortion laws or lack of abortion providers. However, several barriers remain that limit global access to safe abortion services. Simplifying medical abortion could potentially contribute to increased access and acceptability. Possible approaches include the option to self-administer misoprostol at home, also beyond 9 weeks of gestation. Another possibility is task sharing with midlevel providers to allow these health care professionals to be more involved with the care of healthy women undergoing medical abortion. These possibilities have major impact to increase access to safe induced abortion in countries were medical resources are scarce.

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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 - oskari.heikinheimo@helsinki.fi

      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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      Comprehensive pain management in medical abortion

      Christian Fiala

      Gynmed Clinic, Vienna, Austria - christian.fiala@aon.at


      Management of pain during medical abortion has been given insufficient attention in clinical practice as well as in research. For example neither pain nor its treatment are systematically reported in clinical trials: a literature research on Pubmed revealed 1 459 publications on medical abortion from 1988 until 2011, but only 18 trials reported pain when comparing different treatment regimens using mifepristone and misoprostol in first trimester. This shortcoming reflects a neglect of the individual pain perception, yet pain remains a decisive factor for women in the decision making process of abortion. Comprehensive pain management in medical abortion should be based on the principles of general pain management:

      Avoidance of pain

      As a first step, measures should be taken to avoid pain as far as possible:

      * Unrestricted access to abortion would enable women to come as early as possible. Studies show that women’s experience of pain increases with gestational age. Reducing restrictions in access are therefore an important pain reduction measure.

      * Induction of contractions should be limited as far as possible. Therefore the lowest effective dosage of the prostaglandin should be given.

      * Free choice of the method is important because women report less pain when the choice of early medical abortion has been their own decision.

      * Full and accurate information should be given on what to expect and what to do in case of pain.

      * Women should feel relaxed and safe. Taking misoprostol at home is a pain reducing measure for many women.

      Non-medical pain treatment

      Classical hot water bottle, choosing the preferred body position and activity are effective aspect.

      Medical pain treatment

      * NSAIDs such as ibuprofen or diclofenac should be an integral part of pain management. They do not interfere with medical abortion treatment.

      * Codein or tramadol should be available as backup.

      Medication should be started as early as possible or even be given as prophylaxis before intake of misoprostol. (absorption of misoprostol is very fast and the first contractions can occur already within 15 minutes.) Providers should also make sure that patients have analgesics at home.

      Reference: Pain during medical abortion, the impact of the regimen: A neglected issue? A review.

      Fiala C, Cameron S, Bombas T, Parachini M, Saya L, Gemzell-Danielsson K.

      Eur J Contracept Reprod Health Care. 2014 Sep 2:1-17.

  • 14:00-
    W01: ESC- Unplanned pregnancy in adolescents, Linhart Hall
    • Teresa Bombas, PT
    • Kristina Gemzell-Danielsson, SE
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      Barriers in access to contraception for minors

      Katarina Sedlecky Institute for Mother and Child Health Care of Serbia, Belgrade, Serbia - ksedlecki@gmail.com

      Use of effective contraception is one of the crucial issues in the sexual and reproductive health care for minors. However, far too many adolescents are at a risk of unplanned pregnancy, due to the many and varied factors that hinder them from recognizing and fulfilling their needs in the field of safe sexual behavior. The barriers can be grouped into macro and micro determinants. Among macro determinants the most significant are the sexual and reproductive health (SRH) legislative framework, socio-cultural environment, economic conditions, public awareness of the rights and needs of minors in relation to SRH, sexuality education, availability of appropriate healthcare services and access to modern contraceptive choice. The general and individual biological and psychosocial characteristics of adolescents, the influence of the family and peers, as well as school performance and aspirations comprise the major micro determinants of the access of contraception for minors. Due to different historical, sociocultural, political, and economical conditions, a diversity exists across Europe in means and motives of teenagers to use reliable contraception, societal acceptance of sexual activity among teenagers, commitment of different European countries to prevent teenage pregnancy, prevalence of health risk behaviours among teenagers, as well as in sexual and reproductive health care for migrant population and vulnerable groups. Recognition of SRH needs of minors, easy access of contraception, reimbursement of contraceptive methods and higher prevalence rates for medical contraceptive methods usually result in low teenage pregnancy rates.

