Vienna, 9-12 Settembre 2004: „United to improve women‘s health“
10:30Choice in reproductive health: the example of medical abortion, HS 7Sedia:
- Marc Bygdeman, SE
- Régine Sitruk–Ware, US
- Kristina Gemzell-Danielsson, SE (all speeches)
More than 15 years of experience – new developments,
Kristina Gemzell Danielsson. MD. PhD, Associate Professor in Obstetrics and Gynecology at the Karolinska Institute, Stockholm, Sweden
Senior consultant in obstetrics and gynecology at the clinic of Sexual and Reproductive Health, Department of Woman and Child Health, Division for Obstetrics and Gynecology.at the Karolinska Hospital, senior research position at the Karolinska Institute sponsored by the Swedish Research Council
Head of the WHO collaborating centre for research in Human Reproduction, Karolinska Hospital, head of the research group at the WHO-centre. Supervisor of 3 PhDs and 9 PhD students. research nurses and laboratory technicians.
Secretary Swedish association of Obstetrics and Gynecology, task force on Family Planning
Board member of FIAPAC (International federation of abortion and contraceptive associates), and ICMA (International consortium of medical abortion)
Medical abortion with a combined regimen of mifepristone and a prostaglandin analogue was first approved in France in 1988 followed by approvals in the UK and Sweden, and has been used in China since 1992. In China and France medical abortion is used to 49 days amenorrhea. In the UK and Sweden the method is approved to 63 days amenorrhea. Today medical abortion is available in around 30 countries. During the last 15 years since introduction of the method research has focused mainly on the following issues: To find the optimal dose of mifepristone, the optimal type, dose and route of administration of prostaglandin and to increase acceptability of the method
Pharmacokinetic studies have shown that single doses of mifepristone above 100 mg resulted in similar serum concentrations. Randomised controlled trials have shown that 600 mg of mifepristone is equally effective as 200 mg when followed by a sufficient dose and suitable type of prostaglandin. The prostaglandin most commonly used today is misoprostol (Cytotec, Pfizer), a prostaglandin E1 analogue widely available for the prevention of gastric ulcer in patients taking non-steroidal anti-inflammatory drugs. Although licensed for oral use vaginal administration of misoprostol is becoming a common practice in medical abortion. Several clinical studies have found that vaginal administration is more effective than oral administration. When the absorption kinetics was compared between oral and vaginal treatment it was shown that the systemic bio-availability after vaginal misoprostol was three times higher than after oral misoprostol. This was directly reflected in the effect on uterine contractility. A drawback with the vaginal route is the large individual variation in plasma levels suggesting inconsistent absorption through this route. Furthermore most women prefer to take the tablets by the oral route. Recently the new route of sublingual administration has been described. Preliminary studies suggest that sublingual administration is a promising method for medical abortion. This is supported by pharmacokinetic and uterine contractility data indicating that this is probably the most potent route to administer misoprostol in its present form.
Current research also focuses on the possibility to reduce the time interval between mifepristone and misoprostol. Furthermore home administration of prostaglandin has been shown to be safe and effective, to reduce the number of visits to the clinic and to be preferred by many women in both developed and developing countries
- Elisabeth Aubény, FR (all speeches)
Access in different countries and current status
Elisabeth Aubény, gynecologist, President French Association for Contraception, Hopital Broussais, Paris. Co-founder and Past President of Fiapac
The early medical abortion method is authorized in Europe in many countries. The authorized method, in France(since1989), Austria, Belgium, Denmark, Holland, Germany, Spain, Switzerland, Slovenia (since 1999), until 49 days of amenorrhea, is Day 1: mifepristone 600 mg taken at the abortion center with the patient going home immediately afterwards, Day 3: misoprostol 400 µg taken orally, followed by medical supervision for 3 hours in the center; Day 10-15: check-up visit. In Sweden (1993) in U.K,(1994) this method is authorized until 63 D.A. with gemeprost, as prostaglandin, taken vaginally. But among these countries, the use differs from one country to another. It is used in Sweden and Switzerland more than 50 %, in Belgium, France and Finland around 30 %, it is used in Holland and U.K, around 15 % and less than 5 % in others authorized countries. The use of medical abortion in a country depends of many factors: length of legal authorization, price of the abortion and its reimbursement by assurance to the patient, fee of doctors paid by assurance, but also reticence of doctors to change their habits for a method they don’t know exactly. In the future ameliorations can be bring to this method specially used without any hospitalization, practice by trained general practitioners in their on practice. Women who have the possibility to choice this method are very satisfied. It is our medical duty to propose it.
- Peter Safar, AT (all speeches)
Medical abortion, early treatment
Peter Safar MD, Head of Department of Obstetrics and Gynaecology
Humanis-Klinikum Korneuburg, Austria,
Board member of the Regional Executive Commitee of the IPPF/EN
Most women are faced with unnecessary obstacles in access to termination of a very early pregnancy, even when their decision for termination is clear.
Frequently the treatment of medical abortion is delayed until a foetal cardiac activity can be seen on ultrasound. Additionally women are sometimes subject to several ß-hCG tests in the serum. Treatment is delayed until a viable intrauterine pregnancy can be diagnosed, usually around 6 1/2 weeks LMP.
Our experience is presented with medical abortion in very early pregnancy. We also follow patients and repeat ß-hCG in these cases, but we start medical abortion immediately. Patients are counselled about the possibility of an ectopic pregnancy or a missed abortion in cases where no foetal cardiac activity or even no gestational sac can be seen on ultrasound.
Serum ß-hCG is done prior to treatment and repeated at follow-up after one week. There is a marked decline below 20% of the initial value when the abortion has been successful. Sometimes the combination with the serum level of progesteron could be precise the diagnosis.
So far we have not had one persistent ectopic pregnancy in more than 5 years and over 2.000 cases. If an ectopic pregnancy would be detected at follow up the treatment option with MTX or laparoscopy can be discussed in time.
Medical abortion with mifepristone and misoprostol in the early and very early pregnancy is safe and very well accepted by women. The success rate is high and side effects of strong bleeding or pain are infrequent.
- Gabriele Halder, DE (all speeches)
Medical abortion in the private practice,
Specialist in OB/Gyne
Working in private practice
Head of the Family Planning Centre Berlin
This presentation gives you an overview and in depth analysis about induced medical abortion with the abortion pill Mifegyne© ( Mifepristone ) and the Prostaglandin Cytotec© ( Misoprostol) in practical experience as a practicing gynaecologist.
