Vienna, 9-12 Settembre 2004: „United to improve women‘s health“

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  • 09:00-
  • 09:15-
    Abortion in Europe, HS 7
    • Christian Fiala, AT
    • Mirella Parachini, IT
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      Access to and reality of abortion in Europe


      Marcel Vekemans, MD, Ob/Gyn, Medical Advisor, IPPF, London, UK.


      In Europe, access to safe abortion is much easier than in the developing world, de jure and de facto. Legally, 81% of 59 developed countries (10%, in underdeveloped countries) allow induced abortion without restriction as to reason. Only 12% of the European countries (very small ones, except IRL and PL) restrict abortion to “physical risk to the pregnant wife”. Illegal abortion is not necessarily unsafe, or difficult of access, or entailing prosecution. And “legal” does not mean “safe”, or “easy to obtain” (P). Many European women still recourse to “abortion tourism” for discrete or second trimester abortions. But, de facto, Europeans are not equal concerning access to safe abortion, which depends on other than legal variables: availability of trained staff, restrictions on types of providers and facilities (in-, out-patient), dissuasive counselling, “experts” commissions, waiting periods (UK), permission from parents (I, DK) or husband (Turk), negative cultural/religious influences causing delays in care seeking, lack of trust in confidentiality, costs involved (social security reimbursement?), providers’ “conscientious objection” (I, D, Ö). Abortion services up to the full extent of the law should be accessible everywhere: health care providers are legally bound to this be it through referral. “Underserved groups” (adolescents, refugees, illegal immigrants) are targets for expanding our social role. Legal and other restrictions (and popes’ admonishments) do not eradicate induced abortion, as shown all over the world and throughout human history. Nor do prevention, such as modern and emergency contraception, sex education, abstinence vows and ignorance-only education. In the US, 60% of 1.3 million abortions per year are contraceptive failures. The 1991 Tbilissi recommendation “From Abortion to Contraception” has not been fully implemented. 


      A lack of staff trained in abortion techniques (medical, counselling) is alarming. Young professionals might be less motivated. Most have not seen women die after induced abortion. Training is not given enough attention. Also, better pain control and post-abortion contraception, and more humane attitudes, are needed. More training “Centres of Excellence” could be developed (and train providers from the underdeveloped world, where 13% of the maternal mortality, 220 deaths every day, is due to unsafe abortion). In (mainly Eastern) Europe, there remain 600 deaths/year after unsafe abortion, related to high incidence of abortion in some countries, use of less safe techniques (vacuum should replace curettage), and, at times, poor quality of care.


      Advocacy for less restrictive laws and for keeping alive adequate laws remains necessary, in front of the anti-choice movement. The battle is never won for ever. Decriminalization (“l’avortement hors du code pénal!”) is an option: leave this medical issue to the private sphere, abortion being a normal, natural part of reproductive life.

      Thanks to the commitment of governments, NGOs, and international organizations (the European Union has shown commitment to the respect of the women’s rights), access to safe abortion is quite satisfactory in Europe, but not everywhere and not for everybody. Continuous efforts are needed to improve the situation and to defend the progress made.

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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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      Historical background of abortion with an emphasis on medical abortion


      Marc Bygdeman, Department of Obstetrics and Gynecology, Karolinska Hospital,

      Stockholm, Sweden.

      Marc Bygdeman is since 1978 professor of Obstetrics and Gynecology at the Karolinska hospital in Stockholm, Sweden. M. Bygdeman has previously been Head of the department, Medical Director of the hospital as well as President of the Swedish Association of Obstetrics and Gynecology. M. Bygdeman is honorary member of the Royal College of Obstetrics and Gynecology and the American College of Obstetricians and Gynecologists and has been awarded the King of Sweden gold medal for outstanding achievements in education and research. M. Bygdeman has published more than 400 scientific articles mainly concerning infertility, contraception and abortion.  