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      Abortion in minors

      Gabriele Merki-Feld University Hospital, Zürich, Switzerland - gabriele.merki@usz.ch

      Teenage pregnancies must be viewed in the context of sexual and reproductive health (SRH) and rights, with the understanding that the social environment ha a major influence. Most teenage pregnancies in Europe occur unplanned. Therefore access to effective contraceptive methods is a critical point in the prevention of abortions in minors.The decision to pursue or end an unintended pregnancy is based on factors like cultural and religious background, access to safe and legal abortion, access to confidential counselling and support from partners, friends and parents. The availability of legal abortion, the covering of costs and the question of parental consent varies across Europe. Very little is known about factors asscociated with coping afterwards. Across Europe there are countries with very high abortion rate in teenagers, especially in some Northern and Eastern European countries. The majority of southern European and western European countries report numbers below the EU mean of 12.2/1000. Interestingly there is in contrast to other countries a balance between teenage live birth and teenage legally-induced abortions in the UK. Also there are differences between countries. There is a clear trend to decreasing number of abortions in minors in most European countries.

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      Parental authorisation of abortion

      Sam Rowlands1,2 1Bournemouth University, Bournemouth, UK, 2Dorset HealthCare, Bournemouth, UK - srowlands@bournemouth.ac.uk - www.samrowlands.net

      Parental authorisation/notification requirements operate in 34/203 jurisdictions around the world; in the USA 38/50 states require parental involvement. Most of the abortion laws requiring parental involvement insist on one parent giving their consent; some require only that a parent is notified. The age threshold for parental involvement is usually either 16 or 18. Young people usually achieve mental capacity to consent to treatment by the age of 14. Adolescents have the same reproductive rights as adults. Health care professionals have a duty to protect young people from exploitation. Adolescents should expect to have their confidentiality respected and be free to make their own decision about whether or not to continue a pregnancy. A young person’s decision to involve their parents/guardian should be determined by the quality of the family relationship, not by laws. Compulsory parental notification is a strong barrier to a young person’s access to abortion care. Coercion to continue a pregnancy has an adverse psychosocial impact on young people. Breaching confidentiality risks violence and abuse in non-supportive families. Introduction of parental involvement laws in US states has been shown to result in out-of-state travel of young people and an increase in second trimester abortions in this age group. Based on scientific evidence and on basic human rights for young people, those sections of abortion laws insisting on parental involvement should be repealed.

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      The time of an abortion is a window of opportunity for contraceptive counselling. Clinical practice shows us that we can and must provide contraceptive counselling at the first abortion appointment and not leave it for follow-up. There were some concerns that during the time of an abortion the women will be too distressed with the information regarding the abortion decision and abortion method and so will not able to consider the information about contraception. The women and the couples must be informed that fertility returns rapidly after first trimester abortion. Well informed women were able and motived to choose and start a contraception method at the time of the abortion. Starting a contraceptive method at the time of the abortion is safe and good practice. For medical abortion, combined hormonal contraception, oral progestogen, injectable and implant could be start or inserted on the day of misoprostol administration. For surgical abortion these methods could be started or inserted on the day of the procedure. For surgical abortion, an intrauterine device could be inserted at the time as the operation.

      Immediate insertion of an IUD/IUS is safe, results in higher method uptake compared to interval insertion but the expulsion rate seems to be marginally higher. A randomized trial showed that IUD/IUS insertion as early as one week after medical abortion is safe and results in high method uptake and no difference in expulsion rate compared to the insertion at 3-4 weeks. Providing information, updated practices and access to contraception at the time of the abortion will contribute to an immediate start of a contraceptive method and to a lower risk of repeated abortion.

    W02: Advocacy and training, Kosovel Hall
    • Maria Francès- Kircz, NL
    • Vicki Saporta, US
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      Empowering providers and patients as advocates

      Vicki Saporta National Abortion Federation, Washington, DC, USA - vsaporta@prochoice.org

      Although abortion has been legal in the United States for 41 years, we continue to see attacks on women's access to abortion care. In the last few years, anti-choice legislators have made restricting abortion access a priority and we have seen a record number of anti-abortion restrictions being introduced and passed at the state and federal levels. The stigma surrounding abortion has also contributed to this hostile political environment and a lack of understanding for abortion providers and women who access abortion care. One of the most effective ways to fight these attacks and work to dispel stigma is to ensure that the voices of providers and patients are included in the public debate about abortion. We have helped women come forward and speak out about their decision to obtain abortion care and to explain how proposed restrictions would have affected their ability to make the decision that was best for them. These stories have been successful in combating political stigma and challenging restrictions. We must continue to help women share their abortion stories. We have also worked to train and mobilize abortion providers to advocate with lawmakers and speak to the media. Abortion providers are invaluable messengers, who can offer expert medical testimony and dispute false claims made by abortion opponents. Abortion providers are also uniquely qualified to discuss the public health consequences of unsafe abortion and the necessity of ensuring that abortion care is safe, legal, and accessible.

