Seville, 21-24 Ottobre 2010: „Achieving excellence in abortion care“
10:30Session on legal aspects, GChair:
- Gunta Lazdane, DK
- Sam Rowlands, GB
Experiences of decriminalising abortion in Victoria
Dr Leslie Cannold, author, medical ethicist and the President of Reproductive Choice Australia and Pro-
Choice Victoria, grass-roots community groups that have played key roles in reforming Australian laws
In Australia, abortion is regulated by the states, most of which maintain abortion in the criminal code. In 2008, after a brutal political battle within and outside the Parliament, the Government’s Abortion Law Bill 2008 was passed into law without amendment. The new law removes abortion from the Crimes Act. Up to 24 weeks gestation, it is now regulated like all other medical procedures. After 24 weeks, doctors maintain control of the decision, two of whom must judge it as “appropriate in all the circumstances.” Subsequent efforts to reform laws similar to Victoria’s in NSW and Queensland, where a young woman is currently being prosecuted for the crime of procuring her own abortion, have so far been unsuccessful. Based on my involvement in successful law reform efforts nationally (in removing restrictions to the i mportation of RU486) and in Victoria, NSW and Queensland (in attempts to reform state abortion laws), I will identify factors vital to successful law reform efforts.
Impact of legalizing abortion in Portugal in 2007
Mara Carvalho, Portugal
In Portugal, in the past February 11th of 2007, 59,3% of the Portuguese voted “Yes” to a new abortion law and a certainty became evident: an important majority of the Portuguese society identified a persons’ autonomy as an ethical principle, ensuring a free and universal access to safe abortion by woman’s request up to 10 weeks of gestation. This legal framework allows you to have real numbers on abortion, thereby being able to identify vulnerable groups, access the implications and interpretation of possible changes over time.
In this new setting, the estimated numbers were around 20,000 abortions per year, by woman’s request. In a study made by APF - the Family Planning Association - the number predicted was around 17 000. After the implementation of the law the number of abortions by woman’s request up to 10 weeks was similar to predicted (18 014 in 2008 and 18 951 in 2009), about 70% were performed in the public health system and, of those, the medical abortion was the method chosen in 96% of cases.
Over the past few years have been reported less severe complications (infection / sepsis and
uterine perforation) related to abortion5. It was recently made public the report of the Maternal Deaths 2001-2007. During this period, in 14 of 92 maternal deaths reported, the cause of death was associated with unsafe abortion. Are not yet published the data of maternal deaths in 2008 -2009, but preliminary analysis indicates that there have been no deaths related to abortion after the legalization.
Analysing the data we conclude that the big majority of abortions since 2007 were performed in a legal and safe context, the portuguese public health system was capable to properly respond to the abortion requests and regarding the ratio between medical and cirurgical abortion, we realize that medical abortion is the elected method.
In Portugal, three years after the legalization, it’s still urgent to inform all the women that they have a new right of choice with access to non-directive and specialized support and care, to implement consistent Sexual Education policies and improve the abortion network, including medical abortion performed by family physicians.
The campaign to liberise the law in Spain : ACAI´s mark on a new act
Eva Rodriguez, Spain
Twenty-three years since the enacting of the 1965 Abortion Bill, Virginia’s right to decide, like that of
thousands of other women, was once again called into question in Spain, with the outbreak of an unprecedented crisis. Following a report by the Catholic organisation E-Christians on illegal abortions, on the 26th November 2007 the Civil Guard searched the clinics of Dr. Carlos Morín, arresting seven people and seizing the medical records of 2,780 women. The Morín case, still pending a court ruling, burst into the scene, reinstating the dichotomy: abortion yes, abortion no, which the political elite of the Transition had tried to resolve.
The abortion indications law, which legalised abortion in three possible cases: foetal pathology, rape, and in the interests of the pregnant woman's health, allowed professionals to work with the same perspective on health as that of the WHO, which comprehends not only the absence of illnesses but also physical, psychological and social well-being. This professional decision made it possible for 90% of Spanish women to have the option to interrupt their pregnancies during the last 25 years.
If the ambiguity of the Law permitted the standardisation of abortion in Spain, this very same ambiguity has aided the anti-abortion groups which have played the leading role in one of the fiercest battles against this women's right; the politically-instigated inspections, the reporting to the police, the attacks and the circulation of distorted information have diminished the legal and personal safety of medical professionals and women over the last three years.
One of the most serious violations took place in January 2008, when agents of SEPRONA Unit of the Civil Guard appeared at the homes of 25 women, urging them to give evidence. These facts were used in the case against the Isadora Clinic, opened by Judge Sierra, who for a year and a half has been proceeding with criminal charges against three doctors of this Clinic, on suspicion of carrying out illegal abortions and irregular treatment of the remains.
In the same week in which 25 women were investigated for having illegal abortions, 40 clinics - more than half of those in Spain - suspended activity because it was no longer possible for them to guarantee the provision of their services, nor safety. The 2,000 abortions that were not carried out between 7th and 13th January 2008 prove that it is the private clinics that undertake a provision of a service that is technically covered, but not provided, by the Spanish National Health System.
The suspension of activity ended on the 13th January with the publication of a manifesto in the newspaper El País. In it, 66 national and international organisations joined forces with the clinics, to call for respect and personal and legal safety for both women and medical professionals, but above all, to call for a change in the law.
The pressure served to speed up the action and the dialogue between the clinics and the political parties. Also during those days, came the reactions of the Spanish Government and also of an Executive in
charge of delegating mediation with the clinics to its Ministers of Health and Justice.
During those days, the feminist movement, along with civil, legal, trade union and health platforms, took the debate to the streets, with rallies and protests in favour of the right to abortion taking place all over Spain. Instigated by the Alcerín Women’s Association, a campaign was started in Vigo, which would present to different courts all over Spain more than 15,000 voluntary pleas of guilty to having an abortion, while at the port of Valencia the boat of the organisation “Woman on Waves” arrived. On 9th March 2008, the Socialist Party (PSOE) won the election. The electoral victory cleared the way for reformation of the Abortion Law. The Ministry of Equality, headed by Bibiana Aído, was the body commissioned to tackle this reform, for which purpose it would create a committee made up of experts, whose deliberations would be made public to the groups and platforms both for and against the legislative change, among them, the Association of Authorised Clinics.
While the ministerial work was under way, a parliamentary sub-commission, in which would appear experts and spokespersons for both supporters and opponents of a new law, was created. The President of the Association of Authorised Clinics, Santiago Barambio, would participate, at the suggestion of the party in government, in the said sub-commission on 25th November 2008.
The action taken by the Catalan Family Planning Association, coordinated and led by its Vice-president, Isabel Iserte, and the State Family Planning Federation, proved to be essential in the incorporation of some of the historic demands of these Platforms.
As the bill overcame the obstacles involved in its processing, on the streets the position between supporters and opponents of the right to abortion becomes increasingly heated with the approach of the final reading,which took place in the Senate on the 24th February 2010. The bill was carried with 132 votes in favour and 126 votes against and the Sexual and Reproductive Health and Voluntary Termination of Pregnancy Act became law.
