Authors
A B C D E F G H I J K L M N O P QMarianne Racke
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Medical abortion in the hospital or at home - Let the woman chose
Monica Johansson and Marianne Racke, midwifes, Karolinska University Hospital, Division
of Gynecology and Obstetrics Stockholm, Sweden
Introduction: The Board of Healt and Welfare approved medical abortion up to 9 weeks gestation in Sweden in September 1992. Today a majority of induced abortions are performed before 8 weeks and more than 50% of first trimester abortions are medical. The percetage varies between 30 to 90% between different hospitals. Hme-user of misoprostol is approvided since September 2004.
Procedure: Woman with a pregnancy length up to 63 days of amenorrhea, requesting medical abortion, are given the choice between the standard protocol of administration of misoprostol at the hospital and possibility of taken it at home.Information is given by a midwife at the first telephone contact, At the visit in the abortion clinic (day 1) the gestational age is established by menstrual history and confirmed by physical examination and endovaginal ultrasound examination. Whomen are counseled by gynecologist, as well as by a trained and experienced nurse-midwife.
The patients received 200 mg mifepristone orally at the hospital on day 1. The women are also given 4 tablets of misoprostol ( 200µg per tablet) to take vaginally at home 24-48h after mifepristone together with pain prophylaxis. The first follow –up to assess the outcome of treatment is performed by a thelephone call by the midwife within a few days after the treatment.
Follow-up: Is performed on day 14 after the medical abortion.Outcome is evaluated using a urinary HCG test with cut-off value of 500 IU/ml. If necessary, a gynecological examination, an ultrasound examination and seum HCG is performed.Follow-up is mandatory following medical abortion and also includes contraceptive counseling.
Discussion: Home-user of misoprostol reduce the number of visit and improve access to medical abortion. Our data shows a high acceptabilly among women and their partners and confirms the safety and efficacy of home-use of mosoprostol. Women should be pffered this choice to allow more flexibility and privacy in their abortions.
V.E. Radzinsky
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Shelley Raine
Silvina Ramos
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Lynne Randall
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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
Dee Redwine
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Providing safe surgical and medical abortion services in low-resource and legally restricted environments: The Latin American Abortion Provide Network
Dee Redwine, MPH, regional Director for Latin America and the Caribbean, Planned Parenthood Federation of America- International, PPFA-I
Heather Blank, associate Regional Director for Latin America and the Caribbean,PPFA-I
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In Latin America and the Caribbean, Planned Parenthood Federation of America-International (PPFA-I) focuses on establishing and strengthening safe abortion services through partnerships with women’s organizations that advance sexual and reproductive rights and health services. Many of these agencies in Latin America and the Caribbean suffer from a sense of isolation, as they provide life-saving services under severely restricted legal circumstances, in politically difficult and dangerous situations.
Unsafe abortion in Latin America and the Caribbean can be described as nothing less than a public health crisis. The correlation between access to safe, legal abortion and maternal mortality in the region is shocking: approximately 20 percent of maternal deaths in Latin America and the Caribbean are due to unsafe abortion, a higher proportion than in any other region of the world. In 1995 there were 4.2 million abortions in Latin America and the Caribbean region, 4 million of which were illegal. Except for Eastern Europe, Latin America has the highest global abortion rate (37 abortions per 1,000 women aged 15-44) and abortion ratio (27 abortions per 100 pregnancies) (AGI, 1999).
The average Latin American woman is likely to have at least one abortion in her lifetime, with women in some countries, such as Peru (AGI, 1999), having an average of nearly two abortions. Since the vast majority of these procedures are performed illegally and most likely under unsafe conditions, women are taking enormous risks to prevent unwanted childbearing. This situation results in approximately 800,000 hospitalizations per year in the region.
Access to safe abortion services is critical to preventing maternal mortality and morbidity. In developing countries, regardless of the legal status of abortion, it is poor women in rural areas and poor young women who are most at risk of undergoing unsafe abortion, and most likely to die. However, in various Latin American countries, there are a growing number of health care providers who are committed to combating this trend. In areas where women are most likely to die from an unsafe abortion, client-centered sexual and reproductive clinical services must be provided for poor and marginalized women – the very ones who are most likely to face an unwanted pregnancy, seek out an untrained provider, and most likely to suffer severe consequences.
The reproductive health provider network supported and facilitated by PPFA-International is a forum to link these providers in a mutually constructive and supportive way, in order to regularly exchange ideas and expertise. They represent 8 different Latin American countries.
All of these providers offer life-saving services under extremely difficult circumstances, in both geographic and legal terms. From the rural areas to the rapidly expanding urban slums, these providers offer high-quality health services to those most in need. The network offers a forum in which critical mutual support can be lent to those working in this harsh environment as well as an opportunity for the exchange of information and expertise.