      The methods used at present for termination of early pregnancy is vacuum aspiration and the antiprogestin, Mifepristone, in combination with an suitable analogue, either misoprostol or gemeprost. Vacuum aspiration was first described in China in 1958 and started to be introduced in Europe shortly thereafter. It replaced the surgical procedure dilatation ond curettage (D&C). The development of a medical method started when prostaglandin analogues became available. In late 1970 and early 1980 it could be demonstrated that repeated administration of e.g. gemeprost by the vaginal route was highly effective resulting in a frequency of complete abortion of 95% or higher. However, effective dose schedules were associated with a high incidence of side effects such as vomiting and diarrhoea. Even home treatment was shown to be a possibility

      In 1982 Herrman and co-workers (Herrman et al. Comptes Rendus 1882; 294;933-940) demonstrated that treatment with mifepristone could terminate early pregnancy. Although mifepristone induced a bleeding in almost all early pregnant patients the frequency of complete abortion, 60 to 85% depending on duration of pregnancy at treatment, was not sufficient for clinical use. Treatment with mifepristone converts the quite early pregnant uterus into an organ of spontaneous activity, ripens the cervix and very importantly increases the sensitivity of the myometrium to prostaglandin by around 5 times. The increased sensitivity and contractility of the uterus can be demonstrated after 24 hours and is fully developed 36 to 48 hours after the administration of mifepristone. We could also demonstrate that the treatment with mifepristone followed 36 to 48 hours later by a prostaglandin analogue was a very effective method to terminate early pregnancy (Bygdeman and Swahn, Contraception 1985; 32:45-51). The high sensitivity of the uterus allowed a low dose of prostaglandin to be used and the prostaglandin related side effects to be significantly reduced. After extensive clinical trials, mifepristone in combination with a prostaglandin analogue, initially sulprostone or gemeprost later mainly misoprostol, was licensed 1988 in France and China for induction of abortion up to 7 weeks, followed in the United Kingdom in 1991 and in Sweden in 1992 up to 9 weeks. Today the procedure is licensed in around 30 countries in different parts of the world including a number of countries in Europe and in the United States. In most of these countries the upper limit for the procedure is 7 weeks.

      Mifepristone alone is also   used to soften the cervix prior to vacuum aspiration and to induce labour in case of intrauterine foetal death and in combination with a prostaglandin analogue for termination of second trimester pregnancy. 

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    Current issues on contraception, HS 7
    • Jean-Jacques Amy, BE
    • Chantal Birman, FR
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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.

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      New frontiers in contraception research


      Regine Sitruk-Ware  USA

      Regine L. Sitruk-Ware is a reproductive endocrinologist and holds the position of executive director of product research and development at the Population Council’s Center of Biomedical Research.  She organizes pre-clinical research and clinical development of new molecules designed for reproductive healthcare in men and women suitable for use in developing countries. She is a program director for a cooperative contraceptive research center of the NICHD. Prior to joining the Council, Sitruk-Ware had successively an Academic career and then a career in Industry in Research and Development. She taught and conducted clinical research in reproductive endocrinology at the University of Paris for ten years. She was a member of the International Committee for Contraceptive Research, which was established by the Population Council in 1970. She is a member of several national and international medical societies.

      Sitruk-Ware has written eight books and over 200 articles and reviews, mostly dealing with women’s healthcare issues. She served as adviser in several ad hoc committees of the WHO and the NIH. She received her medical doctorate at the University of Paris and is currently an Adjunct Professor at Rockefeller University.


      Estimates predict that by 2015, the population growth rate will decline but that the total world population will reach the 6 billion mark, a 25% increase above the present day population. More than 26 million new couples will need contraceptives. Although a steady increase in contraceptive use has been observed both in developed and less-developed countries, the contraceptive needs of a significant percent of couples have not yet been met, and the number of unplanned pregnancies continue to increase. The actual usage of contraception differs from region to region. Although no new methods were registered for many years, several new products have reached the market during the last 2 years. Among these are new implants, medicated intrauterine systems, contraceptive vaginal rings, transdermal patches, and several new combined oral contraceptives.