Working within existing legal frameworks to improve access to abortion
Joanna Erdman, International Reproductive and Sexual Health Law Programme, Faculty of Law,
University of Toronto, Canada
Despite the liberalization of criminal laws, safe abortion services remain inaccessible in many countries. Lack of information is a significant access barrier. Women and health providers do not know what the law allows, deterring women from seeking and providers from delivering services within the health sector. Third-party authorization, dignity-denying in service provision and health system administration all further contribute to unsafe abortion by restricting access to lawful services. This presentation explores recent developments in transnational law on access barriers to safe abortion, focusing attention on the legal reasoning or rationale that proved persuasive in the reform of laws, policies and practices restricting access to safe abortion.
12:30Workshop E Medical abortion- improving access, Giralda I+IIChair:Workshop F Abortion counselling, Arenal
- Elisabeth Aubény, FR
- OE. Iversen
Chair:Workshop G WHO session, Nervión
Medabon introduced by Concept Foundation
Peter Hall, Chief Executive Officer, Concept Foundation, Bangkok, Thailand and Geneva, Switzerland
In order to make medical abortion more widely available, Concept Foundation, a not-for-profit organization based in Bangkok, Thailand, has been working to get a product available of assured quality at an affordable cost. It has been responsible, though a public-private partnership between WHO, Concept Foundation and industry, for the development of Medabon®, a co-packaged product containing 200mg mifepristone and 800µg misoprostol. The issue of abortion is often highly controversial, sensitive, emotive and with significant socio-cultural and moral dynamics and thus the introduction and use of products for medical abortion products requires careful planning. It is necessary to develop and implement an appropriately designed introductory process, which takes a systematic and incremental approach; ensures coordination and collaboration between the public health system and all key stakeholders; and utilizes a supportive health system. This has been undertaken with Medabon® in Cambodia, Nepal and Zambia.
Medical Abortion at 9-13 Weeks
Professor Allan Templeton, University of Aberdeen, United Kingdom
The formulation of the antiprogesterone drug mifepristone in the 1980s led to the development of safe and effective medical abortion as an alternative to surgery. Initially the regimens were used in the early first trimester and second trimester, and increasingly employed the prostaglandin E analogue misoprostol given by a variety of routes, including oral (swallowing), vaginal, sublingual and buccal.
About ten years ago this approach was also assessed for use in the late first trimester and as a result medical abortion is now used at all gestations, where preferred to surgery. This review will focus on 10 years experience of late first trimester medical abortion at one centre, including efficacy, side-effects and acceptability. It will also illustrate how frequent review has facilitated improvement and development of the regimens used.
- Maria Francès- Kircz, NL
Chair:Workshop H ESC session, Santa Cruz
The decision-making process
Sam Rowlands, University of Warwick, Coventry,United Kingdom
When a woman becomes pregnant, her adjustment to it and decision on how to proceed can be broken down into five stages:
- Acknowledgement of the pregnancy
- Formulation of the three options: continuation of the pregnancy to keep the baby, continuation of the
pregnancy to give the baby up for adoption and abortion
- Selection of continuation of the pregnancy or abortion by a balancing exercise
- Commitment to the chosen outcome
- Adherence to the decision
Many women who learn a pregnancy test is positive have already rehearsed how they would feel; this speeds up the process. Most women are certain about their decision on the three options. Some women have a strong emotional reaction to learning they are pregnant – these include shock, disbelief and self-reproach. Ambivalence is a normal part of the decision-making process; however it delays the decision in only around 1 in 10 individuals. For a large majority, the decision-making process is made quickly.
The decision can be viewed as a balancing exercise between on the one hand constraints such as career, quality of relationship, family size and immaturity and on the other hand the desire to procreate. During the process most individuals discuss their situation with other people, typically partner, significant others and health professionals. A study by Ashton showed that the number of discussants was positively correlated with the stability of the decision.
There are certain difficulties faced by younger women making their decisions. They tend to have more discussants, but to talk at a more superficial level. Their decisions tend to take longer to make; sometimes they conceal the pregnancy so as to avoid having to make a decision. Often for young people,
this is the first major decision they have ever had to make.
When considering the ability of very young women to make decisions, it is helpful to consider intellectual function according to age. At 12 years of age, a young person is able to think in an abstract way. By 14 years of age, a young person is able to make a complex moral and personal decision.
For all women, delay in the decision-making process can occur for the following reasons:
- Variable “recognition threshold”
- Blocks in the five-stage process
- Subtle psychodynamic factors
- Denial of the pregnancy (rare)
For those involved in counselling women faced with an unintended pregnancy, predictors of poor outcome following abortion should be looked for. These include:
- History of mental health problems
- Poor practical or emotional support from family and friends
- Suspected coercion
- Overt ambivalence
- André Seidenberg, CH
Experience of application of WHO tools and guidelines in the WHO European Region
in improving quality of abortion services
Gunta Lazdane, MD, PhD, Regional Adviser Sexual and Reproductive Health and Research, WHO Regional Office for Europe
Prevention of unsafe abortion is one of the five core aspects of the WHO Global Reproductive Health Strategy adopted by the World Health Assembly in 2004. However, up to 20 % of all deaths during pregnancy in several countries of the European Region are due to unsafe abortion. There is a lack of reliable data on morbidity after abortion. Many Member States and ministries of health (in the countries of central and eastern Europe, France, Luxemburg, the Netherlands, Sweden) have focused on prevention of unwanted pregnancy and unsafe abortion and improvement of reproductive health services at primary
The role of the WHO in the Region includes distributing existing evidence on abortion, assisting countries in evaluating health systems’ response to the needs of women with unwanted pregnancies and building the capacity of health care professionals in counselling and abortion care.
WHO has assisted governments and professional organizations in developing national policies on sexual and reproductive health policies based on the detailed analysis of the country situation in prevention and management of unwanted/unplanned pregnancies and quality of abortion services. Recently this exercise has been carried out in Azerbaijan, the Republic of Moldova, the Russian Federation, the former Yugoslav Republic of Macedonia, and Ukraine. In most of these countries WHO’s Strategic Approach tool has been used to answer the question on how to reduce the recourse of abortion and improve the existing health services. National guidelines on safe abortion have been developed with the WHO assistance in Armenia, the Republic of Moldova, the former Yugoslav Republic of Macedonia, Tajikistan, and Ukraine. Summary of the challenges in improving access to quality abortion services in the WHO European Region will be presented.
WHO tools and activities addressing unsafe abortion
R.Johnson, WHO, Switzerland
This presentation will provide an overview of global experience implementing the WHO’s ‘Safe abortion: technical and policy guidance for health systems’*, using the WHO’s ‘Strategic Approach to strengthening sexual and reproductive health policies and programmes’** and ‘Using human rights to advance sexual and reproductive health: a tool for examining laws, regulations and policies’.