The specific goal of the network is to strengthen and expand sexual and reproductive rights through improved and increased access to services coupled with advocacy efforts in countries where the political and social climate is very restrictive. In order to reach this goal, the network facilitates the professional support needed by local groups working to reduce restrictions on abortion and improves services where they exist, as well as increases the sense of solidarity among service providers in the region.
Furthermore, the group is working to increase access to medical abortion throughout the region through the integration of a misoprostol-only regimen of early first trimester medical abortion. This is being piloted in order to decrease the consequences of unsafe abortion, and create alternative pathways for women to access safe abortion.
Throughout Latin America, misoprostol is cheap, easily accessible, and badly mis-used. From physicians to pharmacists, off-label use of misoprostol for pregnancy termination is increasingly common. Misoprostol has been shown to have a high rate of efficacy for abortion, but it must be used with the correct dosages, within certain gestational age ranges, and with clear instructions for follow up for the woman in order to be successfully used. Even so, given the severe legal restrictions on abortion in the region, a widely disseminated protocol for misoprostol, either for clinic- or home-based use, could radically change not only how abortion is viewed, but also prevent women from resorting to other invasive, highly dangerous forms of abortion.
Matthew Reeves
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Wondering how to manage second trimester medical abortion or dilation & evacuation in the setting of an abnormally implanted placenta?
Looking for advice on advancing the gestational age at which you and your team provide? Have questions about cervical preparation, offering a choice of method, managing prolonged inductions, or anything else related to medical or surgical methods of abortion after the first trimester? Bring your questions along to this panel of five leading experts in second trimester abortion care. Experienced, new and curious providers are all welcome to contribute to what should be a lively and wide-ranging discussion. -
Dilatation and evacuation (D&E) is one of the World Health Organization's recommend methods for abortion in the second trimester. In addition to its safety and effectiveness, advantages of D&E are that the procedure can be scheduled as a day case and operating times are short (about 10-15 minutes), as opposed to the unpredictable duration of a medical abortion (MA), which may require hospitalisation. The efficiency and predictability of D&E is also beneficial where women require an abortion for maternal medical conditions or complications of pregnancy which could deteriorate during the course of a lengthy labour induction. Lastly, D&E is an important back-up for failed second trimester MA. In many parts of the world multiple barriers prevent access to D&E. One important barrier is a lack of trained providers. Using a mixture of didactic and adult learning methods, this day long workshop will cover the practical requirements of D&E including pre-operative assessment and planning, instruments, cervical preparation, pain control, procedural steps, immediate post-abortion care, and identification and management of complications. We will also cover the next steps in developing a D&E service such as preparation of clinical teams, training, waste management, and infrastructure requirements.
Åsa Regnér
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EU networking in sexual reproductive health and rights
Åsa Regnér, Secretary General RFSU, Sweden
Working with gender equality issues and SRHR at the international level is a constant battle, not only to advance the agenda but also to defend progress that has already been made. The International Conference on Population and Development (ICPD) in Cairo in 1994 was a breakthrough. This was the first time an international document, agreed within the UN, pointed to unsafe abortions as a major contributor to maternal mortality. The ICPD affirmed that regardless of national legislation, women must have access to quality services for the management of complications arising from abortion. Access to post abortion care is an issue that is still being debated at the UN.
In 1995 the Forth Conference on Women in Beijing sparked a renewed global commitment to the empowerment of women and to gender equality. This time countries around the world agreed to ìconsider reviewing laws which punish women for having illegal abortionsî. When the same language was put forward by the US this year at the UN Commission for Population and Development - some countries did not agree and therefore it couldnít be accepted.
In the European Union we have also seen a development during the last five or six years which points to an increasingly worrying political situation when it comes to SRHR. In 2004, when the ICPD Plan of Action celebrated its 10 anniversary, the EU issued strong and rights based Council Conclusion on the theme. Last year, at ICPDís 15th anniversary, nor the Czech or Swedish presidency dared suggesting the subsequent council conclusions on the agenda in fear of political set-back or conflict.
Within the EU the polarization between on the one side countries like Sweden, which prioritizes these
issues, the Netherlands and Denmark and on the other side Poland, Ireland and Malta has increased in the last decade. This inability to agree has lead to a split in EUís positions at the UN, resulting in member states negotiating as separate countries and not as the EU on issues on SRHRadmin. This is an obvious failure for the EU as an global actor.
One reason for the development within EU and globally is an unfortunate mixture of religion and politics.
Luckily, I think this last year there has been an awakening regarding the slow progress on reducing maternal mortality in the world. The UN Secretary General is particularly concerned about this and has therefore recently launched a Global Strategy and Joint Action Plan on women and childrenís health. In the strategy, the Secretary General points out life-saving interventions such as family planning services and making childbirth safe He underlines that in order to reach MDG 5 on maternal health women need to have access to comprehensive and integrated health services that include skilled care during childbirth at appropriate facilities, HIV prevention and also to safe abortion services (when abortion is not prohibited by law).