      New methods have been developed to meet the objectives of expanding contraceptive choices for both women and men and, of answering an unmet need for contraceptives with long-term action that meet the expectations of consumers. When interviewed, women request affordable methods that are highly effective and reversible, easy to use, and under their own control.  Preference is given to methods that do not interfere with sexual intercourse and that result in regular withdrawal bleeding or, at least, no unpredictable bleeding. Men now tend to accept the concept of taking responsibility for the control of the couple’s fertility, leading to a growth in requests for male contraceptives, an emerging area of research. Simplicity, reversibility, and effectiveness are the desired features of a male contraceptive but no method is yet available.


      New areas of basic research include studies of genes, proteins, and enzymes involved in the reproductive system. Identifying specific genes and the proteins induced by these genes and finding molecules that specifically antagonize gene action will open new avenues for the development of contraceptives that do not modify the hormonal profile of the individual.  The new methods will be targeted to specific interactions within the reproductive system at the level of the ovary and testis, as well as between spermatozoa and the ovum.


      Genes involved in the regulation of human reproduction are explored first in animal models but these models must then be validated by studies in humans. As an example, spermatogenesis requires a complex interaction between various cellular compartments of

      the testis, and proteins involved in these interactions are now targets for contraceptive methods. These new approaches also require the engineering of original drug-delivery methods that reach the target very specifically but do not interact with other tissues in the body.


      This futuristic approach still keeps in mind the need for better access to existing contraceptive methods, as well as the discovery of new contraceptives that are simple to use, safe, reversible and inexpensive. In the future, contraceptives may be combined with other medicinal agents to provide dual protection against both pregnancy and another preventable condition, such as sexually transmitted infections. Some preliminary studies suggests that certain contraceptive methods, given alone, may not only prevent pregnancy but may also prevent common disorders of the female reproductive system, such as menorrhagia and the anemia it causes. When a contraceptive method provides dual benefits, women may have a greater motivation to use a contraceptive method, reducing contraceptive failures and unwanted pregnancies.

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    W01 Free communications, HS 8
    • György Bártfai , HU
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      Sexual Education Measures in the Framework of the Vienna Women’s Health Programme


      Angelika Wolff  ,  Project Management, Vienna Women’s Health Programme

      In general, there has been a downward trend in teenage pregnancies in Vienna and also in Austria. In 2002 the number of children born to mothers under 20 years of age dropped by 2,000 compared to 1993[1]. All in all, however Austria ranks only fourth-last in a European comparison of birth rates of women under 20 years of age. Austria does not yet have a comparable countrywide programme.

      The Vienna Women’s Health Programme deals with health promotion for girls and young women. Experience has shown that health promotion must start as early as possible. Gender-related measures in schools are therefore of vital importance. Sexual education and information for young people helps to prevent unwanted pregnancies, abortions and psychological stress, caused by teenage motherhood. On the one hand, it is important to close the information gap in boys who still know little or nothing about the female body, ovulation days, the female cycle, etc. On the other hand, it is important to promote empowerment in girls and convince them to be self-determining, not let themselves be pushed, insist on contraception, etc.


      Initiative – Youth Information Fair

      Information events on the issue of adolescent sexuality are a measure provided for students, teachers, pedagogues, youth workers, parents, school physicians, etc. The information fairs, which have taken place so far, reached up to 1,000 young people. The evaluation data has shown that this form of knowledge transfer has proved of value.

      [1] Source: Statistics Austria

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      The development of a nationwide central booking service for abortion


      Sam Rowlands, Clinical Director bpas and Visiting Senior Lecturer, University of Warwick (UK)


      bpas is a national abortion charity in the UK that provides around 48,000 procedures each year to UK residents and women from other countries on a not for profit basis.  Central booking services have been proven to facilitate access to abortion services.  City-wide models have previously been described.  A nationwide central booking service has been developed in the UK.


      A nationwide central booking service was introduced in 1993.  Initially a manual booking system was used.  In 1996 the appointment system was computerised.