The description of the problems in Germany in terms of having to deal with the german federal law and the regulations about the specific distribution channels of the abortion pill is considered as well as the increased requirements in the fields of care and consulting service for the female patients.
The complexity in practice and the fact that in Germany the existence of prohibition for advertisment of induced abortions in general is another hurdle for the application of Mifegyne©. This is one section of the many reasons why last year 2003 only a percentage of 6,12 % of all induced abortions in Germany were done the non -surgical way.
- Pierre Moonens, BE (all speeches)
Why do we need medical abortion when surgical abortion works so well?
Pierre Moonens, MD, Boardmember of the “Fédération de Centres de Planning Familiaux” and of “Gacehpa”, Belgium. Co-founder and Vice President of Fiapac
In the French spoken part of Belgium, we have a 25 years old experience of performing abortions in family planning clinics, using the aspiration’s technique under local anaesthesia. We are very pleased with this way of working. Description of disadvantages and advantages of this technique.
- How did we introduce the medical abortion technique in our Centres?
- Which protocol are we following for medical abortions?
- Which are the changes introduced in our daily work by this new technique?
- In which particular situations are preferring one method or the other?
- Which changes could be introduced in the protocol of medical abortion to improve the women’s rights ?
- Some ethical principals that should not be forgotten in our work of “abortion practitioners”.
12:30W05 Eastern Europe after the transition: What do women win and loose in reproductive health?, HS 8Sedia:W06 Emergency contraception, HS 9
- György Bártfai , HU
Sedia:W07 Starting medical abortion, HS 7
- Irina Savelieva, RU (all speeches)
Irina Savelieva, MD, Russia
The growing economic difficulties have made it hard to implement universal access to health in Russia. Significant cuts in the public health care budget have resulted in a decrease of state-guaranteed health services for women and children. Due to the lack of appropriate contraceptives and counseling services, abortion was and still remains the principal means of fertility regulation in Russia, sometimes exceeding the number of live births by two or three times. Though the number of abortions performed annually has declined drastically over the past decade (the abortion rate was 100.3 per 1,000 in 1991 compared with 47.7 per 1.000 women of reproductive age in 2001) abortion remains to be an important cause of preventable morbidity and mortality among women of reproductive age. In 2001, abortion accounted for 27,7% of maternal deaths in Russia, as compared with an estimated 13% of maternal deaths attributable to abortion globally. At the same time the number of post-abortion complications remains high, and according to some research can reach 40-60% with high level of incomplete medical abortions, of which nearly half (46.2%) required hospitalization. There are also several safety issues (abortion in nulliparous women, multiple pregnancy terminations, second trimester abortion) which have not be addressed adequately and need special attention, not to mention the psycho-social effects of multiple abortions and possible secondary infertility, and the growing interest and practice of assisted reproduction techniques, such as in vitro fertilization (IVF). These data demonstrated that quality abortion care in Russia does not satisfy world standards and WHO recommendations.
Abortions are more common among women ages 20 to 34 (approximately 70%), with 15.3% women who were pregnant for the first time; the mean number of abortions is 2.8-3.07. Almost 40% of abortion clients had already terminated a pregnancy by abortion during the previous 12 month. About half (43%) were using contraception at the time of their last pregnancy (39% were using condoms, 20% - natural family planning, 12% - spermicides and 11% - pills). The principal reasons for abortions (62,3%) were indicated as socioeconomic reasons; and 20,0% did not want more children. Only 36,9% of abortion clients, including young adults and primigravidae, what is of a crucial importance, received family planning counseling prior to the discharge and only 22,0% left medical facility with a contraceptive method of their choice. Since many women who are terminating an unwanted pregnancy intend to have a child later, it is extremely important to identify high level of post-abortion complications on subsequent reproductive function. The entire population is covered by a national health insurance, but abortion as a procedure has not been included. The country has adopted the Essential Drug Policy but has not included contraceptives in the Essential Drug List.
Clinical abortions are performed in medical facilities. The services are provided in maternity hospitals, consultancies of obstetrics and gynecology, private practices and Family Planning Centers. According to state regulations and laws all state institutions provide family planning counseling and abortions free of charge, but the present socio-economic situation has triggered a growing habit of charges made for clinical abortions.
Increasing and more human counseling, improved and good quality of services, good technology (including new medications), good facilities, better information through well-trained providers, careful follow-up, offer choices of contraceptive methods to women and help them to avoid unwanted pregnancies and consequent maternal health risks.
- Medard Lech, PL (all speeches)
Medard Lech, MD, Director of the Fertility and Sterility Research Center in Warsaw, Poland. He is also a Senior Consultant Gynecologist in ENELMED Medical System in Poland. After earning his medical degree from the Medical University of Warsaw in 1967 he has completed his postgraduate education at Bielanski Teaching Hospital of Warsaw obtaining the Fellowship Diploma of the Obstetrics and Gynecology College of Poland. He is also a specialist in Public Health. He has obtained broad clinical and educational experience during his service in State Postgraduate Medical Education Center of Poland, State University of Maiduguri (Nigeria) and St Luke’s Teaching Hospital of the University of Malta. The author of more than 100 published abstracts, peer-reviewed papers and reviews, he has served as Principal Investigator and Investigator on numerous clinical trials. He is Editor-in-Chief of Polish Quarterly Journal Antykoncepcja – Aktualności. He is a member of the Polish Gynecology Society and Society of Social Medicine and Public Health. He is a member of Board of Directors and the Executive Committee of European Society of Contraception.
It is important that couples have easy access to a wide range of methods of birth control so they can freely exercise their choice in the matter of procreation. This can be achieved in several ways; sterilization (male or female), effective contraception, or abortion. Abortion should be a “last resort method” of birth control. Wherever the availability of effective methods of contraception is restricted, the rates of induced abortions are high.
51.5% out of 377.5 million of European women live, in Eastern/Central Europe (year 2003). Historically, induced abortion has been a common method of birth control in this part of Europe, mostly due to the lack of modern contraceptives (ie any method other than the rhythm method or coitus interruptus). In these countries in 1994, 43% of women aged 15-44 years used no contraceptive method, 27% relied on withdrawal and 6% the rhythm method. In 1996 the contraceptive prevalence rate was still only 35%. As a consequence of a low usage of modern methods of contraception these countries have high birth rates in very young women (ie. 6% in Czech Republic, 7.4% in Poland, 9.1% in Hungary). The increased use of modern contraceptives is directly correlated with declining abortion rates. As an example, the annual number of abortions in the Czech Republic declined by 65% from 107,100 in 1990 to 37,200 in 1999 as modern contraceptive use increased seven fold in the same period of time. Inverse correlation can be seen between the abortion rate and use of modern contraception in Romania and Bulgaria is very well documented for the years 1950 – 2000.