The WHO safe abortion technical and policy guidance was first published in 2003. The second edition is scheduled for publication in 2011 in addition to new WHO clinical guidelines on comprehensive abortion care. The WHO Strategic Approach is a three-stage process that includes;
1) a strategic assessment to identify and prioritize sexual and reproductive health needs;
2) implementation of policy and programme interventions to address those needs;
3) scaling up interventions so their benefits can have broader impact.
It has been applied to prevention of unsafe abortion in 13 countries to date. The WHO human rights tool (still in draft form, but piloted in several countries) is an instrument that can be used to document and examine laws, regulations and policies related to a broad range of sexual and reproductive health issues. In June 2009, it was incorporated for the first time into a strategic assessment on unsafe abortion, conducted in Malawi.
- Johannes Bitzer, CH
- Medard Lech, PL
Contraception and obesity
Jan Brynhildsen, Faculty of Health Sciences, Linköping University, Sweden
The prevalence of obesity is still increasing. The most rapid increase during the last years has been in female adolescents. Obesity is associated with many health risks including cardiovascular disease, hypertension, the metabolic syndrome, malignancies and venous thromboembolism. Because hormonal contraception might interfere with these risks, both in negative and positive ways, it is important to address and discuss this issue.
The COC-associated risk of thromboembolism seems to be higher in obese than in normal weight women. The interpretations of these data vary and consequently also recommendations vary between different authorities. The situation might be confusing. The obese woman runs a higher risk of endometrial cancer and COC offers protection. COC offers protection against ovarian and endometrial malignancies etc.
During years it has been discussed whether obese women run a higher risk of contraceptive failure. Recent studies indicate that COCs seems to be as effective in obese as in normal weight women.
The management of contraceptive counselling and prescription to the obese woman will be discussed in relation to the options available in the specific situation. Even though fertility might be decreased in obese women there is a strong need for effective and safe contraception
New progestogens in contraception
Regine Sitruk-Ware, MD, Population Council & Rockefeller University, New York, USA
The synthetic progestins used for contraception are structurally related either to testosterone (estranes and gonanes) or to progesterone (pregnanes and 19-norpregnanes). Several new progestins have been designed to minimize side-effects related to androgenic, estrogenic or glucocorticoid receptor interactions. Dienogest (DNG), and drospirenone (DRSP) exhibit antiandrogenic activity and DRSP has predominent antimineralocorticoid properties. The 19-norpregnanes include Nestorone® (NES), nomegestrol acetate (NOMAc) and trimegestone (TMG) and possess a high specificity for binding to the progesterone receptor with no or little interaction with other steroid receptors. DRSP has been developed as combination oral pills with ethinyl-estradiol (EE) and dienogest which shows 40 percent of the antiandrogenic action of cyproterone acetate, has been successfully combined in contraceptives either with EE and more recently with estradiol valerate (E2V). NOMAc, exerts a high antigonadotropic action and has been used as a progestin only method and more recently combined with estradiol (E2) in an oral monophasic contraceptive. Nestorone* is not active orally but proved to be the most active antiovulatory progestin when used parenterally. It has been developed in various formulations such as implants, one-year vaginal ring, in combination with EE, or transdermal gel or spray, in combination with the natural estrogen E2. Active derivatives of older progestins have proven high effectiveness in preventing ovulation and low doses of these steroids have been used combined with EE in non-oral delivery systems e.g etonogestrel in a 3-year progestin-only contraceptive implant or combined with EE in a monthly vaginal ring; norelgestromin in combination with EE in a transdermal weekly patch. Risks and benefits of the newer progestins used in contraception depend upon the type of molecular structure, the type of estrogen associated in a combination and the route of administration.
*Nestorone has been developed by the Population Council with grants from USAID, NICHD and UNFPA
Gabriele Susanne Merki-Feld, MD, PhD, Universtiy Hospital, Zürich, Switzerland
Contraceptive counseling is an important part of postabortion care and should include accurate and comprehensive information about different contraceptive options. Surprisingly not all studies provide evidence for a higher acceptance and lower rate of repeat abortions in women after extensive postabortion counseling. Other studies investigate preabortion counseling in comparison to postabortion counseling.
Today most abortions are performed with medical procedures. Use of combined contraceptive pills is recommended to start already on day 3 of abortion ( day of misoprostol administration). After abortion 80% of all women ovulate before the first menstrual period and many of them ovulate within 22 days. Thus providing the pill before leaving the hospital is of importance. Immediate IUD insertion after surgical abortion is effective and safe, even if some studies suggest a slightly increased rate of partial or complete expulsions. Since medical abortion takes longer than surgical abortion, IUD insertion is recommended during the first menstrual cycle after medical abortion. This procedure is of course associated with a small risk for another pregnancy. Progestagen-only methods can be started immediately after medical abortion. The implant in an important alternative for women with desire for longterm contraception.
Quick start and extended use of hormonal contraception
Anne Verougstraete, Gynaecologist, Family Planning and Abortion Centre Vrije Universiteit Brussel,
Hôpital Erasme Université Libre de Bruxelles (Obstetrics), Brussels, Belgium
Heath care providers usually advise women to wait until the next menses before starting hormonal contraception. The idea is to avoid the use of hormones in a beginning undetected pregnancy. An alternative is to start hormonal contraception immediately with a back-up birth control method for the first seven days. For long-acting methods (implants and injectables), the necessity of doing a pregnancy test after 2-3 weeks should be evaluated.
When women come for contraceptive advice, their motivation to start a method is high and the risk of an unwanted pregnancy may also be high. We therefore should have good reasons to delay the start of the chosen contraception. The advantages, disadvantages and management of quick start of oral contraception, patch, vaginal ring, implant and injectable will be discussed.
Extended use of hormonal contraception is becoming more common. A woman can chose continuous
use or insert a break every 3 or 4 months in the following situations: at the woman’s choice, headaches or migraine during the hormonal free interval, painful or heavy withdrawal bleeds, absent withdrawal bleeds, endometriosis, premenstrual syndrome, suspicion of decreased efficacy for any other reason.
The advantages, disadvantages, management and risks will be discussed. Quick start and extended use of hormonal contraception should be offered and discussed with women.
15:30Workshop I IPPF, The role of NGOs in ensuring safe abortion care, ArenalChair:Workshop J Training / Education, Giralda I+II
- Carine Vrancken, BE
Chair:Workshop K Misoprostol, Santa Cruz
NGOs providing information and technical skills to service providers
(following the law reform in Portugal)
Duarte Vilar, Sociologist, APF Executive Director, Portugal
Co-author: Elisabete Souto, Psychologist, Help Line Opções Coordinator
In July 2007, following the pro choice victory in the Referendum of February 2007, the majority of the Portuguese Public hospitals, 3 health centers and 3 private clinics started to provide safe abortion cares.
This enormous change effectively provided an easy access of Portuguese women to safe and legal abortion cares. In 2009 19572 legal abortions were performed.
The new situation also implicated a change in the role of APF (the main NGO of S&RH&R in Portugal) taking into consideration our profile – we don’t provide clinical services and we work mainly on information, education training and advocacy. Since 2007, we have developed a large training program to service providers and we still are the main providers of training on abortion in the country.