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      Integrating abortion and contraception training into medical education: the Family Planning Fellowship and Ryan Residency Training Programs in the US

      Uta Landy The Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences; University of California, San Francisco, San Francisco, CA, USA - landyu@obgyn.ucsf.edu

      Although abortions were legalized in the United States in 1973, the focus was on service access, not training. As a result, the number of teaching hospitals offering abortion services and conducting research declined steadily. A training mandate was finally passed by the US professional standard setting organizations in 1995 when a lack of trained physicians was noted. The mandate has been affirmed regularly despite the increasing political interference with abortion care and teaching. The Fellowship in Family Planning was founded to ensure future generations of leaders for abortion services, research, teaching and advocacy. During the past 23 years, its graduates have ensured the integration of family planning into the curriculum of medical students and postgraduates, conducted seminal research in abortion and contraception, contributed to the family planning work of national and international governmental and non-governmental organizations and become advocates for evidence-based policies. A parallel organization, the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning, was founded in 1999 to support academic programmes in complying with the new training standards. Since its inception, it has initiated formal programmes in 78 departments of obstetrics and gynaecology to ensure the clinical competence in evidence-based approaches in family planning and abortion for future generations of OBGYNs. Systematic training is an essential aspect of ensuring that future physicians are clinically competent, understand and contribute to research, understand the medical, social and psychological aspects of uterine evacuation and contraception and become advocates for evidence-based policies.

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      UK Faculty programme

      Katherine Guthrie City Health Care Partnership CIC, Hull, UK - k.guthrie@nhs.net

      Training in abortion provision is within the postgraduate specialty training programmes of the Faculty of Sexual and Reproductive Healthcare (FSRH) and the Royal College of Obstetricians and Gynaecologists (RCOG). These cover medical abortion and 1st trimester surgical abortion. The RCOG programme does not cover local anaesthetic procedures. The College has an optional advanced programme to cover local anaesthetic procedures and later gestations for surgery. The Faculty also has a training programme accessible to doctors and nurses who wish to undertake further training in this field. Conscientious objection within the National Health Service plus the shift in the provision of care to non-NHS providers has created a challenge in accessing training.

    W03: Eastern-European Alliance for Reproductive Choice. - Advocating for the access to safe abortion in Eastern European and Central Asian region: continuing challenge. , Room E1-2
    • Elisabeth Aubény, FR
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      Sustainability of medical abortion services in the Caucasian region

      Tamar Tsereteli Gynuity Health Projects, Tbilisi, Georgia - ttsereteli@gynuity.org

      Caucasian women, as residents of former Soviet republics, have had widespread access to legal abortion for almost one hundred years. Abortion rates are high, and many women rely on abortion as their primary means of fertility regulation. Current laws provide for abortions up to 12 weeks’ gestation without restrictions, and up to 22 weeks’ gestation for broad medical and selected socioeconomic grounds. Until recently, surgical abortion was the only option available to women in Caucasian countries. Very few doctors were trained in medical abortion provision, most women did not know what medical abortion was or had an incorrect understanding of the procedure and there were no recommended national protocols doctors could consult if they were interested in providing the service. In addition, mifepristone was not always available: if registered at all, it often was unavailable outside of the capital cities. In 2006, Gynuity Health Projects launched a series of collaborative activities in Armenia, Azerbaijan and Georgia with the goal of increasing the availability of safe abortion services and access to medical abortion. Activities included training for doctors and nurses on medical abortion, clinical research studies, dissemination meetings to present study findings, development of Information, Education and Communication (IEC) materials for women and assistance in developing national protocols. In some cases data generated from the clinical studies supported mifepristone registration and informed national protocols. Between December 2011 and June 2013, Gynuity conducted studies in Armenia and Georgia to assess ongoing provision of medical abortion services and evaluate the quality of care provided at former research sites. This presentation will describe how programme components have contributed to sustainability of medical abortion in the Caucasian region.