Prevalence of contraceptive usage in Central/Eastern Europe (in women aged 15-49 years) varies from 20-23% in Lithuania, Moldova and Ukraine to 73-76% in Hungary and Bulgaria, In some countries, modern methods of contraception are unpopular (eg in Romania; use of all methods – 57%, but modern methods only - 14%. Total fertility rates all over Central/Eastern Europe - in recent years - have fallen, and in most countries have reached less than 1.9 (excluding Albania). It seems unlikely that this is due to a decrease in sexual activity of the people; it must be due to increased use of birth control methods, especially the use of modern contraception. The increase availability of modern methods of contraception is a signum temporis for people living in Central/Eastern Europe, but from the other hand quality family planning services are getting less and less available in these countries. In many of these countries there are still barriers to proper information and sexual education of young people
- Elisabeth Aubény, FR
Sedia:W08 Beyond first Trimester, HS 10
- Fatim Lakha, GB (all speeches)
Impact of emergency contraception (EC) on contraception and abortion
Fatim Lakha, MD, Contraceptive Development Network, University of Edinburgh, UK
Emergency contraception (EC) has the potential to reduce the numbers of unintended pregnancies and thus reduce both rates of abortion and total fertility rates. However, this is only if everyone uses it every time the need arises.
A pilot study undertaken in Edinburgh in 1997 demonstrated that having an advanced supply of EC led to increased use of EC and a trend towards a decreased relative risk of unintended pregnancy (relative to not having advanced supplies).
A large Lothian-wide study followed in 1999. Women aged 16 to 29 were offered 5 packets of EC to keep at home.
At the end of 2001 25% of the targeted population had been reached.
A random sample of 11 general practice (GP) clinics and the family planning clinic (FPC) were used to audit data. Women who had supplies from these clinics were asked to complete a questionnaire. 5,543 questionnaires were analysed.
It was estimated that at least 8,800 courses of EC had been used during the study. 75% of women who had used EC had within 24 hours. This indicated increased but responsible use of EC with home supplies. The trend was for women to move to a more effective method of contraception after being supplied with advanced EC.
Disappointingly, whilst advanced provision increased use, it did not result in a reduction in numbers of unintended pregnancy.
74% of those followed-up who had had an unintended pregnancy had not used EC to prevent that pregnancy because they had not recognised the risk.
Regardless of potential efficacy of EC, effectiveness depends on the user and their individual perception and acknowledgement of risk.
- Lena Marions, SE (all speeches)
Mode of action
Lena Marions MD PhD,
Dep of Ob/Gyn, Karolinska University Hospital Stockholm Sweden
Emergency contraception is a method that is used after sexual intercourse to prevent unwanted pregnancy. Available methods are combined contraceptive pills (the Yuzpe method), levonorgestrel only, the antiprogesteron mifepristone and the insertion of a copper IUD.
Levonorgestrel has become the drug of choice in many countries because it is effective and well tolerated. However due to lack of knowledge, about the mechanism of action, millions of women have no access to postcoital contraception because of religious and/or political reasons. The sensitive question is whether the mode of action is exerted before or after fertilization. The only method that has shown to exert an inhibitory effect on the implantation process is the copper IUD, the EC pills act by postponing or prevention of ovulation and can not be regarded upon as abortifacient.
Even though the use of EC pills has significantly increased during the last years, the number of induced abortions has not decreased as expected. Studies indicate however that both women and providers have a tendency to underestimate the risk for pregnancy. It is important to recommend treatment after every unprotected intercourse at any time during the menstrual cycle.
- Helena von Hertzen, CH (all speeches)
Where is the evidence : results from clinical trials
Helena von Hertzen , MD, DDS,
Since 1990 Medical Officer, UNDP/UNFPA,WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
Managerial responsibility for the research initiated and carried out by the Research Group on Post-ovulatory Methods for Fertility Regulation, and for the research on breast-feeding with emphasis on its birth spacing effect.
The absolute efficacy of emergency contraception (EC) can only be investigated in placebo controlled trials. As such trials have never been undertaken, we do not know with certainty how effective emergency contraceptive pills are. It is evident that the copper IUD is very effective when used for EC, as there were no pregnancies among nearly 2000 women who had a copper IUD inserted after unprotected intercourse.
Different hormonal EC regimens have been compared in large randomized controlled trials (RCT), which constitute a sound tool to estimate a difference between treatments if properly conducted. It should be noted, however, that comparison of pregnancy rates between trials is subject to bias as women's characteristics and eligibility criteria usually differ. The main outcome in efficacy trials of EC is the occurrence of pregnancy, which is a rare event even if no EC is used: it has been estimated that even without treatment only some 8% of women would become pregnant after one act of unprotected intercourse. Thus, the trial size has to be large enough to provide power for treatment comparisons. Such large RCTs have demonstrated that both levonorgestrel and mifepristone are more effective and better tolerated than the regimen of combined oral contraceptives.
- Dominique Roynet, BE
- Ismini Staboulidou, DK (all speeches)
The ultrasound simulator system- a novell training system in ultrasound examination
Staboulidou I., Fiala C., Wüstemann M., Scharf A.
Medizinischen Hochschule Hannover
Although ultrasound examination became almost indispensable in prenatal diagnostics as well as in gynecologycal examination, there are still a lot of short comings concerning the quality of sonographic education in OB/GYN.
At the Departement of Gynecology and Obstetrics of the Medizinische Hochschule Hannover (MHH) a multitude of normal and pathologica 3 D l volume cases were scanned and projected into a simulation object to be used for teaching and training purposes.
The ultrasound simulation system makes it possible to simulate a complete real time 2 D ultrasound examination. The system is able to simulate all imaginable kinds of ultrasound examination. It offers a novel opportunity of structured ultrasound training including the option to define various levels of difficulty. Thus it can also be used as a training tool to assess the competence of the sonographer.