At the same time, we have used our Helpline OPÇÕES as an observation post on the implementation of the law, and the quality of services. In fact, more than 1000 women contacted the help line and it was possible to use their testimonies to better understand eventual problems and barriers in the provision of legal abortion cares, all over the country. This continuous information flow permitted updated information and the identification of new issues to be worked along the training activities.
Another strategy is the dissemination and debate of research results with service providers. In this field,
APF produced a first qualitative research based on the women testimonies collected through OPÇÕES helpline and a quantitative and qualitative research on abortion recidivism will be presented in the beginning of 2011.
Also we have to say that APF, as an NGO always was and continues to be a network of service providers that use the NGO as a free space of discussion of their practices and problems.
Finally, APF produced a set of educational materials that have been provided to the NHS and, thus, to service providers, as a tool to be used with the women that attend the abortion services.
NGO providing support to improve the quality of abortion services
in a government clinic: case study from Armenia
Meri Khachikyan, “For Family and Health” Pan-Armenian Association, Yerevan, Armenia
Co-author: Ruzanna Abrahamyan
In Armenia, as in all former Soviet countries, induced abortion was the primary means of fertility control
for many years. The most frequently used methods for pregnancy termination are Dilatation and Curettage (D&C) and Electrical Vacuum Aspiration (EVA). More modern methods like medical abortion and Manual Vacuum Aspiration (MVA) are not commonly used. In 2002 the Parliament of Armenia adopted a new law on “Human Reproductive Rights and Reproductive Health” that legalizes induced abortion on request up to 12 weeks of gestation and legalizes induced abortion up to 22 weeks for medical or social reasons. According to official data from the Ministry of Health of Armenia, induced abortions before 22 weeks of gestation constituted 33 percent of all maternal deaths in 2002. In 2005 this had been reduced to 7% of all maternal deaths. Among women that have an abortion, the average number of abortions per lifetime is 2.6 (the survey reached 14-24 year old male and female respondents). Repeat abortions are common due to the lack of post-abortion contraception.
In the National Survey and Case Studies on Sexual and Reproductive Health Knowledge, Attitude, Behaviour and Experiences conducted among young people 16% of sexually active young women reported having had an unintended pregnancy in comparison with 19% of young men. The attempt to self-induce abortion is common. The rates of miscarriages and abortion-related complications are quite high. Most of young women were not happy with the quality of abortion care when having had a hospital-based abortion.
“For Family and Health” Pan-Armenian Association NGO (PAFHA), with support of the IPPF/IF and other donors has established its own clinic in Yerevan to provide sexual and reproductive health services, including comprehensive abortion care in response to the needs of young and poor women who cannot access high-quality care due to financial or social barriers. Since January 2009, the PAFHA has been involved in implementation of the IPPF Global Comprehensive Abortion Care Initiative in partnership with tertiary referral level health facility - Institute of Perinatology, Obstetrics and Gynaecology and a regional clinic that provides services for the town of Vayk and five neighbouring villages in Vayots Dzor region of Armenia. The purpose of the project is to reduce the incidence of abortion complications, and enable poor and young women in Armenia to access high-quality abortion services.
The project used different strategies like capacity building, community participation, and advocacy to improve abortion care and access to high quality abortion services. Within the framework of the project the PAFHA established an effective model of public-private partnership that involves introduction of the quality of care approach, improvement of the systems of clinical information management, improving the referral and follow-up systems. Support from decision makers, health professionals, journalists, community leaders, parents and peer-educators were essential in increasing access to comprehensive safe abortion care.
As an outcome of the initiative significant progress was revealed in the improvement of the quality of abortion care at the PAFHA clinic and its two partner clinics. Furthermore, the IPPF GCAC initiative gave a unique opportunity to PAFHA to introduce international approaches towards quality of abortion care nationally. In June 2010, the National guidelines and standards for providing safe abortion services in line with international recommendations were endorsed by the Ministry of Health. The implementation of a national program on monitoring and evaluating the quality of SRH services, including maternal and abortion care has been initiated.
Young people advocating for access to abortion services - case study from Ireland
Meghan Doherty, IFPA Policy & Advocacy Officer, Ireland
Abortion is criminalised in almost all circumstances in Ireland. Since 1983, a succession of referenda, high-profile legal cases and the annual exile of approximately 5,000 women and girls to England, has characterised Ireland’s official policy towards women and girls’ need for safe and legal abortion services. Legislators have consistently abdicated their responsibility in this area, even pro-choice legislators, largely because they fear malicious attacks from anti-choice groups. These fears are not unfounded, however, the influence of anti-choice groups is on the wane and the majority of the Irish population now support access to abortion services in Ireland.
Ireland in 2010 is a much different place than it was in 1983 but the abortion discourse is often stuck in that era. In response, the IFPA has been working with a new generation of advocates to reclaim the public debate on abortion and articulate a pro-choice position based on international human rights standards, equal access to health services and connections to a broader social justice movement. This is a proactive strategy that represents a shift away from reactive and ad-hoc campaigns whereby the agenda has customarily been set by anti-choice groups. As media spokespeople, community organisers, bloggers, youth leaders and engaged citizens, young women and men in Ireland are succeeding in changing the language and tone of public discussion on abortion and are focussed on holding policy-makers accountable for the realisation of reproductive rights in Ireland.
Abortion and adolescents: case study from Kyrgyzstan
Tatiana Popovitskaya, Reproductive Health Alliance, Kyrgyzstan
Co-author: Galina Chirkina
For a long time abortion has been used as the main method of contraception in Kyrgyzstan. According to independent research, 7 out of 10 pregnancies end in an abortion. Young people under the age of 19 account for more than 200 abortions each year. This takes into account only the officially recorded and reported abortion figures. 70% of all abortions are still performed using dilation and curettage (D&C) contributing to the high level of post-abortion complications. The systematic underreporting of abortion figures is another sore point. Research performed by the Reproductive Health Alliance Kyrgyzstan (RHAK) showed that only one in 8 abortions performed in governmental clinics is registered and private clinics do not report their abortion figures.
According to the official figures of National Statistic Committee of Kyrgyz Republic the number of abortions has increased, especially amongst young people between 13 and 19 years of age*. At the same time we can see that the rate of contraceptive use by adolescents also decreased during the last 5 years by 1.8 times.
Several barriers to reproductive services influence the choices for adolescents in Kyrgyzstan:
- Adolescents have limited access to quality information and there is no sexuality education
- Adolescents have limited access to information on contraceptives and to contraceptives
- Adolescents are victims of violence based on tradition and violence within families and communities**
- Lack of quality of abortion care in the country; in 70% of the cases abortions are performed by D&C
- Lack of governmental commitment towards adolescents’ reproductive health
RHAK has played an important role in recognizing the need of young people to be able to access quality reproductive health services and has implemented several strategies to improve the reproductive health of young people in Kyrgyzstan. RHAK is now operating their own clinics providing high quality abortion services.