      More than ¼ million calls are now received each year.  The highest demand weekday is a Monday.  The volume of calls peaks at mid-morning.  There is a 36% increase in calls between December and January.  More than a quarter of calls originate from mobile phones.


      The computerised central booking service has radically improved the efficiency of the organisation.  Waiting times can be actively managed using data from the system.

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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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      Use of misoprostol for priming in Italy


      Giovanna Scassellati, Daniela Valentini, Maurizio Bologna and  Maurizio De Felice

      San Camillo-Forlanini Hospital, Rome - Italy


      We report our clinical experience with Misoprostol, a drug registered in Italy exclusively for its gastroprotective action, in the pharmacological induction of VIP within the 90th day of gestation. The protocol that we used provided for the vaginal application of Misoprostol, with the dosage of 400 mg one hour before surgery, in a randomized sample of 50 women (double-blind trial), all adult and consenting, and this in order to induce a passive dilatation of the cervical channel, thus making the surgical intervention easier. Besides the excellent clinical result we underline its low cost, especially if compared with other drugs with a similar therapeutic action.

    W02 Immigrant patients, HS 9
    • Helga Seyler, DE
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      Special aspects: Minors, Virginity                       Anne Verougstraete(B)


      Gynaecologist working in SJERP-DILEMMA VUB (family planning and abortion centre of the Flemish Free University in Brussels) and in Cesar De Paepe Hospital in Brussels.


      Premarital virginity for girls is an important value in traditional Moroccan and Turkish culture and for a majority of men and women. This value seem to have more importance when the educational level is low. Most of the second-generation Moroccan boys in Brussels want to marry a virgin, and most girls agree.

      The girls who have premarital sex usually bear the blame for having said “yes” and often carry the entire responsability if they get pregnant.

      Due to conflicting norms and values, migrant girls may have more difficulties to use contraception properly.

      In most families male dominance is the traditional norm and the girls have usually integrated the feminine role model since childhood. It is therefore often more difficulties for them than for European girls to be assertive and persuade unwilling boys to use condoms.

      So the girls who break the traditional rules are not only more at risk for unwanted pregnancy but also for acquiring STI and HIV.

      The selfesteem of the girls who lost their virginity is often low and they may be very anxious about their chances in future life.


      In the workshop, the following topics will be discussed:


      How do we deal with minor migrant girls who want an abortion?

                  What about parental consent??

                  Is it a good idea to use mifepristone and misoprostol??

                  Specific contraception counseling??

                  Specific psychologic support??


      Should we do virginity repair???

      if we do:

      - which technique do we use?

      - which recommendations can we make to providers dealing with a demand of virginity repair?

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      Survey of immigrant women who have an induced abortion in Italy


      Angela Spinellia, Michele Grandolfob, Emanuela Forcellaa, Giovanni Baglioa,

      Giovanna Scassellatic, Augusto Colombod, Graziella Sacchettie, Paola Serafinif, Maria Giovanna Caccialupig, Gabriella Guasticchia


      aAgenzia di Sanità Pubblica della Regione Lazio, Rome; bIstituto Superiore di Sanità, Rome; cOspedale San Camillo, Rome; d Clinica Mangiagalli, Milan; e Ospedale San Paolo, Milan; f Ospedale Sant’Anna, Turin; gCentro per la salute delle donne straniere e dei loro bambini, Bologna


      The number of foreign women who have abortions in Italy is increasing; the number of induced abortions performed on foreign women has increased from 8967 in 1995 to 13826 in 1998 and to 25094 in 2001, the last being 19% of all abortions in Italy. In some regions of Italy, particularly where more immigrants have settled, this percentage is even higher. For example, in Lombardia it is 30%, while in Emilia Romagna, Lazio and Piemonte it is  26%.


      The Istituto Superiore di Sanità ( the Italian National Institute of Health) which for many years has monitored induced abortion in Italy, has collaborated with the Agenzia di Sanità Pubblica (Regional Health Authority) of Lazio to launch a project in six regions of Italy to understand the rationale which leads these women to seek abortions, to identify risk factors and understand the ways and means by which these women have achieved their abortions.