I recently attended the Millenium Development Goal Summit in New York. During the negotiations on the Outcome document the EU was able to take a strong approach on human rights and defended and pushed for wording on for example human rights and gender equality. This resulted in a better document than was first anticipated. However, because of this political division the EU could not push for wordings on reproductive rights or even state the linkages between unsafe abortion and maternal health. Still, we know unsafe abortion is the third biggest reason for maternal deaths. As a result the document doesn´t even mention access to post-abortion care, something that I as mentioned was already agreed upon in Cairo 1994.
The EU must do better. The EU, including the Commission and all member states, is the worldís largest donor of development aid. The EU is committed to reach the MDGs. This summer the Commission adopted a paper on a twelve point Action plan to reach the MDGs. One important point in the document is to focus on the MDGs most off-track, one of them being MDG5 on maternal health. Progressive and brave policies on issues on SRHR are therefore vital.
One formal obstacle when advocating for better SRHR policies within the EU is that the EU has no mandate to legislate on SRHR issues like abortion, sexual or reproductive health or sexuality education. Those are political decisions that fall under the so called principle of subsidiary, which means that member states decides on their own.
There are however some openings to include SRHR in EU politics:
1. The most obvious being that all member states have committed to implement the ICPD Programme of Action and the Beijing Action Plan and the MDG. In June the Development Committee in EP adopted a report on implementation of MDG in which it clearly states that EU member states and the commission should support policies on safe abortion.
2. There are also several important areas of EU-competence that touches upon issues of sexual and reproductive health and rights. Trafficking for the purpose of sexual exploitation is one example. Gender equality is another very important area. The EU also has some competence in the area of public health.
Experiences show that it has been easier to talk about sexual and reproductive rights in the area of HIV and AIDS. Recently (June 2010) the European parliament adopted a resolution on a rights based approach to the EUís respons to HIV and AIDS. The EP calls on the Commission and Member States to ensure the promotion, protection and observance of the human rights, including the sexual and reproductive rights, of people living with HIV and AIDS and other key population. The High Representative / Vice-President, Catherine Ashton, made a very supportive statement in front of the Parliament, committing to fully implementing this resolution.
3. EU claims to be a protector and promoter of human rights. EU:s inability to push for sexual and reproductive rights is not worthy an institution that is built on the fundament of human rights and democracy.
Lately we have seen a positive development on a human rights perspective on maternal mortality. It was a major breakthrough in June 2009 when the Human Rights Council of the UN adopted a resolution (resolution 11/8) stating that preventable maternal mortality and morbidity should be seen as a human rights issue. The human rights argument should be used towards the EU, now more than ever. The adoption of the Lisbon Treaty has strengthened the protection of human rights and hopefully also sexual and reproductive rights. For example:
The Charter of Fundamental Rights of the European Union (CFR-EU), 2000, can also be utilised to advance SRHR. Since December 2009, with the adoption of the EU Lisbon Treaty, member countries are bound to follow the Charter's provisions.
Since the adoption of the Treaty the European Union, as an institution, is also in process to accede to the European Convention for the Protection of Human Rights and Fundamental Freedoms Convention. The process of accession is expected to be finished in 2011.
The Treaty also gives EU citizens' a ìright of initiativeî. It means that a million citizens may sign a petition inviting the Commission to submit a proposal on any area of EU competence.
In addition the parliamentary assembly of Council of Europe ((PACE) has adopted a resolution in 2009 on ICPD +15 in which they call on the members states review, update and compare members statesí national and international SRHR policies and strategies and, in the context of reducing maternal deaths, reduce the numbers of unsafe abortions. Already one year earlier the assembly adopted a resolution on "Access to safe and legal abortion in Europe" in which they invite member states to guarantee womenís effective exercise of their right of access to a safe and legal abortion and decriminalize abortion.
4. The EUs role as international actor, for instance within the UN and through it´s development aid, which I described before.
There is much need for cooperation between actors who are determined to fight for a woman´s right to decide over her body, to reduce maternal mortality rates, to safeguard access to safe and legal abortions Global politics is not looking too good in this field right now, but some governments are determined to work in a progressive way. I believe it´s important that civil society, human right´s advocates, medical experts and politicians from many countries work strategically together and I am happy to be able to speak about these injustices in front of such a knowledgeable audience. I am convinced, although it sometimes looks difficult, that joint efforts will change the world to the better for women.
O. Revenko et al.
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Status of reproductive health of women after surgical abortion
O. Revenko, I. Vovk, A. Kornatskaja (Ukraine)
Institute of pediatrics, obstetrics and gynecology, Kiev, Ukraine
olegdoc@voliacable.com
In branch of planning of family the statistical analysis of 300 histories of illnesses of patients with pelvic inflammatory diseases with the purpose of definition of risk factors is spent. Wereresearch of the woman with secondary infertility - 1 group (150 women) and with not broken reproductive function - 2 group (150 women).