The Safe Abortion and Family Planning clinics in Bishkek (capital city) and Karakol were established under a Safe Abortion Action Fund project and further supported by IPPF EN through the GCACI project and SALIN+ project. The main goal of the clinics is to increase access to high quality information and services on abortion and family planning for young girls and women, especially poor, marginalized, socially excluded and underserved groups. The doctors were trained in safe abortion methods using Manual Vacuum Aspiration (MVA) and trained on providing pre - and post abortion counselling and contraceptive services. Clients can receive contraceptive services in the clinic and young people receive all services free of charge.
RHAK is recognised as the leading expert on safe abortion in the country and has delivered government sponsored training to a total of eight governmental clinics of family medicine and three maternity hospitals.
Besides medical services the RHAK clinics are also involved in prevention activities like information campaigns aimed at young people, open – door days, group consultations or discussions with students and schoolchildren which the aim to further reduce barriers to accessing services provided by RHAK clinics.
RHAK believes and proves that an NGO can be a good promoter of safe abortion and can successfully train service providers, assess the quality of care, increase the knowledge of the population as well as the medical and business community, support and develop safe abortion pilot clinics and projects, join forces
with key partners for advocacy and promotion of safe abortion.
*The official rate of abortions in the age group from 13 to 19 in 2009 was 3,6 for 1000 girls, in comparison with 2008 –3,0 and 2005 - 2,9 for 1000 girls.
**An example of such a violent tradition is bride napping or bride kidnapping also known as as marriage by abduction or marriage by capture.
- Gabriele Halder, DE
- Allan Templeton, GB
Chair:Workshop L Free communications, Nervión
Training of abortion providers: how and when
Vicki Saporta, President and CEO, National Abortion Federation, USA
In the 1990s, obstetrics and gynecology (OB/GYN) residency programs were falling short of their responsibility to train new physicians in abortion care and contraceptive services. Through targeted efforts, organizations addressed this problem with the introduction of a wide range of training opportunities, including newly established residency- and fellowship-based training programs in family planning and abortion care.
Residents receive hands-on training through residency program partnerships with freestanding clinics and private medical practices. Current providers have also partnered with some of these sites to learn abortion techniques, including later abortion procedures to expand their practices. Additionally, providers stay current in abortion practice through continuing medical education (CME) opportunities such as educational conferences and accredited online resources.
Despite the fact that OB/GYN residents have had more training opportunities in the past 15 years, this has not necessarily resulted in increased numbers of clinicians providing abortion care. Efforts are underway to train physicians in other specialties such as family practice, as well as to train advanced practice clinicians. By integrating abortion care into other broader practices, we hope to see an increase in the number of providers who actually go on to offer abortion care.
- Kristina Gemzell-Danielsson, SE
- Helena von Hertzen, CH
Cervical dilatation with misoprostol in pre- and postmenopausal non-pregnant women
Kevin Sunde Oppegaard, MD, Ph.D., Hammerfest Hospital, Norway
Two randomised controlled trials to investigate whether misoprostol is effective for cervical ripening in non-pregnant women were conducted between 2006 and 2009 at Ullevål University hospital, Oslo, Norway.
In the first trial, one thousand micrograms of self-administered vaginal misoprostol taken 12 hours before day-care operative hysteroscopy showed a significant cervical ripening effect, compared with placebo. However, this effect is limited to premenopausal women; in postmenopausal women, there was no difference in cervical dilatation between the placebo and misoprostol groups. This trial was the first to allocate women referred to hysteroscopy according to their menopausal status and therefore provided a conclusion that was not subject to sub-group nor post-hoc analysis. In premenopausal women receiving misoprostol, a greater number had a satisfactory preoperative cervical dilatation, as compared with women receiving placebo. Dilatation of the cervix was easier and quicker in premenopausal women
In the second trial, one thousand micrograms of self-administered vaginal misoprostol taken 12 hours before day-care operative hysteroscopy results in significant cervical ripening in postmenopausal women, compared with placebo, after 14 days pre-treatment with vaginal estradiol tablets. Cervical dilatation in the postmenopausal study participants was easier and comparable to the premenopausal women from the first trial. Self-administered vaginal misoprostol at home the evening before operative hysteroscopy is safe and highly acceptable. Few side effects were reported. There is a risk of moderate lower abdominal pain and light preoperative bleeding with this regimen, which is inexpensive and easy to use.
Misoprostol and management of missed and incomplete abortion
Kristina Gemzell-Danielsson, Professor, MD, PhD, Dept. of Woman and Child Health, Div. of Obstetrics
and Gynecology, Karolinska Institutet/ Karolinska University Hospital, Stockholm, Sweden
Misoprostol, a synthetic prostaglandin E1 analogue, is commonly used for medical abortion, cervical priming, the management of miscarriage, induction of labor and the management of postpartum hemorrhage. Thus, misoprostol is a very versatile drug in obstetrics and gynecology. Knowledge of the pharmacokinetic profiles is important for designing regimens for various applications. Misoprostol can be given orally, vaginally, sublingually, buccally or rectally. Studies of misoprostol’s pharmacokinetics and effects on uterine activity have demonstrated the properties of the drug after various routes of administration. These studies can help to design the optimal dose and route of administration of misoprostol for the management of missed and incomplete abortion.
- Sam Rowlands, GB
- Lucie Van Crombrugge, BE
Abortion stigma, conscientious objection and women’s rights: a qualitative study
on health professionals’ attitudes toward abortion in two public maternity hospitals
in Salvador da Bahia
Sylvia de Sordo, Brasil
In this presentation I will discuss some key findings of my qualitative study on health professionals’ attitudes toward legal and illegal abortion in Salvador da Bahia (Brazil). Through this study I investigated the impact of the Brazilian scientific and political debate on abortion and maternal morbidity and mortality and the resulting expansion of legal abortion services, on physicians’ attitudes toward both legal and illegal abortion.
This study was carried out through participant observation, short questionnaires and semi-structured interviews with obstetricians-gynecologists and other health professionals working in two public maternity hospitals of Salvador da Bahia. The first one is located in one of the outlying urban areas where the highest rates of maternal mortality are found. This hospital doesn’t have any legal abortion service, while the second one, which is located in a middle class neighborhood, is the only Hospital which offers a legal abortion service in Salvador, one of the leading cities in terms of maternal mortality-morbidity due to unsafe abortions.
One of the main objectives of this study was to examine if the increasing establishment of legal abortion services influenced physicians’ attitudes toward abortion, toward women who have them illegally or ask to have legal abortions, as well as toward the law. Another objective was to evaluate which characteristics - socio-demographic, religiosity, professional experience, knowledge (of abortion and epidemiology of maternal morbidity and mortality, of the Brazilian Law regarding abortion) - influence physicians’ attitudes toward both legal and illegal abortion and how. The Brazilian Ministry of Health and FEBRASGO (Brazilian Federation of Gynecology and Obstetrics) are interested in promoting the establishment and expansion of legal abortion services in public maternity hospitals. My study will therefore provide new data which will have immediate relevance, both from a scientific point of view, and from a policy point of view.
British Gynaecologists’ attitudes towards and practice of induced abortion.