      The project is in two parts: the first is a quantitative survey, while the second is an in-depth interview of a smaller sample of the women. Given that the attitudes and use of contraceptives depends very much on the country of origin, it has been decided to concentrate on women from Ecuador, Peru, Nigeria, Marocco, China, Romania and the Ukraine, these being the six largest immigrant groups.


      In the quantitative survey, about 600 foreign women who have had a termination of pregnancy will be questioned by interviewers who have been specifically trained, using a tailored questionnaire. The sample will be all the women from these countries who have had an abortion in one of four hospitals in the period March to June 2004. The questionnaire contains closed questions which seek information about knowledge and use of contraceptives, use of local family planning clinics, how the women discovered how to use the health services to obtain their abortions, their reproductive history and social-demographic information.


      The in-depth study will be on about 50 women from the same countries, who have had a termination in the last six months, using a semi-structured questionnaire. The questions will include information on their immigration to Italy, their knowledge and use of contraceptives, the reasons why they decided to seek an abortion and the assistance they received from the local health services.


      The preliminary results of this project will be presented at the conference. 

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      Immigrant patients


      Who is doing the translation


      Thea Schipper  RN, Managing director of the Abortion Clinic “Beahuis & Bloemenhove” , Heemstede, the Netherlands. Co-founder and member of the FIAPAC Board.


      In early 2003 the story of a Moroccan woman whose pregnancy was terminated against her will in a Dutch abortion clinic attracted a lot of media attention. A political reaction from our State Secretary for Public Health quickly followed.


      How can staff at Dutch abortion clinics deal with patients with whom they cannot, or can barely, communicate through language?


      When should a professional interpreter be called in and when is it sufficient to allow the accompanying partner, family member or friend to act as interpreter?

      How can it be known what the woman wants when there is a language barrier and does the choice to involve a professional interpreter depend on her wishes?

      What can the referrer contribute?

      How can healthcare laws be respected without bringing into question the integrity of the woman and the professionalism of the worker in the field of abortion?

      Can wilful deception be prevented?

    W03 Practical aspects of abortion, HS 10
    • Kristina Gemzell-Danielsson, SE
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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.

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      Practical aspects of abortion


      Who is paying for abortions in Europe?

      A comparative study

      Christian Fiala, Sophie Hengl, Chantal Birman

      Christian Fiala, MD

      Gynmed Ambulatorium, Vienna

      Karolinska Institute, Division of Woman Child Health, Stockholm



      Introduction: Despite the steadily growing attention for abortion practices, little is known about the economic aspects of abortion. Although medical, psychological, political and legal issues have been recurrently raised within an international context, there clearly remains a lack of comparative data on the actual costs of abortions. The present study provides an overview on abortion costs throughout Europe including cost coverage and refund policies of national health care systems.


      Material and Methods: Data were collected with a questionnaire, which was sent out to abortion providers, gynecologists, hospitals, family planning centers, and health care organizations. Responses were processed qualitatively as well as descriptively. The costs of abortions in each country were interpreted relatively to the per capita indicator of the Gross Domestic Product (GDP); this allowed for more accurate comparisons of the results.


      Results:Abortion costs vary considerably throughout Europe. Even within the European Union, patients’ costs for the abortion range from € 0 to € 517,-. However most countries in Western Europe provide full or almost full refund to a majority of women. In contrast, most women in Eastern Europe as well as in Austria have to pay by themselves. And there are still a few countries where due to the persisting pressure of the Catholic church women have no access to abortion at all because of its illegal status: Ireland, Malta, Poland, and Portugal.


      Conclusion: We are currently engaged in the application of evidence-based medicine as well as in joint international efforts to further improve the health care systems. With regard to the access to abortion in Europe, the particularly heterogeneous economic conditions seem to reflect an “evidence-free zone”. There seems to be insufficient communication and cooperation among health care professionals regarding the practical aspects of abortion. It seems essential to recall that easy access to free contraception and abortion services is not a mere luxury; rather, it is the very basis for the high standards both of women’s reproductive health and generally, life in society.