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      Using research to increase access to medical abortion in Uzbekistan

      Diffuza Kurbanbekova Women's Wellness Center, Tashkent, Uzbekistan - dilfuzabegim@yahoo.com

      The Republic of Uzbekistan, located in Central Asia, is the most populous country in the region with 28 million people. More than a quarter of the population are women of reproductive age. Abortion in Uzbekistan has been legal for over 50 years and abortion services are available without restriction in the first 12 weeks of gestation. Abortion in the second trimester (up to 24 weeks) is available only on broad medical and select socioeconomic grounds. Until recently, the prevailing methods for termination of pregnancy were manual vacuum aspiration (MVA) using outdated equipment and dilatation and curettage (D&C) under local anaesthesia. Although mifepristone has been registered in the country since 2005, there were no national guidelines on medical abortion provision. In addition, the lack of trained providers and absence of an established distribution system for mifepristone inhibited its use on a wide scale. In 2007, Gynuity Health Projects launched a series of collaborative activities in Uzbekistan with the goal of increasing access to medical abortion services in the country. Through its clinical research projects and trainings, Gynuity introduced an evidence-based regimen, trained providers in provision of early medical abortion and expanded access to medical abortion services by conducting a study on an alternative method of follow-up. Additional collaborative activities included dissemination meetings to present study findings and assistance in developing national protocols. This presentation will describe how clinical research has contributed to increased access to medical abortion in Uzbekistan.

    W04: Counseling, Room E3-4
    • Ann Furedi, GB
    • Nausikaä Martens, BE
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      Decision assessment and counseling in abortion care

      Alissa Perrucci University of California, San Francisco, San Francisco CA, USA - perruccia@obgyn.ucsf.edu

      In this session participants will learn an approach and framework for conducting pre-abortion decision assessment and counseling that is applicable across all types of decision conflict and ambivalence as well as decision certainty. I will outline the components of this model of counseling and how it corresponds to the process of informed consent in the practice of medicine. I will also describe my philosophy of education and training for counselors in this field. Decision assessment and counseling is an approach and framework that is grounded in patient autonomy and agency and follows the fundamental principle that the patient has the answer to her dilemma. The approach emphasizes techniques for active listening, bracketing of assumptions, and self-reflection. The framework provides a conversational map as well as specific skills for working with challenging patient statements. Participants will be able to describe the components of the framework, analyze their own style of counseling in the context of this model, and plan for implementation of new skills for working with emotional, spiritual and moral conflict with pregnancy decisions.

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    W05: Free communication, Room M1
    • Sharon Cameron, GB
    • Françoise Dedrie, BE
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      Objectives: The purpose of this pilot study was to ensure that the insertions and early expulsion rates were acceptable in order to plan a larger trial with the IUB.

      Methods: This was an observational pilot case series. The inclusion/exclusion criteria were similar to those for non-study patients receiving IUDs. Women aged 18-50 requesting intrauterine contraception were enrolled. Exclusions included recent pelvic inflammatory disease, genital malignancy and anaemia. The main outcome measure was expulsion by the 6-8 week follow-up visit. Ease and pain of insertion as well as complications and side-effects were also recorded.

      Results: 50 women had IUBs inserted between January and April 2014 by a single clinician in Canada. Only 6 (12%) had had a previous birth and 16 had had previous IUDs. There were no failed insertions and 43 (86%) insertions were found to be "easy". The mean pain score for insertion was 5.3/10. There were 32 follow-up visits 6-8 weeks post-insertion by May 2014. There were 8 expulsions (one post medical abortion and accompanied by a "gush of blood"), there was one removal for pain and bleeding and no other complications.

      Conclusions: Including the first study of 15 women, there are now data on 65 insertions with no problems, so the insertion technique and equipment for IUBs can be considered acceptable. The early expulsion rate appears too high and may require some change in design. The lack of other complications warrants further studies with this innovative product.

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      Cultural beliefs on the so-called natural methods and their impact on abortion in Slovenia

      Gabrijela Simetinger1, Vesna Leskosek2 1General Hospital, Novo Mesto, Slovenia, 2Faculty of Social Work, University of Ljubljana, Ljubljana, Slovenia - gabrijela.simetinger@siol.net

      Objectives: The use of contraceptives in a particular social environment depends on a cultural conviction about the body, sexuality and conception. One of the ideological issues is also the so-called natural methods of contraception, i.e. coitus interruptus (CI) that are used independently of health care professionals. According to the data, CI is the major cause of abortions in Slovenia among those that use it as a contraceptive method. The aim of the study was to explore women contraceptive users’ views and opinions on contraception and sexuality, focused on CI. Method: Qualitative study included in-depth interviews with women contraceptive users regarding contraception and sexuality in general and CI and sexuality in particular. A total of 52 semi-structured in-depth interviews with women contraceptive users from various geographical parts of Slovenia were carried out between December 2010 and May 2011. Results: Results show that 38 out of 52 interviewees used CI as contraception at a particular time of their life. Of those, 23 interviewees use it on a regular basis and the same number believe that they have no other choice. Eight out of 38 got pregnant using CI. They use CI despite the fear of getting pregnant and awareness that sexual pleasure is therefore limited. More than half of the interviewed users of CI experience difficulties in having orgasm. Most of them think that they cannot influence their sexuality and accordingly they feel powerless. Conclusions: Even though gynaecologists in Slovenia generally do not promote CI as a method of contraception the use among women is quite widespread. They still follow traditional cultural beliefs about ‘reliable natural methods’ even though they are familiar with the consequences. In addition, new channels of communication and ways of exchange of information contributed to a new belief that ‘natural’ prolongs human life and ensures health and well-being.