Wendy Savage and Colin Francome, Middlesex University, United Kingdom
In 2008 questionnaires were sent to a one in six random sample of British gynaecologists which asked about their attitudes and practice.. After three mailings the response rate was 70%. The major findings were that there was less satisfaction about the way the 1967 Abortion Act operated than 20 years before and support for less bureaucracy.
Support for a limit of 24 weeks was lower than 20 years before with only half accepting this limit in 2008 compared with two thirds accepting 24 weeks or above in 1989. A majority of consultants were no longer involved in providing second trimester abortions which has implications for training. 60% thought abortion should be separated from general gynaecology and over half thought that there should be separate abortion units for gestation over 13 weeks and that fertility control (abortion sterilization and contraception) should be a sub-specialty, an increase since 1989.
The range of attitudes remains wide with clear implications for women seeking abortion. We conclude that streamlining the service and decriminalising abortion would reduce the number of later abortions.
Attitudes and practice of gynaecologists towards abortion in Northern Ireland
Women from Northern Ireland have to travel to Britain and pay for their terminations as the 1967 Abortion Act does not apply in Northern Ireland (NI). This article analyses the attitudes of gynaecologists. The response rate was nearly ninety per cent of the 42 practicing in the NHS in NI. We found that a clear majority favored a liberalization of the law in Northern Ireland. Over one in three wanted unrestricted access in the first trimester which is a more liberal position than the British law.
Almost five out of six gynaecologists were in favor of free abortions for Irish women as is largely the case in England and Wales. Furthermore a majority were in favor of the abortion charities being licensed to carry out legal abortions in Northern Ireland
Anneli Kero, (co-authors: Marianne Wulff and Ann Lalos), Department of Clinical Sciences, Obstetrics
and Gynaecology, and Department of Social Work, Umea University, Umea, Sweden
Home abortion implies radical changes for women
Objective: To gain knowledge about women’s experiences, views and reactions regarding having a home abortion (medical abortion with the use of misoprostol at home).
Methods: One hundred women were interviewed one week post-abortion; this yielded both quantitative and qualitative data.
Results: The overwhelming majority of the women experienced wellbeing and were satisfied with their choice of abortion method. They appreciated the privacy and the comfort of being at home which also allowed the presence of a partner. The intake of mifepristone at the clinic was described by many in existential terms as an emotionally charged act, experienced by some as more difficult than expulsion at home. However, relief was the predominant emotional feeling during the expulsion day. Most women did not find it especially dramatic to see and handle the products of conception although some felt uncomfortable at the sight.
Conclusion: Given that they choose this method themselves and are well informed, women are able to handle the abortion process by themselves outside a clinical setting. The option to choose home abortion implies a radical change in empowerment for women. Also allowing them the possibility to take mifepristone at home would increase their privacy and personal integrity even more.
Home abortion - experiences of male involvement
Objective: To gain knowledge about the male partner’s experiences of being present during induced home abortion.
Methods: Twenty-three couples, whose male partner had been present when the woman aborted at home, were interviewed one to two weeks post-abortion.
Results: All mengavesupport to their partner’s decision to have a home abortion, as this gave them the possibility of being near and of caring for her needs on theexpulsion day. In fact, all men took the opportunity to be present and all their partnersconfirmed that they had been supportive. Half the men had been anxious prior to the expulsion, but most considered that their experiences during the expulsion had been ‘easier than expected’ and their dominant feeling was one of relief.
Conclusions: Abortion is an important life event. When taking place at home, it increases the possibility for the couple to share the experience. Sharing an abortion may have a positive impact on those males who lack a sense of responsibility regarding reproductive issues, such as contraceptive use. This could facilitate society’s efforts to involve men as a target group in this field. Designing an abortion policy that caters for the needs of both partners is a challenge.
Medical abortion: analysis of three marketing websites selling misoprostol
Deyanira González de León, A., Universidad Autónoma Metropolitana Xochimilco, Mexico City, Mexico
Co-authors: Erika Troncoso, María Elena Collado, Raffaela Schiavon (Ipas Mexico)
The use of Internet has increased considerably and has become a common tool to search for information on issues like abortion, especially among young people. Internet is an important source of information about the use of misoprostol as abortifacient and currently there are websites selling the drug (commercially distributed as Cytotec). In this paper we present the results of a study aimed to explore the information about medical abortion (MA) offered through websites selling Cytotec, as well as the most common questions from its users. The final purpose of this study was to obtain evidence that could be used to improve information strategies on the use of misoprostol as abortifacient.
MA is, alongside with manual vacuum aspiration, one of the standard methods recommended by the World Health Organization (WHO) to terminate pregnancies. The practice of MA has increased in many countries over the recent years and has substantially contributed to improving the quality of legal abortion services. The combined use of mifepristone and misoprostol is currently the most effective regimen for early MA and has been included in the complementary List of Essential Medicines of the WHO since 2005. Millions of women worldwide have used this combination of drugs and have found it to be safe and
Mifepristone is not legally available in most countries of the developing world and the use of misoprostol alone has become a safe alternative to provide early MA in places where the drug is available. An optimal regimen for the use of misoprostol alone is still under research, but clinical studies report high efficacy rates –around 85% and more- when applied vaginally or sublingually for pregnancies of 63 days’ gestation or less.Because of legal restrictions on abortion the use of misoprostol alone has gained interest and acceptability among physicians in Latin America. Besides, the drug is increasingly being self-administered by women as an alternative to other dangerous methods. In many countries, misoprostol is available at pharmacies without medical prescription, and in some, such as Brazil and Peru, its use has been associated with less complications and deaths.
In Mexico, abortion laws remain highly restrictive except for Mexico City where abortion was decriminalized in 2007 and is permitted on demand during the first 12 weeks of gestation. Since then, public health services governed by the local Department of Health provide abortions using the WHO recommended methods. In 2008, 39% of all legal pregnancy terminations were done using misoprostol alone.11 On the other hand, the use of misoprostol as abortifacient is common and increasing in Mexico, but as in other Latin American countries both women and pharmacists, and even many physicians, lack of enough information on the safest and most effective doses of the drug, or about what to expect during the process or what to do if it fails.
A search performed in 2008 found seven websites offering misoprostol, out of which three were selected for further analysis: Ayuda Cytotec, Cytotec México, and Soluciones Cytotec. Criteria used for the selection was that these websites had question/answer sections, open not only to buyers but also to all visitors. 20% of all questions and answers registered between January and June 2008 were randomly selected for each one of these websites. The search was done giving a marker to each question and then making a random selection of them using the SPSS. The analysis was performed on 215 cases, which were incorporated into an Excel database. The database included the specific website, questions, dates of questions and answers, and answers from the website. Although the database included information on sex and age of those consulting, as well as weeks of pregnancy and use of misoprostol at the time of the query, these data were not always consistent because of insufficient information at the websites.
The results show that the five most common questions asked by users referred to: how to detect if the abortion was completed (21%); information about the use of misoprostol, including efficacy, risks related to previous abortions, weeks of gestation, and confirmation of pregnancy, among others (17%); routes of administration and dosage (11%); side effects (9.7%); and post-abortion care (7.9%). In addition, 79% of questions were made by women; 41% of those consulting had 9 or less weeks of gestation; and 43% were using misoprostol at the time of the query.