    W04 Emergency contraception, HS 7
    • Beate Wimmer-Puchinger, AT
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      Emergency contraception


      Emergency contraception, can it be handed out without medical prescription?


      E. Aubény, gynecologist, President French Association for Contraception ,

      Hopital Broussais,  Paris. Co-founder and Past President of Fiapac


      Levonorgestrel can be used in emergency contraception (EC) at a dose of 1.50 taken in oneintake. This progestin has no contra-indications, and its efficacy is greatest when taken very quickly after unprotected intercourse (95% success rate if taken within 24 hours). Taking into account these facts, in 1999 the French government approved the sale of levonorgestrel emergency contraception on a non-prescription basis in pharmacies. This makes its use easier and quicker as pharmacies are widespread and have on-call service. Since that time, many other countries have authorized this distribution without medical prescription in Europe :(Albania, Belgium, Estonia, Denmark, Finland, Latvia, Lithuania, Netherlands, Portugal UK) and outside Europe. In Norway and Sweden the product is available over the counter in pharmacies : the user does not need to ask a pharmacist for the product. In France the product can also be directly delivered for free by high-school nurses to pupils and by pharmacists to minors. Since these decisions, the product has been widely used. In France and in the U.K. 80 000 women use it per month. In others countries, sales of levonorgestrel EC pills keep increasing. Post-marketing surveillance of EC has not detected any unexpected side effects in any country. Women use EC properly; they do not use EC as a regular contraceptive method (focus group study), and in France sales of birth control pills continue to increase. Even so, many women who have unprotected intercourse do not use EC because they do not think they are at risk of pregnancy. E.C is under utilized, an information process must be increased. 

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      Emergency contraceptive pills over- the-counter; practices and

      attitudes of pharmacy and nurse-midwife providers


      Gunilla Aneblom *, Karin Eurenius, Tanja Tydén,  Department of Women’s and Children’s Health, Uppsala University

      Cecilia Stålsby Lundborg, Department of Public Health Sciences, IHCAR, Karolinska Institutet, Stockholm, and Nordic School of Public Health, Göteborg,

      Cecilia Stålsby Lundborg, Anders Carlsten, Research Division of Apoteket AB, Göteborg,

      Tanja Tydén , Department of Public Health and Caring Sciences, Uppsala University,


      Introduction: Deregulation of emergency contraceptive pills (ECP) has led to pharmacy staff becoming a new provider group of ECP, together with nurse-midwives, who are already experienced in prescribing contraceptives.


      Aim and Method: This postal questionnaire survey aimed to assess practices and attitudes towards ECP and the over-the-counter (OTC)-availability among pharmacy staff (n=237) and nurse-midwives (n=163). Attitudes were measured on a six-point Likert scale.


      Results: The overall response rate was 89%. Both study groups were positive to ECP and the OTC-availability and the vast majority agreed that sexually active women should be aware of ECP and that routine information about ECP should be included in contraceptive counseling. Verbal information on all aspects of ECP to clients was reported more often by nurse-midwives than by pharmacy staff. Experience of ECP sale to men was reported by 25% of pharmacy staff, and 38% of pharmacy staff reported on referral of women to local clinics for follow up after treatment. Both groups supported collaboration between providers.


      Conclusion: Our findings suggest that further collaboration between pharmacies and family planning clinics should be encouraged to ensure a competent and client-friendly provision of ECP.

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      Supply of emergency hormonal contraception without prescription

      in Swiss community pharmacies


      Spycher C, Beutler M, Lemke S, Bruppacher R, Hersberger KE,

      PLANes – Lausanne , CH


      Introduction: Levonorgestrel for emergency hormonal contraception (EHC) is used by the Familiy Planning Center of the Department of Obstetrics and Gynecology, Inselspital Bern since 1999 (along with guidelines and a specific EHC-protocol). Experiences have been analyzed and were favourable. Levonorgestrel was officially introduced in Switzerland as EHC in November 2002. It is available without prescription (‘pharmacist only’). The same Guidelines and a specific EHC-protocol were implemented to assure safe and rational drug use.