- Lynne Randall, US (all speeches)
Training for the doctor
Lynne Randall , ppfa - USA
In the 3.5 years following governmental FDA approval for Mifeprex, Planned Parenthood centers have provided medication abortion to over 100,000 women, now accounting for 22% of first trimester abortion services at Planned Parenthood. A comprehensive training program was designed to assist staff and physicians to incorporate medication abortion into their practices. A system-wide approach was taken to train, track, and communicate with providers in over 200 centers in the US. Technical assistance, on-site training, and data collection were critical in overcoming resistance and concerns about a new method of abortion care. Medication abortion, including home administration of misoprostol, has proven to be extremely safe, well accepted, and cost effective in Planned Parenthood centers
- Richard Burzelman, ZA (all speeches)
Who should perform medical abortion
Richard Burzelman, Richard Burzelman is an Assistant Director for Reproductive Health with the Provincial Government Western Cape Province in South Africa since 2002. His responsibilities include development of policies, guidelines and protocols for the reproductive health services in the Province. He has been involved with reproductive health since 1997 when he started managing an abortion service at a district health facility in Cape Town. This service became the referring facility for the Metropole Region giving access to all clients up to 20 gestational weeks. At the time access was limited as the “Choice on Termination of Pregnancy”, Act 92 of 1997 was just introduced and very controversial.
The Reproductive Health Sub-Directorate collaborates with the World Population Foundation (WPF) in the Netherlands, the Johns Hopkins University Centre for Communication Programs, and the Reproductive Health Research Unit in Johannesburg and the Women’s Health Research Unit at the University of Cape Town undertaking reproductive health research.
Qualifications:Registered Professional Nurse/Midwife (Accoucheur) with Diplomas in Psychiatric Nursing, Operating Room Nursing, Nursing Administration, a Certificate in Termination of Pregnancy and a post-graduate BA Nursing Degree.
Making safe, legal abortion services available to all women is likely to require that all levels of professional health care service providers i.e. the traditional gynecologist, trained physician, and mid-level health professionals participate in the services.
Medical doctors trained in abortion services are not available in many parts of the developing world. This necessitates training of mid-level providers who are not physicians to deliver quality abortion care.
These mid-level providers refers to a range of non-physician clinicians – midwifes, nurse practitioners, clinical officers, physician assistants, and others who are trained to provide basic, clinical procedures related to reproductive health, including bimanual pelvic examination to determine pregnancy and positioning of the uterus, uterine sounding, transcervical procedures, and who could be trained to provide early abortion services.
A previous study in the USA seemed to indicate that complication rates between physicians and other mid-level health care professionals show no difference in first trimester abortion procedures. A study in SA and Vietnam looking at whether there are any differences in medical outcomes between physicians and mid- level providers providing first trimester abortions is currently being completed.
Operations research being undertaken in SA to determine the acceptability and feasibility of medical abortion findings will be presented to policy makers later in the year.
In South Africa, the provision of first trimester surgical terminations have been delivered by registered midwifes since the implementation of the “Choice on Termination of Pregnancy Act” no 92 of 1996. An amendment to the Act later this year will include medical abortions as an added choice for women in the first trimester of pregnancy. In this talk, emphasis will be placed on the South African situation, as an example for other developing countries where there is a shortage of abortion care providers.
- Pascale Rogie, BE
- Maria Francès- Kircz, NL (all speeches)
Continuing abortion tourism in Europe
Maria Francès RN, co-founder and Secretary General of Fiapac
Bloemenhove Kliniek - The Netherlands
There have always been women with an unwanted pregnancy who were forced, by lack of possibilities in their own country, to cross borders, spend money and take risks in order to get what should be their right: a termination of their pregnancy, after all the most performed medical act in the world.
Since the 1970 ‘s the countries – in western Europe - which receive most of these women are the UK, the Netherlands and since some years also Spain, where the implementation of the - not so liberal - law is quite loose.
Although the number of “abortion tourists” has dramatically – in a positive sense – dropped since several countries have liberalized their law (in 1980 26.200 German women came to Holland for an abortion, in 2003 not more than 1254, in 1985 18.000 women came to the UK for an abortion, in 1996 only 66…) there is still a too large number of women who have to undertake this unfair, costly and emotional heavy trip. In the Bloemenhove clinic where I work, the yearly number of patients is about 3300, of which still 60% are coming from abroad. At the same time we may expect an increasing number of women from the eastern part of the European Union with al their specific - for instance financial - problems.
In this short intervention I would like to emphasize one part of the subject: the responsibility towards the woman in demand.
It goes without saying that the first responsible is the woman herself. She has taken the decision not to continue her pregnancy – even if circumstances, financial, emotional or others, may have forced her to do so. After an appointment with her gynaecologist or her generalist, the most positive scenario is that this doctor will give her the address of a Centre or Clinic in the area where she lives to have the abortion as soon and as safe as possible, assuming that the term of her pregnancy is within the legal delay.
Unfortunately this is not always the case, and if yes the doctor sends her to a hospital or clinic the waiting time is very often so long that the legal delay will be passed at the moment she will get an appointment.
Then starts the search for a liable alternative, by experience I know that it takes some times more than 3 weeks to find an organization - like in France the MFPF – or a doctor who will cooperate to find a solution. The pregnancy in the mean time, is far beyond the legal delay in her country, the costs are doubled, the strain becomes unbearable.
What if, at the moment of her arrival in the Clinic of her choice, be it in the UK, Holland or Spain, she finds that her pregnancy has exceed the legal delay in the “guest” country, she happens to have a too low HB, ( Dutch hospitals are not prepared to give transfusions to foreigners unless there is danger of life), there is a problem with her coagulation, she is HIV positive, she has Hepatitis or she has simply not sufficient money,( this is what we experience frequently in our Centre in Holland). Do we send her back home, do we take risks concerning her health or our finances?
Who should we or she turn to: the organization in her home country? her gynaecologist?
Who is responsible for this woman, this moral problem often weights heavy and gives a feeling of powerlessness.
From these experiences one may get the tendency that country’s with a restrictive law give the impression to be more or less content at the idea that the neighbour will do the job and that consequently administrations do not move. I know that this negative thought is unfair towards all those who are risking their necks in order to improve the legal situation in their countries.
No – the sad reality, to my opinion, is, that abortion will never be “Salonfähig”, will always be a political “ non-issue” , and will continue to depend on militant “fieldworkers”.