A first conclusion is that the selected websites not only sell misoprostol but also represent a useful source of information about the drug (dosage, gestational limit, side effects). However, these websites do not include accurate information about the evolution of an abortion using misoprostol or what to do in case of failure. This kind of information is only available to those using the question/answer sections and answers from the websites do not always meet the needs of users. Another conclusion is that self-administration of misoprostol without all the necessary information is a common practice among women. Finally, the analysis of the questions made by users demonstrates the need to elaborate documents and other resources that give women complete, accurate and reliable information about MA.
Results from a 4-year study on 15447 medical abortions performed by privately-practicing general practitioners and gynecologists in France
Sophie Gaudu, Hôpital Cochin-Saint Vincent de Paul, Centre d’orthogénie et de planification familiale
Co-authors: Drs I. Dagousset, L. Esterle, S. Eyraud, P. Faucher, D. Hassoun, and M. Teboul
The French legislation allows women to get a medical abortion at home under the control of GPs or gynecologists in private surgeries. In 2007, these abortions represented almost 9 % of induced abortions in France and 18% of the medical abortions (DREES, Etudes et résultats, n°712, 2009). The process is strictly defined by law. The termination of pregnancy (max 49 amenorrhea days) should be carried out by doctors who have signed a contract with a referral hospital. This hospital takes the charge of treating any complication that may arise. REVHO, a network of private physicians and hospitals, has been created in Paris and suburban areas in order to train the doctors, to set-up contract-based links with hospital family planning centers and to evaluate the quality of the method as well as the users’ satisfaction.
Five years after the creation of REVHO, 20 200 abortions at home using mifepristone and misoprostol have been performed within the network. This paper presents the results of 15 447 abortions carried out in the network. Data were entered on a PC held database and analyzed using EPI INFOTM Version 6. The women were 41 days of amenorrhea on average (90 % between 35 and 49 days) and their age varied from 14 to 55 (median: 28 years).
From 2005 to 2008, 162 physicians with private practices were involved: respectively 44 % and 56 % of abortions were carried out by GPs and gynecologists. The quantity of supervised abortions varied from 1 to more than 3600 per physician on the 4-year period. Twenty-three physicians (14%) performed more than 200 medical abortions and three, more than 1500.
About 80% of the abortions were followed up two weeks later. The success rate (as defined by the absence of surgical completion) was 97.9%, which is among the highest rates reported for medical abortion. There was a statistically significant difference between GPs (success rate of 98.2 %) and gynecologists (success rate 97.5 %) which can be discussed. The global rate of continuing pregnancy was 0.7%. No serious complication was observed.
These results demonstrate that medical termination of pregnancy at home can be performed under the control of physicians in their private practices without increasing the risks of failures or complications. GPs are efficient as well as gynecologists, which could allow an increase of the number of practitioners involved and contribute to health care proximity. Five years after its creation, REVHO demonstrated its capacity to incorporate the medical abortion into primary practices, with referral hospital services available for complications or surgical completions.
Gabrielle Falk, Division of Obstetrics and Gynaecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden
Co-authors: A.B.Ivarsson, School of Health and Medical Sciences, Örebro University and J.Brynhildsen,
Faculty of Health Sciences, Linköping University, Sweden
Topic and problem: Teenage pregnancy rate in Sweden is low compared to other European countries. However abortion rates are high despite education in school about sexual and reproductive health (SRH) and access to youth clinics and subsidized contraceptives. To find reasons for this we conducted an interview-study with questions aimed at examine teenagers experiences with contraceptives and to explore the reasons behind their contraceptive choices. The participants attended an out-patient clinic.
Methods: Twelve teenagers who had applied for induced abortion were interviewed three to four weeks after abortion. The interviews comprised open questions about contraceptive experiences focusing on hindrance for contraceptive use. Six topic questions were used with further exploring questions posed when needed. Qualitative content analysis was resorted to.
Results:One theme was identified:Struggling with feelings of uncertainty and patterns of behaviour. Three categories emerged from the analysis. Uncertainty dealt with decisions and behaviours that varied with time and between the different individuals. Factors that influence contraceptive use dealt with the persons that the participants had discussed contraceptives with, how they acquired knowledge about contraceptive use and the nature of their behaviour. Anxiety dealt with the side effects of contraception and feelings of fear related to contraceptive use.
Conclusion: The participants had feelings of uncertainty, anxiety and fear towards contraceptive use which led to non use and inconsistent use. They revealed insufficient knowledge about SRH at times. Guidance from health care providers and access to youth clinics varied and was sometimes unsatisfactory. Parents were supportive of contraceptive use but not active in the process of initiate it. Friends and the Internet were the main sources for acquiring information that was not always correct.
Unplanned pregnancy and abortion decision making – a report on the circumstances and experiences of contemporary Australian women
Annarella Hardiman, manager of the “Pregnancy Advisory Service”, at the Royal Women’s Hospital in Melbourne, Australia.
Investigators: Annarella Hardiman, Maggie Kirkman, Heather Rowe, Shelley Mallet, Doreen Rosenthal
Topic: This paper presents the results of a two part project on abortion: an audit of records of around 5500 women contacting the Pregnancy Advisory Service at the Royal Women’s Hospital in Victoria, Australia, and in depth interviews with 60 women who had contemplated or undergone abortion in Victoria.
The project was funded by grants from the Australian Research Council and the Victorian Health Promotion Foundation, and the audit and the research was approved by the Hospital’s Research and Ethics Committee.
Problem: In the context of little recent Australian research on women’s experiences of abortion or their demographic and social circumstances, Australia’s largest public hospital provider of abortion, in partnership with the University of Melbourne’s Key Centre for Women’s Health in Society, undertook to contribute to the knowledge in relation to this issue. Abortion research in Australia has lacked a coordinated national approach, for instance 7 separate States and Territories provide abortion services within their individual criminal laws (abortion is still located in the criminal laws of 5 states/territories) and health laws.
Theoretical approach and method:A quantitative audit of 5462 (de-identified) electronic records of women
who had contacted the Royal Women’s Hospital regarding their unplanned and/or unwanted pregnancy during a 12 month period, in order to analyse and describe their demographic and psycho-social circumstances.
- In-depth qualitative interviews with 60 women regarding the circumstances of their pregnancy and their decision making and experience of abortion or continuing the pregnancy (the majority had chosen abortion.)
Results: The audit demonstrated the variety of socio-demographic and personal circumstances of Australian women seeking abortion, and assists in challenging the negative stereotypes about the many Australian women who have unintended pregnancies and contributes to societal understanding and acceptance of this fundamental women’s health issue.
The interviews revealed rich information about women’s complex lives within which they made decisions about abortion. Each woman’s story is different, yet women have much in common. In considering their own needs, desires, and capacities, the well-being of potential children, and their responsibility for children and adults already in their lives, these women were making considered decisions to terminate or continue their pregnancies, based on multiple and contingent factors.