      Objectives: Monitor in a pilot study the demand and the pharmacists’ counselling activities and search for improvement potential concerning supply and pharmaceutical care.


      Design: Retrospective analysis of the EHC-protocols, collected from pharmacies to elicit request and supply problems as background for the development of a questionnaire.

      Prospective query of all women requesting EHC in 4 community pharmacies with enlarged opening hours and known supply of EHC of more than 20 times a month. A 13 items questionnaire, filled in by the customers immediately after triage in the pharmacy, was linked with the respective EHC-protocol.


      Setting: Random sample of 14 community pharmacies in German speaking Switzerland offering access to their EHC-protocols; 4 of them with frequent requests approached their customers for answering the questionnaire.


      Results: In 14 pharmacies a total of 205 protocols were documented during the first 6 month after introduction of Levonorgestrel for EHC. Only 44 missing data (3.0% out of 1435 items) demonstrated that triage was based on complete information.

      During 10 weeks the 4 pharmacies approached 177 women requesting EHC, of them 141 (71%) (median age 23 years, range 16 - 47) filled in the questionnaire. 59% used EHC for the first time. The major reasons for EHC request were problems with condoms (69%) and non-compliance with hormonal contraception (13%). Before sexual contact only 55% knew about availability of EHC without prescription through pharmacies. Alternatively women would have contacted a physician (55%) or a hospital (27%), but 11% would have waited without action. In 91% of all requests EHC was supplied. General satisfaction with pharmaceutical care was rated best (on a 4 point scale) by 86% of the women. Deficits concerned counselling about future contraception and risk of sexually transmitted diseases.


      Conclusions: EHC through pharmacies could successfully be implemented. The structured counselling protocol was well used and is likely to support good counselling.

      To monitor problems and changes in the quality of pharmaceutical care and in emergency contraception behaviour a larger study should follow this pilot study.

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      The role of the doctor

      Pedro Peña Coello (Sp)

      Clinica Campo de Gibraltar

      San Roque Cádiz, Spain


      The emergency contraception’s objective is to avoid a non-desired pregnancy in case of having had unprotected intercourse.  We know that a large percentage of these intercourse’s end in non-desired pregnancies (NDP), which usually are terminated with an abortion, which we all intend to avoid.


      The most frequently used molecule today as a contraceptive is the LEVONORGESTREL, a highly recognized and used drug, secure, functional and with almost no side- effects.  How many over the counter drugs with these characteristics are available today?


      The association which I represent (ACAI) believes unanimously that the benefits to any easy access to apc are larger than the risks.


      We largely defend that APC could be recommended, given, or prescribed by any person with minimum health information about this subject, health agents, sexual educators, social workers, nurses, doctors, or pharmacists.

      We believe that us doctors have a great responsibility; therefore, our role is an important one concerning the investigation, prevention, education, and care of the sexual and reproductive education, but not necessarily nor obligatory the APC should be given by medical authorization.

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    Abortion and contraception, HS 7
    • Paul Cesbron, FR
    • Dharani Hapangama, GB
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      New perception on contraception


      Fatim Lakha,  MD, Contraceptive Development Network, University of Edinburgh, UK


      Abortion is inevitable. Intuitively, one would hope that numbers of abortions could be reduced by women using contraception more consistently. In practise this is difficult to achieve.

      In first world countries where awareness of contraceptive methods is good, correct utilisation, if at all, remains poor.

      There are very few data on the effectiveness of counselling to reduce rates of unintended pregnancy.

      A small study from Switzerland investigated behaviour modification following professional counselling six months post termination of pregnancy. It demonstrated a high prevalence of contraceptive use after abortion. A similar small UK study of women undergoing repeat abortion indicated inconsistent counselling leading to women opting for less effective methods of contraception. In depth interviews with a group of women following abortion in London described little change in behaviour and contraceptive counselling was shown to have been superficial.