I therefore urge that it is the duty of us, Fiapac members, to advocate the right of every woman to have a safe abortion, to help local organizations in reaching that goal and to develop teaching programs for doctors, nurses and social workers.
15:30W09 Beyond first Trimester, HS 8Sedia:W10 Legal aspects, HS 9
- Pedro Peña Coello, ES
Sedia:W11 Counselling, HS 7
- Kristina Gemzell-Danielsson, SE (all speeches)
Beyond the first trimester: Medical methods
Kristina Gemzell Danielsson MD, PhD, Dept of Obstetrics and Gynecology,
Karolinska University Hospital/ Institute, Stockholm, Sweden
Second trimester abortion constitute 10-15% of all induced abortions but are responsible for two thirds of all major complications. The non-surgical methods to terminate 2nd trimester abortion have shown a considerable development during the last 30 years. In the beginning of the 70ies prostaglandins become available on this indication. The non-invasive mode of administration has certainly facilitated the treatment and reduced the risk for complications. With the introduction of mifepristone the method could be further improved.
Mifepristone has been registered in Sweden since 1992 for termination of early pregnancy until 63 days and from 1994 for termination of second trimester pregnancy in combination with gemeprost. With the approved regimen 600 mg mifepristone followed by 1 mg gemeprost vaginally every 6 hours the median prostaglandin to abortion interval was shown to be 9.0 (1.4-40.5) hours for primigravidae and 7.2 (0-152.5) hours for multigravidae. The medium number of gemeprost pessaries to induce abortion was 2. Our data confirms the efficacy and safety of mifepristone combined with gemeprost for termination of second trimester pregnancy when used on a routine basis in the clinic. Today, another prostaglandin analogue, misoprostol, has been shown to be an attractive alternative to gemeprost with higher efficacy and a lower rate of side effects. Various regimens of misoprostol with or without mifepristone have been investigated. Recently it has been shown that sublingual administration of misoprostol is also an effective alternative for second trimester abortion.
- Oskari Heikinheimo, FI (all speeches)
One-and two day mifepristone-misoprostol intervals are both effective in medical termination of second trimester pregnancy
Oskari Heikinheimo, Satu Suhonen and Maija Haukkamaa, Department of Ob&Gyn, Helsinki University Central Hospital, Finland
Termination of pregnancy because of fetal anomaly requires the utmost clinical sensitivity and individualized patient care. We compared the efficacy of a one-day mifepristone and misoprostol –interval in medical termination of second trimester pregnancy performed because of fetal anomaly with that of the standard two-day interval among the first 100 women in each group. A 200 mg dose of mifepristone was used; 0.4 mg of misoprostol was administered vaginally at three-hour intervals until abortion occurred.
When calculated from ingestion of mifepristone, the time to abortion was 28:25 h (23:10 – 50:40 h) (median (range)) and 52:43 h (45:55 – 83:15 h) (p<0.0001) in the one- and two-day MIFE-MISO groups, respectively. However, following initiation of misoprostol administration the time to abortion (7:25 h (1:00 – 23:15 h)) was longer (p<0.05) in the one-day interval group than in the two-day interval group (6:20 h (0:45 – 36:30 h); by 12 h 82 and 87% (n.s.), respectively, of the subjects had aborted. The proportions of cases undergoing surgical evacuation of the uterus were 64 and 45% (p<0.001), in the one- and two-day interval groups, respectively.
Thus both one- and two-day mifepristone-misoprostol intervals are both valuable in termination of second trimester pregnancy.
- Chantal Birman, FR (all speeches)
Psychological aspects of second trimester abortions for medical indications
Chantal Birman (F)
The Midwife’s Role in Helping Parents Through a Termination of Pregnancy
Before dealing with the subject proper, I feel I should describe briefly the situation in France.
Ultrasound was introduced in 1974. Early in the eighties the complete system for prenatal diagnosis was put in place. Over the same period, we learned how to extend the term of pathological pregnancies. Concurrently, progress in the management of prematurity helped these neonates to survive.
Currently, fewer than 20% of terminations are performed under the provisions of the 1975 Act that allows such procedures where the mother’s health is at risk. Some 80% are carried out for foetal indications. Indications for terminations on medical grounds involve 1% of all births. The number of such terminations due to foetal abnormalities went from 1 in 400 births en 1981/83 to 1% in 1989/90. Down’s syndrome represents 50% of all anomalies found and 90% of these pregnancies are terminated. However, 30% of abnormalities escape antepartum detection (references: « Faire vivre et laisser mourir » by Dominique Memmi who recompiled data taken from the degree in social anthropology done by M. Piejus).
The reason I have given these figures is to show that we midwives, whose role is to see mothers through their confinement, are confronted regularly, though not daily, with terminations of pregnancies for medical reasons.
Over one year, these terminations involve few tours of duty and, for me, seldom number more than 5. At the Maternité des Lilas, where I work, two midwives are on duty and I always volunteer unless my colleague has managed the woman before I begin my shift. The terminations are performed in the delivery room, between normal births.
It has been my experience that the vast majority of these procedures are done in the second three months of the pregnancy, rarely in the last three months.
In France, we induce labour by the well-known Mifegine/Misoprostol protocol. Analgesia is induced in two phases:
1° Fentanyl perfusion with the flow rate adjusted to the requirement of the woman;
2° epidural analgesia when required.
It should be noted that conversely to the appeals of their partners and the opinions of the medical team, most women (of course not all of them) are less inclined to ask for immediate pain relief. For some of them, pain is a physical support for their intangible – because incomprehensible –torment caused by the anomaly.
We midwives also are reminded by the painful contractions that this child, just like those of the other women giving birth, has become incarnate within this body and will soon be born dead or alive.
While French legislation allows terminations on medical grounds, it outlaws infanticide. Application varies from one facility to another.
The couple will not get the child of their dreams.
The couple give birth to a dead baby.
But the thing is that this child is abnormal; that is, a monster. Remember that monster derives from the Latin [from Old French monstre, from Latin monstrum (portent), from mon‘re (to warn)] and the term conveys at once the idea of foreboding and demonstrating or showing. Indeed the anomaly is only realised once it is revealed by the scrutiny of the ultrasonographer or the geneticist.
The parents break both their lineages of normal children and register forever the anomaly in both families. Through this deed, for which they are not responsible, they actualise their monstrous parenthood and can bestow affection on the child they have borne.