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      Reasons that motivate requesting induced abortion and the options that women choose facing a restrictive abortion law in Spain

      ACAI Clinics1, Carolina Ribas Barrera2 1ACAI associated Clinics, from all regions, Spain, 2Clínica El Sur, Sevilla/Andalucía, Spain - alberto.ginecenter@gmail.com

      Objectives: After the 2010 law on abortion came into force, the objective of the study was to find out what are the motivations to have an abortion and what changes should take place in the women’s situation to make them continue their pregnancies. After presentation of the abortion Bill December 2013, it was important to know, what women think they will do in the future, if the law is restrictive. Method: In 2 different periods (2012 and 2014) 5100 and 6045 women had abortions in 15 ACAI clinics . Besides sociological and medical data, they were asked about the pregnancy (originally not wanted/wanted) and the conditions that should change (socioeconomic, partnership etc.) to make them reject their decision to terminate the pregnancy. In the second period another question was added, what they would do in the future, if the new law does not allow them to perform the abortion. Results: Data for both periods were statistically analyzed. Results for both periods are similar. The variables are: age, nationality (34% and 29 % foreigners), educational level, job (35% and 36.5% jobless), contraceptive method (nothing 36.8% and 47.9%), abortion method (medical 5% and 4.7%), pregnancy condition (wanted/not wanted from the beginning) and circumstances that should change to reject abortion (none 48% and 41%, economic situation 21% and 23%). In case of a restrictive law, 29% would continue the pregnancy, 31% would go abroad and 30% would try an illegal abortion. Conclusions: 95 % of pregnancies that actually end as a legal abortion are unwanted from the beginning. Modern contraception is not widely used by the women. In 60% no changes in the women’s situation could make them take another decision. If the announced law comes into force, more than 99% of 120,000 women asking for abortion in 2012 couldn’t perform it under legal conditions.

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      Women’s experiences and perceptions of simplified medical abortion: a qualitative study in Rajasthan, India

      Kirti Iyengar1 ,2, Birgitta Essen3, Marie Klingberg-Alvin1, Kristina Gemzell-Danielsson1, Sharad Iyengar2, Sunita Soni2 1Karolinska Institutet, Stockholm, Sweden, 2Action Research & Training for Health, Udaipur, India, 3Uppsala University, Uppsala, Sweden - kirtiiyengar@gmail.com

      The requirement for repeated clinic visits remains an important barrier to access to medical abortion. Home use of misoprostol and alternatives to routine follow-up have been suggested as interventions to simplify the medical abortion, however there is little evidence on women’s experiences on these from low-resource settings. This qualitative study was conducted in Rajasthan, India, and explored women’s experiences and perceptions of home use of misoprostol and self-assessment of outcome of medical abortion. The reasons for preferring home use included inconvenience of travel, lack of confidentiality and child care commitments. After taking home misoprostol, most women continued with their routine household work, although they didn’t go for work outside the home. Most women experienced no major health problems, while some women made an extra clinic visit because of perceived health problems. A majority said that if they have to undergo another abortion, then they would prefer to use misoprostol at home. On self-assessment of the outcome of abortion, many women were fairly certain that their abortion was complete either because they experienced bleeding or expulsion or because their pregnancy symptoms subsided. Despite this, a majority of women found it reassuring to do the pregnancy test, to confirm that their abortion was complete. According to one woman, “if abortion is not done then we remain in confusion, any problem can arise inside the body, so it’s good to do the test”. Despite low literacy levels, the majority of the women were able to interpret the results of a pregnancy test. They felt that that this saved them a visit to the clinic. The checklist was used by many women, largely as a refresher to see how to do the pregnancy test. Our results indicate that home use of misoprostol and self-assessment using a low sensitivity pregnancy test is feasible in low-resource settings.