      Two randomised control trials have attempted to evaluate counselling as an intervention designed to improve contraceptive use after abortion. One from Iceland showed no significant difference in contraceptive use, the second from Scotland demonstrated an increased uptake of long-acting methods. Follow-up in both these studies was too short to confirm a reduction in repeat abortion rates.

      Further studies are needed to evaluate strategies to improve contraceptive uptake and continuation rates, and to determine their effectiveness in reducing unintended pregnancies.

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      The importance of education on contraception


      Bojana Pinter , MD, PhD. University Medical Center, Ljubljana -Slovenia



      Family planning, sexual and reproductive health are essential components of individuals, couples and societies. Information on sexual and reproductive health and sexual education are very important in improving the knowledge and practice of contraception and thus in preventing unwanted pregnancies, which mostly end in induced abortions, and in preventing sexually transmitted infections (STIs).


      Sexual education

      The aim of sexual education is to change the sexual behavior with improving KAS (K–knowledge, A–attitude, S–skills) through education in sexuality, contraception, abortion prevention, avoiding risk-taking behavior and STIs (with HIV). Sexual education can be formal or informal, at school, in the family, by the media and through service providers. It needs broader approach than simply giving information and education on contraceptive and other preventive methods. Mechanical and organic bodily information are not enough as people, especially adolescents, are much more concerned about other aspects of love and sexuality: emotions, thoughts and anxieties should be addresses and discussed. Besides, training in communication skills is an important aspect of sexual education. 


      Innovative approach in sexual education could be as SPICES: S – stimulating, P – problem oriented, I – interactive, C – community based, E – extensive, S – students centered. Studies and practice have shown that “peer education” is one of the most successful approaches in sexual education. However, sexual education is only one part of a holistic approach to sexual health promotion and behavioral change, which develops through consecutive steps: awareness – knowledge - attitude – intention – behavioral change – sustained behavioral change.  


      The majority of sexual education programs have some positive effects upon some outcomes (such as greater knowledge), but only some of the programs actually result in some behavioral change as: delay in the initiation of sex, increase in condom or contraceptive use, reduction of unprotected sex among youth and reduction of unwanted pregnancy and induced abortion rates. The studies show that effective sexual education programs:

      -   include a narrow focus on reducing sexual risk-taking behaviors that may lead to STIs or unintended pregnancy (e.g. delaying the initiation of sexual intercourse, using protection)

      -   use social learning theories as a foundation for program development

      -   provide basic, accurate information about risks of unprotected intercourse and methods of avoiding unprotected intercourse through experiential activities designed to personalize this information

      -   include activities that address social or media influences on sexual behavior

      -   reinforce clear and appropriate values to strengthen individual values and group norms against unprotected sex

      -   provide modeling and practice in communication and negotiation skills. 

      The studies also show that sexual education programs do not increase any measure of sexual activity.


      Sexual education in Slovenia

      Because most youth are enrolled in school for many years before they initiate sex and when they initiate sex, schools have the potential for reducing adolescent sexual risk-taking. Unfortunately, the practice in many European countries, as in Slovenia, is that there is no formal sexual education nor in primary nor in secondary schools. The study on sexual behavior of secondary-school students in Slovenia has shown, that the majority of students get the information on sexuality from friends, parents and different sources together and that the school is less important source of information. In the absence of formal sexual education other sources of information (e.g. internet, journals) could provide youths with minimal information. However, more cooperation on national level should be established to introduce formal sexual education in schools.  


      Triple protection

      The suggestion made by the Population Council is that rather than dual protection, what many young and adult people need is “triple protection” against unintended pregnancy, STIs and infertility (which is possible consequence of STIs in women and men). Triple protection can be achieved by ABC approach: A – abstinence, B – being faithful and using contraception, C – condom use. 



      Effective sexual education programs can be an effective component in a larger initiative to reduce the unintended pregnancy, STIs and infertility risks in youth and adults

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