The voice of the midwife points out that the woman giving birth in the next room to a normal baby cannot be blamed for that normality. The voids between us are made of all these unanswered questions, and the unwinnable revolt against utterly unjust circumstance.
Right then, the parents also want to vanish with their baby; yet they already know full well that the time afterwards is to come, that in it they will be survivors, and that life goes on.
You have to be mad to go through pregnancy terminations however much - or little - involved you may be. For my part, I feel that the most fragile, because at once the most vulnerable, without being able to incorporate his grief is the father. It takes modesty to help him through. Often, I try to come to their aid through their wives, explaining to the women what is about to happen. In fact, the women have an inkling of what is to come; but not the men. Such indirect assistance helps the father realise that there are limits and that the madness in which he is entangled will come to an end.
Strangely, the process of cervical dilation mimics the abnormality. Instead of being steady and predictable, as with the delivery of a normal child, the cervix remains hard, almost entirely effaced, only just patent, with a presentation bulging behind it. Suddenly, and quite unpredictably, the cervix opens and the foetus proceeds into the vagina, or is even expelled.
Often, to shield the woman from the sounds of neighbouring births, her transfer to the delivery room is delayed. Hence, so that they will know what to expect, the couple must be informed that the birth may occur in the patient’s room. Quiet, cool-headed efficiency of the team appears to be the prime requirement to ensure the smooth progress, both technical and psychological, of these births.
If necessary, once the foetus is born there is time to take the woman to the delivery room, for the placental birth and a uterine exploration. However, expulsion of the foetus on the stretcher is always upsetting to both parents and care providers.
In conclusion, to help people through a termination of pregnancy is to weave mortality with monstrosity. This takes us to the borderline of humanity. You don’t know whether you come through it a better person or a destroyed one. One thing is sure: afterwards, it’s my skin (organ delineating the inside from the outside) that I determinedly scrub under the shower. I have long kept quiet about this cleansing, that I believed private; but my colleagues also feel this need. Now I know why that ablution belongs in traditional and religious rituals surrounding death.
- Janna Westerhuis, NL (all speeches)
Janna Westerhuis MD, & Daan Schipper MD, medical director Bloemenhovekliniek, Heemstede, Holland
Since 1973, second trimester pregnancy terminations have been carried out using the D & E method introduced to us by Arnold Finks. This method has been subjected to adjustments by the introduction of prostaglandin induction with F2, Sulproston, E2 gel and now misoprostol. With the assistance of prostaglandin alone, a fully successful method has never been found within the reduced time frame of around 8 hours, which is dependant on the maximum time women can stay in the clinic (limit of 24 hours). Furthermore, it has always been strongly asserted in the Netherlands that attempts should be made to reduce the suffering of the woman during the abortion procedure as far as possible.
This is why there is still a great deal of emphasis placed on maintaining the skills and training of young doctors in this surgical technique. An approach has since been developed in Heemstede which occupies the middle ground between surgical abortion and procedures involving the use of medication.
- Mirella Parachini, IT
Sedia:W12 Surgical first trimester, HS 10
- Joyce Arthur, CA (all speeches)
Do we need a law on abortion at all?
Director Pro-Choice Action Network
Editor of the Pro-Choice Press
"Keep Your Laws Off My Body!"
Canada is the only democratic, industrialized country in the world with NO laws against abortion (since 1988). Abortion is managed like any other necessary health procedure, and as a result, services have flourished and improved significantly, with no ill effects or abuses. Legal restrictions against abortion are leftover artifacts from the days of criminal abortion and are fundamentally unjust, with many negative consequences: They reduce access to abortion, pose arbitrary obstacles, marginalize abortion outside the medical mainstream, stigmatize healthcare professionals, turn abortion into a political target for extremists, and breed hypocrisy and disrespect for the law. Most importantly, they discriminate against women and violate women's constitutional right to equality. Laws against abortion amount to a publicly-sanctioned judgment against women's moral reasoning, their sexuality, and their right to control their own lives.
- Gunta Lazdane, DK (all speeches)
Situation of induced abortions in Europe and policy changes
Gunta Lazdane , WHO Regional Office for Europe
There are 52 Member States in the European Region of WHO with a diverse political, economic, religious and social situation. There are countries with diversity of legal grounds to perform abortion, and countries with the lowest and highest numbers of induced abortions in the world.
The numbers of induced abortions have been decreasing all over the Region for the last 10 years, yet the rate of abortions per 1000 women 15-19 years old is much more stable and even increasing in some parts of the Region. The same trend is observed in some migrant groups or in ethnic minorities.
Despite the improved access to information, reproductive health services and contraception that decreases the number of unwanted pregnancies, there are still many problems to be solved:
- in some countries more than 20% of maternal deaths are due to the complications of abortion,
- the complication rate after abortion is high,
- there is a lack of statistics in many countries,
- there is a lack of political will to face and solve the problems related to abortion.
The Reproductive Health and Research programme in the WHO Regional Office for Europe has included the reduction of induced abortions as one of the objectives and targets in the WHO European Regional Strategy on Sexual and Reproductive Health (2001) and recommends the implementation framework to reach this target. WHO assists those Member States who have prioritized this problem as one of the major causes of women’s ill-health in their countries.
- Pierre Moonens, BE
- Philippe Lefèbvre, FR (all speeches)
Choice between medical and surgical abortion,
Philippe Lefèbvre MD, Président de l’ Association Nationale des Centres d’Interruption de grossesse et de Contraception, Chef du Service d’Orthogènie – Hôpital La Fraternité, Roubaix, France
Interrupting her pregnancy is a decision which belongs to the woman and only to her. However, once this decision is made, since a medical environment is required to guarantee her safety, the choice of a technique will take place whereas medical power is potentially at risk of being overbearing. The purpose of this paper is to evaluate if the objective and subjective elements of choice are the sole factors to intervene in the choice of the TOP method.
The duty of informing the patient about the various available options , their respective efficiency, and their potential risks, allows in theory , the woman to make an informed choice.
However, the medical practices are subject to numerous contingencies such as : access time, availability of mifepristone, presence of an anesthesist practitioner, economical viability of the medical act, implementation of the hospital-city network, lack of training, and sometimes , the difficulty for a doctor to challenge himself his own practices or habbits.
The litterature about good practices and clinical guidelines states that the type of technique , medical TOP or chirurgical TOP, is defined by the gestationnel age. But working by this sole criteria is obviously not enough, while the choice of a technique should be reached through a good medical consultancy , establishing a dialog between the patient and the professional (counsellers, nurses, doctors,) developping appropriate proposals.