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      Ability to receive informed choice impacts upon contraception uptake and compliance

      Rochelle Hamilton Barwon Health, Geelong, Australia - rochy321@hotmail.com

      Background: Previous research highlights significant uptake of various contraceptives for women of all ages. More recently, studies support long-acting reversible contraceptives (LARC) specifically for younger women for efficacy, cost and return to fertility. So why do a high number of unplanned pregnancies and subsequent need for termination continue? This outcome is not only about risky sexual behaviour. If women are not supported to make informed choices, poor uptake and poor compliance with contraception continue. Aim: Although previous studies have primarily focused on risky sexual behaviours with adolescents, this research aims to explore the relationship between the education health care professionals (HCP) impart versus the understanding the woman has of the contraceptive. Consequently, this has an impact upon compliance and subsequent efficacy of contraceptives. Method: The clinical information obtained during the period 2001 - 2011 included 3,500 women aged between 12 - 53 years attending a public health setting for first trimester surgical termination. The information collected is part of routine counselling undertaken by all attending. The data collected was originally for a different purpose, however the findings highlighted various themes. Results: Findings revealed that a large percentage of women chose not to use specific contraceptives largely due to a combination of either real or perceived information they receive from their HCP. Additionally, it appears implementation of Quick Start methods is not routinely undertaken. Further barriers to utilisation of LARCs appear to include health literacy, socio-economic status and age. Conclusion: Negative consequences of unplanned pregnancy affect women of all ages. Poor choice or no choice of contraception, together with poor information and preconceived ideas about specific contraceptives by both the HCP and the woman contribute to poor compliance. Education needs to be improved first line to HCP's with unbiased views so all options are available from a biopsychosocial delivery point.

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      Lessons from the Contraceptive CHOICE Project: The Hull LARC Initiative

      James Trussell1 ,2, Katherine Guthrie3 1Princeton University, Princeton NJ, USA, 2The Hull York Medical School, Hull, UK, 3City Health Care Partnership Hull, Hull, UK - trussell@princeton.edu

      Objective: To discover whether a hand-out explaining the benefits of intrauterine contraceptives (IUCs) and implants could increase their uptake in Hull, England. Methods: We developed a simple double-sided A4 hand-out. On one side was a script with pictures of copper and levonorgestrel IUCs beside a 20-pence coin and of an implant beside a hair grip. On the other side was the three-tiered effectiveness chart from Contraceptive Technology. The receptionist would give the hand-out to every woman and ask her to read it before seeing a clinician. Then the clinician would ask the woman if she had read it and if she had any questions. Although we implemented the project in family planning (FP), abortion, and antenatal clinics and GP practices, we evaluated it only in FP clinics and GP practices because electronic records are available. Results: There was no impact in GP practices. There was no overall impact in FP clinics. However, only one, the service hub (Conifer House) is open daily (except Sunday) and has permanent sexual health staff on the reception desk. In Conifer House there was an increase in the proportion of women receiving IUCs or implants of 15.2% from October 2011-April 2012 to May 2012-November 2012 (from 31.0% to 35.7%, p=0.0002). The proportion returned to baseline in December 2012-November 2013, when there was a change at reception to reduce waiting times. Conclusion: This was not a formal study, so there was no research coordinator to monitor the project. We think there was no impact among GPs or among peripheral FP clinics because the project was never implemented. And we think the change at reception at Conifer House caused an already overworked staff to stop dispensing hand-outs. This simple, extremely low-cost LARC intervention at Conifer House was highly effective, by far the most cost-effective on record.

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      Postpartum contraceptive preference in South-Eastern Hungary

      Melinda Vanya1, Ivan Devosa2, Zoltan Kozinszky3, Katalin Barabás2, György Bartfai1 1Department of Obstetrics and Gynaecology, Faculty of General Medicine, Albert Szent-Gyorgyi Health Centre, University of Szeged, Szeged, Hungary, 2Institute of Behavioural Science, Faculty of General Medicine, Albert Szent-Gyorgyi Health Centre, University of Szeged, Szeged, Hungary, 3Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, University of Tromsø, Tromsø, Norway - vmelinda74@gmail.com

      Objective: The objective of our study was to determine the contraceptive practices among mothers in the postpartum period. Patients and methods: All women who delivered between 1st September 2013 and 31st March 2014 in the Department of Obstetrics and Gynaecology, University of Szeged were invited to participate in the cross-sectional survey. We prepared a 63-item questionnaire form which was asking socioeconomic and demographic background, contraceptives methods before/after delivery, sexual activity after delivery, length and effectiveness of lactational amenorrhoea as a natural contraceptive. Structured questionnaires have been sent by code to a secured webpage by email. Results: Data from 200 questionnaires were analysed. The average age of women in the study group is 26 (±4.96) years. 18.4 % of women didn’t use any contraceptive methods at 6 weeks after delivery because of the lactational amenorrhea. 53.2 % of the 200 couples didn’t used reliable contraceptive methods such as (40.7%) condom, (10.7%) withdrawal, (0.9 %) vaginal douche and (0.9%) spermicide. 12.6 % of women used progestogen-only pill (POP), 3.7 % of women reported that they used an intrauterine device, 4 % of participants were using an intrauterine system and 2.7 % of the study group underwent sterilisation. The influence of planned pregnancy and the father’s income were significantly higher among the reliable contraceptive user than in the less reliable contraceptive user (p=0.002 and p=0.036) Conclusion: In our setting 81.6% of women have used a contraceptive method in the postpartum period. The POP was the most preferred method. Acknowledgement: The project was supported by the European Society of Contraception and Reproductive Health.