Together they provide evidence to inform policymaking, service provision, further research, and public debate. For instance, since the Victorian legislation had recently removed abortion law from the criminal law and formally acknowledged abortion as part of women’s health care, the findings and recommendations of this research will assist the health system to recognise service needs, identify gaps, and ensure the equitable provision of timely and affordable services across the state.
Why different intervention rates after online medical abortion and why do they matter?
Gunilla Kleiverda, gynaecologist, Women on Waves, Netherlands
Co-authors: Kinga Jelinska, project manager Women on Web, Rebecca Gomperts, MD, director of
Women on Waves
The online non-profit project Women on Web was set up in 2006 with the aim of increasing access to safe TOP and improving maternal health in countries where TOP is not available without restrictions. The website [womenonweb.org] refers women to a doctor who can provide them with a medical TOP using the combined regimen of mifepristone and misoprostol, provided they fill in the online consultation form, meet the specified inclusion criteria and none of the exclusion criteria.
A previous evaluation of the service provided by Women on Web showed a surgical intervention rate of 13.6%, and after maximizing the follow-up, of 6.8%. We will present data about the follow-up of 2323 women who had a medical TOP and spontaneous start of expulsion from February 2007 to September 2008. Of these women, 289 (12.4%) had an additional surgical intervention
Intervention rates varied widely by region, from around 5% in Western Europe (mainly Ireland) up to nearly 15% in Eastern Europe (mainly Poland) and Latin America/Caribbean. The differences will be related to patient characteristics, patient’s acceptability. The reasons and implications of those differences for the medical abortion clinical procedure, public perception of MA and accessibility will be discussed during the presentation.
17:30Medical abortion, Giralda I+IIChair:
- Elisabeth Aubény, FR
- Marc Bygdeman, SE
Home use of misoprostol in medical abortion uo to 63 days gestation
Helena Kopp-Kallner, Karolinska Institute, Sweden
In 1997 home administration of misoprostol was shown to be a safe option up to 56 days gestation (Schaff et al J Fam Pract, 1997. 44(4): p. 353-60) and studies of efficacy of home administration of vaginal administration of misoprostol at home for medical abortion have recently included women with pregnancies up to 63 days gestation (Westhoff et al Analgesia during at-home use of misoprostol as part of a medical abortion regimen. Contraception, 2000. 62(6): p. 311-4, Creinin et al Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion: a randomized controlled trial. Obstet Gynecol, 2007. 109(4): p. 885-94, Kopp Kallner et al Home self-administration of vaginal misoprostol for medical abortion at 50-63 days compared with gestation of below 50 days. Hum Repr 2010 May;25(5):1153-7).
In Europe, medical abortion was introduced and used in clinics and most countries have not adapted their legislation or interpretation of legislation to home use of misoprostol for medical abortion. When medical termination of pregnancy was introduced in the U.S. in the year 2000, home administration of misoprostol became the standard treatment.
Home use of misoprostol has so far been studied only after administration of mifepristone. The regimen is identical to that used in medical abortion in clinics and efficacy rates are identical to medical abortion in clinics. The most frequently mentioned reasons for medical abortion are perception of a more natural course and higher safety, avoidance of surgery or general anaesthesia and having more privacy and autonomy. Women often object to the number of visits required for a medical abortion. Women are required to visit the clinic three or four times to have a medical termination performed, depending on mandatory waiting periods and number of follow-up visits (Winikoff, Acceptability of medical abortion in early pregnancy, Fam Plann Perspec 1995, 27(4): p. 142-8, 185).
Home use of misoprostol is therefore an attractive treatment option for many women requesting medical abortion. Acceptability does not depend on gestational age or parity and has been been shown to be high among women and their partners (Kopp Kallner et al Home self-administration of vaginal misoprostol for medical abortion at 50-63 days compared with gestation of below 50 days. Hum Repr 2010 May;25(5):1153-7).
Women should be carefully counselled and given realistic expectations as to pain and bleeding. They should be provided with written and oral instructions for the procedure. Measures should be taken to confirm that the pregnancy has been successfully terminated.
Medical abortion in adolescents
Maarit Niinimäki, MD PhD, Department of O&G, University Hospital of Oulu, Finland
Pregnancies among teenagers, mostly unplanned, offer a special challenge to family planning. Vast majority, about 80%, of teenage pregnancies are unintended (Guttmacher Institute Report 2010). In 2009 9.5% of all abortions were performed for girls <18 years in UK. Also in Finland teenage abortions are relatively common. In the youngest age group (15-19 years) the abortion rates were higher than in the whole population (12.8 vs. 8.8/1000 women in the same age) in 2009.
Despite the widespread use of medical abortion, data concerning the safety and feasibility of medical abortion among adolescents is scarce. A small prospective study found medical abortion to be highly effective and well tolerated among minors aged 14 to 17 years in duration of gestation 56 days maximum (Phelps 2001).
The present study aimed to compare the incidence and risk factors for adverse events among adolescents and adult women. The study was based on the national registry-based cohort in which all the medical abortions during 2000-2006, 27.030 women, were included. The duration of gestation was 5 to 20 weeks. The cohort was divided into two subgroups; adolescent < 18 years (n=3024) and adults ≥ 18 years of age (n=24.006). The categories for adverse events were: I hemorrhage, II post-abortal infections, III incomplete abortions, IV injuries or other reasons for surgical operation, V thromboembolic disease, VI psychiatric morbidity and VII death. The classification was based on that reported in the Joint Study of the Royal College of General Practitioners and the Royal College of Obstetricians and Gynaecologists and modified for the present study. Codes for interventions and diagnoses (ICD-10) found in a national Hospital Registry were linked with the abortion registry. For 2004-2006, individual data on STDs (Chlamydia trachomatis and gonorrhea) in this cohort was also available. The screening for Chlamydia infections has been recommended in the national guidelines for termination of pregnancy.
The overall number of adverse events was higher in adult cohort. Also the incidence of hemorrhage, incomplete abortion and surgical evacuation was significantly higher among adults. The incidence of infections was similar in the cohorts. However, adolescents had more psychiatric morbidity. In subanalysis of primigravid women, the overall rate of adverse events and hemorrhage was higher in cohort of adult women. The risk factors for adverse events (e.g. age, duration of gestation) were mostly similar in the two cohorts.
In 2004-2006, the incidence of STD was significantly higher among adolescents (5.7% vs. 3.7%). No difference in the rate of post-abortal infections emerged between the two cohorts among women positive in the preabortal STD-screening. Also, positive preabortal STD screening had no effect on rate of postaboral infections when compared to STD-negative women in the whole cohort.
In conclusion, we find that the rate of adverse events and complications following medical abortion in adolescents is similar or lower than that seen among adult women. Thus medical abortion is not to be evaded as a method among adolescents once the decision of termination of pregnancy has made. In addition, based on these data, preabortal screening for STDs (“screen and treat”) seems to be a feasible strategy in all women.
- Christian Fiala, AT
- Mirella Parachini, IT