The buy-in of the patient to the chosen method plays an essential role in the physical as well as psychical acceptance of the TOP.
Experience in the field shows that the TOP method will be all the more accepted by the patient that her buy-in shall have been seeked and reached.
Despite the ongoing upgrades of the techniques for the last 30 years , it is a shame that making a true choice available to the patient remains so highly dependant on some practitioners good will.
- Olga Loeber, NL (all speeches)
Contraceptive counselling after abortion
Olga Loeber MD, Mildredhuis-Rutgershuis, Centre for Contraception, Sexuality and Abortion, Arnhem, The Netherlands
In the Netherlands contraceptive counselling forms an integral part of the intake procedure. Almost all forms of contraception is feasible after an uncomplicated first trimester abortion. Still the number of repeat abortion is relatively high in most countries even if there are a broad knowledge about and availability of contraceptive possibilities.
Knowledge and availability are only partly the prerequisite for effective contraception. Social personal factors (for instance fears, myths, ambivalence towards pregnancy, ability to negotiate, characteristics of the relationship with the partner) are equally important. Personal counselling with tailored advice is of utmost importance. This counselling could be done not only by doctors but also by various other personnel with a broad understanding and knowledge of contraception and underlying personal factors as for instance nurses and midwives.
Possible explanations for the repeat abortion rate and practical solutions will be discussed.
Cases and points of view dealing with this topic will be the basis of a discussion with the participants of the workshop. Comparison between countries could lead to a better understanding of the subject.
- Karen Schlie, DK (all speeches)
Who should do the counselling: doctor – non doctor?
Karen Schlie , Family Planning, Hamburg - Germany
The first question arising in this connection is the question of what is at issue in the counselling. As a counsellor having graduated in pedagogic with additional therapeutic qualifications I have to focus on the client’s issues.
What are her needs and wishes concerning counselling prior to an abortion.
- Does she need support in taking her decision or rather an opportunity to reflect whether she has taken the right decision?
- Does she require information about abortion: medical information, the selection of the right method, the procedure, framework conditions or the steps to go – just to mention a few examples?
- Or does the client rather wish information about social/financial support in order to reconsider whether this would influence her decision?
- Are there any specific legal conditions concerning abortion to be observed in different countries?
- Are there any legal conditions for the physician such as her duty to inform about complications?
- Does the client wish any counselling at all?
This range of questions shows that different qualifications are required to provide adequate and professional help for the respective problem.
Therefore I would not ask who should do the counselling prior to an abortion but rather which qualifications the physician or other professional should have.
I work as a counsellor at the family planning centre in Hamburg/Germany. I have a university degree in pedagogics with additional qualifications in social work and psycho-therapy. These are qualifications from which I benefit in my pre-abortion counselling work.
As counselling prior to an abortion is compulsory in Germany, we often have to deal with resistance and fear. Frequently, our clients are insecure and don’t know what they have to expect from the counselling.
In our counselling work we distinguish between clients who have already taken their decision to have an abortion (which is the case for about 80 % of our clients) and those who rather seek support in their decision-taking process (some 20 %). The latter need a therapeutically trained counsellor.
Mostly, both types of clients wish to also receive medical information.
Therefore, medical knowledge about the performance of an abortion and any potential complications is required. In our team at the family planning centre, we have physicians and perform abortions ourselves. If the client has any questions I cannot answer, I can refer her to a physician or can acquire the relevant knowledge myself. Vice versa, the physicians can refer to me or one of my colleagues, if they become aware that the client has not yet taken her decision or is in a crisis due to an inner conflict.
Of course, these opportunities are not available at every institution or clinic; and therefore it is essential to try to establish a good network of cooperation and, if necessary, to take part in specific training.
Regardless of your profession, I think it is important to reflect your own inner processes as well as your practical work. Counselling competence, such as certain communication techniques, might also be of help in the medical context.
Thus, in supporting the client in her choice of the appropriate abortion method you should also talk about her personal situation taking into account her particular needs.
- Are there, for example, small children but nobody who could take care of them?
- Is she afraid of surgical abortion because of past bad experience with operations?
- Does she consider Mifegyne to be a more self-determined way which she would prefer while a surgical abortion might give her the feeling of being in someone’s hands (“there’s someone doing I don’t know what to me”) – possibly due to a history of sexual abuse?
- In case the pregnancy is too advanced for medical abortion so that she has to choose the surgical way, it may be important to reflect whether it is more appropriate for her to get local anaesthesia as she could then participate consciously in the entire process.
- Or would she rather prefer not to live consciously through the surgical abortion process because it might lead to retraumatization due to past experience with violence? Then general anaesthesia might be her choice.
For all these questions it is useful if I as a counsellor can reflect my own feelings while I inform the client about the various methods. Am I able to go with the client and her decision even if I would choose a different method in a similar situation? And by the way, what is my way of informing? Do I conduct the dialogue in a way ensuring that the client can take a self-determined decision about the method she considers most appropriate? Am I the one determining what is “self-determined” or am I rather able to put aside my own concepts of what might be best for the client.
Summarizing I come back to the one central question: What are the qualifications required by a counsellor to deal with abortion, no matter whether she is a physician or another health professional?
In my opinion we are not looking for an either-or solution but rather for an as-well-as solution. This means that physicians and other professionals should cooperate and support each other in order to participate from each other’s competence in striving for the greatest possible benefit for the client.
- Marijke Alblas, ZA
- Helena von Hertzen, CH (all speeches)
Cervical priming – where is the evidence?
Helena von Hertzen (WHO), Geneva
Cervical priming before surgical abortion is especially beneficial for women with cervical anomalies or previous surgery, young women and those with advanced pregnancy, as they have a higher risk of cervical injury or uterine perforation. WHO Scientific Group, therefore, recommended routine priming for durations of pregnancy over 9 completed weeks for nulliparous women, for women younger than 18 years old and for all women with durations of pregnancy over 12 completed weeks.
Recent research, however, suggests that all women (and doctors performing the procedure) benefit from routine priming, especially when misoprostol is used. The use of laminaria seems to be outdated, as in comparative studies more complications were seen after laminaria than after gemeprost. Further, gemeprost has been shown to be associated with more side-effects and complications when compared to oral (0.4 mg) or vaginal (0.2 mg) misoprostol, although cervical dilation, operation time or bleeding are similar. Only the use of mifepristone can compete with misoprostol in efficacy and low rate of side effects, but its high price and the long interval required between the treatment and procedure makes it less attractive.