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      Postpartum contraception: a missed opportunity for preventing termination of pregnancy and short inter-pregnancy intervals?

      Rebecca Heller1 ,2, Rosie Briggs2, Norma Forson1, Anna Glasier2, Sharon Cameron1 ,2 1NHS Lothian, Edinburgh, UK, 2University of Edinburgh, Edinburgh, UK - rheller@staffmail.ed.ac.uk

      Background: There is a growing realization that women's need for effective contraception in the immediate postpartum period has been underestimated. Unintended pregnancies soon after childbirth may lead to termination of pregnancy (TOP), or short inter-pregnancy intervals that are associated with adverse maternal, perinatal and infant outcomes. Using local TOP and maternity databases in Edinburgh, Scotland, we examined (1) the proportion of women attending for TOP over a 6-month period (Sept 2013 - Feb 2014) who had given birth within the preceding 12 months, (2) the proportion of postpartum mothers over the same time period whose baby followed an earlier birth to pregnancy interval of 12 months or less. (3) We also conducted an anonymous self-administered survey of mothers (n=250) within the first week postpartum about contraceptive intentions. Results: Database analysis showed that (1) 75 women out of 1052 (7.1%) attending for TOP had given birth within the preceding 12 months and that (2) 311 out of 4713 postpartum mothers (6.6%) gave birth following a preceding birth to pregnancy interval of 12 months or less. The majority of postpartum women surveyed - 62/250 (76.6%) - had not decided on an ongoing method of contraception and most (174/247, 70.4%) had not discussed postpartum contraception during the pregnancy with a health care professional. Discussion: Almost 1 in 13 women in our population who present for TOP or who deliver a baby have conceived the pregnancy soon after childbirth. Given the consequences of an unintended pregnancy for women and the risks of short inter-pregnancy intervals, consideration needs to be given to interventions that might improve uptake of effective contraception in the immediate postpartum period.

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      Marie Stopes International UK Abortion Study: the association between choice of method of abortion, postabortion contraception and the risk of having another unintended pregnancy

      Louise Bury Options Consultancy Services Ltd, London, UK - loulou.bury@gmail.com

      Objectives: The aim of this study is to explore the behavioural, social and service-related factors that are associated with one or more unintended and unwanted pregnancy amongst young women. Methods: A cross-sectional survey of 430 women aged 16 - 24. Interviews took place four weeks postabortion and participants were asked about pre and post abortion contraceptive use. Women who had had a previous abortion were also asked about their contraceptive use between their two most recent abortions. Results: More than half of the women (57%) reported to have been using contraception (pill and condom) at the time they got pregnant. There were no differences between women who had had a previous abortion and those having one for the first time. Uptake of contraception postabortion was very high with 86% of women reporting using a method at four weeks for both groups of women. Women who had had a previous abortion were more likely to start using effective contraceptive methods (LARCs) (74% and 59% respectively). More women who had a surgical abortion (than those who had an EMA) left the clinic with a method of contraception (84.7% vs. 68.6%) and more women who had a surgical abortion started to use a LARC method (70.3% vs. 49.5%). 82% of women who had had a previous abortion started to use contraception following their last abortion, but 60% discontinued their method within one year due to menstrual irregularities (LARC) or not renewing a supply (pill). Conclusions: Service providers could explore more innovative ways to support women to use their choice of contraceptive method effectively following an abortion, as well as ensure women who choose EMA are provided with appropriate support and information to easily access LARC if this is their chosen method, as well as being provided with a bridging method of contraception.