The optimal dose of misoprostol is 0.4 mg: lower doses are less effective and higher doses do not give any advantage, they only cause more side effects. The appropriate interval between misoprostol administration and vacuum aspiration is 3 hours, because shorter intervals are not sufficient for full priming effect, even if the dose is increased. Oral, sublingual and vaginal routes of administration of misoprostol have been compared, sublingual administration may give somewhat better results compared to oral administration, but has more side effects, but when compared to vaginal administration there does not seem to be a difference in efficacy, but in some studies women have reported more side effects after sublingual administration.
- Annet Jansen, NL (all speeches)
Is there a lower limit in gestational age?
Annet Jansen MD, 1979-1984 Curaçao (Dutch Antilles), 2 years department gynaecology and obstetrics, 1984 rehabilitation outpatient department university hospital Groningen, 1985-1998 primary health center baby and child care (prevention), 1993- medical supervisor center for sexual and reproductive health Amsterdam
It is acceptable to perform an abortion from 2.5- 3 weeks gestation if the pregnancy test is positive and the pregnancy is detected intra uterine by ultrasound examination.
In the Netherlands there is quite a lot of experience with early first trimester surgical abortions with good results. The percentage of failures is 2-5%, comparable with failures by use of the abortion pill.
The failures are usually not on going pregnancies, but retained placentaparts.
A higher risk of failed abortion is seen by uterine anomalies, by twin pregnancies, extreme position of the uterus, retroflexion or anteflexion.
The follow up after 3 weeks is offered to each woman. It includes a laboratory test and if positive an ultrasound examination will follow to exclude an on going pregnancy.
Depending on the complaints of the failed curettage there is required a repeat curettage.
- Marie-Jeanne Martin, FR (all speeches)
Pain treatment in local anaesthesia
Marie Jeanne Martin MD, Hopital d’Armentières – Armentières - France
I represent a team from an abortion centre, in the North of France. In this region, most abortions are practiced in public hospitals. We are a small team and I want to lay stress on the presence of counsellors fully fledged in the team.
A modification in the law, in 2001, has authorized abortions until 14 weeks since last periods. This modification has generated a lot of discussions and debates, sometimes very severe between professionals, but not at all in the public opinion. During these discussions, some of our colleagues were very surprised to learn what we practiced all abortions with local anesthesia (whatever the term). They considered that general anesthesia was always indicated for pregnancy which were above 12 weeks since last periods because of pain.
So, we asked ourselves on our « evaluation » of the pain felt and also on our method of local anesthesia. We asked us few questions:
- Are surgical abortions more painful after 12 weeks since last periods?
- What adequacy can be found between the level of pain felt by a woman and the evaluation of this pain by the practitioner of the aspiration ?
- It should be noted that during our current study, we have modified technique of anesthesia. Also we have introduced an additional question:
- Is this technique more effective on the level of pain felt ?
The study deals with all the women having a chirurgical abortion whatever the term of the pregnancy. This study was made over a period of 4 months (from March 4 to July 11, 2003). This is an analysis of a subjective evaluation of the pain collected by means of the analogical visual scale, the scale being held vertically. The collection of these feelings was made during the hospitalization at 6 different periods. The presentation and the collection of the scale were made by the same nurse all along the study. Just after the aspiration, at the same time as his report, the doctor notes from 0 to 10 his own evaluation of the pain felt by the lady during the aspiration.
We will present our work with the help of a short film. (see technical drawings in attached)
Principles which are important are:
- Using medicines to dilate cervix, to calm down anxiety, to calm pain in advance.
- A warmth atmosphere, with attention, where we could be close.
- A technique, always looking for improving.
We collected 188 exploitable cards (55 aspirations took place without addition of bicarbonate, that is to say approximately a third, 133 took place with bicarbonate which is to say two thirds of the total). Half of abortions were done between 9 and 11 weeks since last periods which is a representation of the French national statistics.
It’s a modest study:
- by the number of “exploited” files since we have only 188 files
- and by the realization of the study itself and the results obtained since we are not accustomed a realization of studies.
With the impression that the aspirations are felt by woman as more painful for the most advanced terms (superior with 12 weeks since last periods) we could answer : no
and than on the contrary the aspirations of the smaller pregnancies hurt the most.
With the search of the reliability of the evaluation of the pain, by the practitioner, one sees that whatever the doctor, there are errors in undercutting and on quotation, with tendency to on quotation. So this study gives us the opportunity of staying on our place and of committing us to remain vigilant not to plate our impressions like single truth..
With the search for an improvement of the local anesthesia, it appears clearly that our new way of making (with addition of bicarbonate to the lidocaïne in order to plug acidity off it, and with multiple microinjections in the cervix) is much more effective and decreases pains to a significant degree.
Our objectives are always to improve the accompanying of the women and the couples. The alleviation of this moment of their lives forms part of our objectives and this alleviation helps to reduce the painful. This is why we should seek the greater comfort for the lady (who is not the same think as greatest comfort for the doctor). And for this reason the presence in the team of full-time counselors, and this throughout the experience of the women and couples, is a paramount element in this alleviation of the procedure and thus in the pain felt.
- Marijke Alblas, ZA
- Elisabeth Aubény, FR
- Pierre Moonens, BE (all speeches)
A good law is not enough
Pierre Moonens MD, Member of the Board of the “Fédération de Centres de Planning Familiaux”, member of the Board of “Gacehpa”, Belgium. Co-founder and Vice President of Fiapac
In my daily work at a southern family planning of Belgium, a third of our clients are coming from Luxemburg. They do not find an opportunity to be aborted in their own country. This situation is very surprising: the Luxemburg’s law is very similar to the Belgian one, and any way those women should find the possibility to be helped by their own medical structures, but it does not work.
Why is it so?
Which “bad reasons» do give the possibility to those medical structures not to apply their law?
Even in Belgium, we do not use all the potentialities of our so said “good law”.
What did we loose in Belgium with the introduction of our so said “good law”, in comparison with the previous so said “bad obsolete law”?
How has it be possible in Spain, with such a weak law, to develop a so “liberal” situation for women asking for abortion?
Some tactical and ethical reflections when the opportunity appears to improve a national
law about abortion.