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    • Christian Fiala, AT
    • Gabriele Halder, DE
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      Pain and abortion: women’s perspective, including cultural aspects


      Anne Verougstraete1 1-Sjerp-Dilemma-VUB: Family Planning and Abortion Centre: Vrije Universiteit Brussel, Brussels, Belgium, 2-Hôpital Erasme: Université Libre de Bruxelles (Obstetrics), Brussels, Belgium - ann.verougstraete@telenet.be


      Surgical abortion: Surgical abortion is a very safe procedure and with local anaesthesia it is even safer than with general anaesthesia. In Europe, there are huge regional differences in the anaesthesia used for surgical abortion, and in a given region, some institutions perform the procedure only under local anaesthesia and others only under general anaesthesia. It seems very unlikely that these differences reflect the choice of women! A growing number of women choose "not to be there" at the moment of the abortion, while others prefer to be in control even if this means they will feel some pain.

      Given the choice, many women appreciate emotional support during the surgical abortion procedure; some may want respect for a desired scheme (silence, music etc). Recently hypnotic techniques have been introduced in medical care: it is now used in emergency medicine, during interventional radiology, diagnostic procedures and surgical treatments. In some hospitals breast cancer operations and thyroid operations are performed under local anaesthesia and hypnosis so that general anaesthesia is not needed. There is growing interest in also using hypnosis during abortion procedures to reduce anxiety and pain, in women who desire it.

      Medical abortion: Most women prefer home use of misoprostol but it is important to maintain the option to reside in the medical setting for those who wish. At home, women appreciate the possibility to have personal phone support or support by mobile phone messages in order to better manage pain and bleeding by reducing anxiety and stress. Conclusion: Woman-centred care should respect pain management and some rituals women wish for their abortion. In a lot of settings, women do not have this choice!

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      Providers’ perspective on pain in abortion care, including cultural aspects

      Regina-Maria Renner University of British Columbia, Vancouver, BC, Canada - rerenner@bluewin.ch

      The majority of women report pain associated with abortion; either during or after the procedure. A variety of pain management options are available but no option is perfect. A paracervical block with or without oral analgesics has been shown to decrease pain but typically not enough to be pain-free whereas general anaesthesia provides a pain-free experience for the procedure, but women still report pain postoperatively. Conscious sedation provides an option in between the two. Access to these pain management options varies internationally, and is influenced by the interplay of safety concerns, woman's choice and available resources. Providers' perspectives of women's pain experience and pain management also vary internationally and are shaped by their respective clinical and in some cases, personal experience. In many European countries the majority of abortions are provided under general anaesthesia, while in North America the majority of procedures are done under local anaesthesia. In Canada, for example, IV sedation is more common. Cultural norms affect patient's reaction to pain and coping mechanisms coping with pain, not only in the context of abortion provision. All these aspects influence providers' perspective on women's pain and the acceptance of women's pain. Providers accustomed to an asleep patient may not be used to seeing patients in pain and "talking a woman through the procedure". Providers used to an awake patient oftentimes are more comfortable with a patient experiencing some pain and have practice in supporting her. Additionally, studies have shown that providers' perception of women's pain does not always correlate with the women's self-reported pain.

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      Pain management

      Nathalie Kapp HRA Pharma, Paris, France - n.kapp@hra-pharma.com Background: Pain is a predictable feature of induced abortion in both the first and the second trimester, but pain control regimens available to women vary considerably.

      Methods: We searched the PubMed and Cochrane databases for publications of trials comparing methods of pain control during induced abortion.

      Results: Few rigorously conducted studies of pain control regimens for medical abortion have been conducted. Five studies conducted in women with pregnancies <9 weeks' gestation found that prophylactic analgesia did not reduce medical abortion pain, including the most recent rigorous trial where prophylactic ibuprofen was administered and dosing was repeated through the abortion process. In second-trimester medical abortion, one study found more pain relief with higher doses of fentanyl delivered through PCA than lower doses; the only adjuvant therapy shown to be associated with decreased opioid use has been diclofenac. During first trimester surgical abortion, more than 40 randomized controlled trials are available. Paracervical block, conscious sedation, general anesthesia and non-pharmacologic interventions decreased procedural and postoperative pain during first trimester abortion. Second trimester surgical procedures generally use conscious sedation or general anesthesia which have not been the subject of comparative trials. The severity of pain experienced by a woman varies considerably, but appears to be influenced by the age of the woman, parity, history of dysmenorrhea, and fearfulness/ anxiety. Prior vaginal delivery and a shorter procedure time are associated with lower levels of pain.

      Conclusion: As pain associated with the process of abortion should be expected, medication for pain management should always be offered to women who desire it, and may be combined with non-pharmacologic techniques. Further research is needed to determine the optimal analgesia regimens for first-trimester and second-trimester medical termination of pregnancy. To facilitate comparability of data, researchers should use contemporary medical abortion regimens, outcomes and study instruments to measure pain.

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