Women with not broken reproductive function authentically connected the beginning of disease with the beginning of a sexual life 78 (52,0 %) is more often, while women with secondary infertility the main reason of disease considered surgical abortion - 78 (52,0 %) against 8 (5,3 %) - in 2 group).
Operative intervention in the anamnesis was at 98 (65,3 %) women of 1-st and at 53 (35,3 %) women of 2-nd group, authentically more often at women with secondary infertility, (р <0,05).
At the same time, there are more than complications after abortions it was marked at women with secondary infertility: in 76 (50,7 %) against 24 (16,0 %) women with not broken reproductive function.
At gynecologic survey presence of chronic inflammatory diseases of internal genitals has been diagnosed for all women of 1-st group.
Thus, the comparative analysis of data of clinical inspection has shown, that for the majority of women with secondary infertility (78,0 %) which were in marriage interruption of the first non-planned pregnancy by means of surgical abortion (46,7 % against 18,7 % at women with not broken {disturbed} reproductive function), and also smaller quantity of sorts of 30,6 % (against 81,4 % accordingly) and greater percent of operative interventions - 65,3 % (against 35,3 % accordingly) is characteristic.
The received results testify, that interruption of non-planned pregnancy is beyond especially medical question and is an actual social problem.
Anne-Marie Rey
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Abortion practice in Swiss hospitals – results of an inquiry by APAC-Suisse in 2009
Anne-Marie Rey, secretary of APAC-Switzerland
Despite a liberal legislation since 2002 (abortion on request in the first 12 weeks of pregnancy and without time limit if it is necessary to turn away from the pregnant woman the „risk of a serious emotional distress“), we suspected certain gaps in service provision in Switzerland.
In summer 2009, we made an inquiry among private and public hospitals, including some day care clinics we were aware of. Out of 157 clinics contacted, we received 113 answers that could be evaluated (72%). Among these, 93 clinics (82%) practice abortions.
In the first trimester, two thirds of them offer the surgical as well as (in the first 7 or 9 weeks) the medical method with mifepristone plus misoprostol. Only 12 clinics (13%) offer local anesthesia for surgical abortions.
As for abortions after 12 weeks, an earlier inquiry among family planning centers had revealed that almost half encountered difficulties in their region in this respect. In fact, after 12 weeks gestation, only 49% of the clinics accept psychosocial indications as defined by law and most limit abortions for these reasons to 14 or 16 weeks.
Access to abortion in the second trimester or later remains very restricted in Switzerland. The range of discretion allowed by the law is not sufficiently used. Moreover, the surgical method is very rarely offered in the 2nd trimester
These are the reasons why a certain „abortion tourism“ still exists, estimated at 50 women who every year have to seek second trimester abortions in clinics in other countries.
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Different strategies to legalize abortion: Successes and lessons from Switzerland
Anne-Marie Rey (Switzerland)
arey@svss-uspda.ch
Situation in Switzerland before start of pro choice campaign in 1971. Penal Code of 1942: abortion allowed for health reasons only, to be certified by a second doctor. By 1971, 6 out of 25 cantons applied the law quite liberally and accepted mental and social health reasons for legal abortion, most of the other cantons stayed rather or very restrictive. Hence:
- abortion tourism from conservative to liberal cantons or to other countries,
- 20.000 illegal abortions estimated per year, with concomitant complications and death cases,
- some 100 women condemned each year for illegal abortion.
30 years of campaigning. June 1971 launch of a radical initiative for a constitutional amendment aiming at the repeal of abortion legislation. Its primary purpose was to break the taboo and raise public and parliamentary debate.
1975: launch of a second „reasonable“ initiative (abortion on request within the first 12 weeks of pregnancy), which was narrowly rejected on the ballot in 1977, by 51.7% of the votes.
1978: referendum and vote on a very unsatisfactory compromise law, rejected by a 2/3 majority.
1985: an initiative by the antis to write the right to life from conception into the constitution was rejected by 69% of the votes.
1993: a parliamentary bill proposed legalization of abortion on request in the first few months of pregnancy.
In March 2001 Parliament finally approved a corresponding amendment to the Penal Code. Conservatives immediately asked for a referendum.
June 2002: 72% of voters approve the new legislation. On the same ballot, an anti-initiative asking for a total abortion ban is defeated by a 82% majority.
Achievements.
- Gradual liberalization of abortion in practice over a period of 30 years (1971-2001).
- Reimbursement of the costs of abortion by health insurance (1981).
- Obligation for the cantons to create family planning counselling centers (1981).
- Abortion on request in the first 12 weeks of pregnancy (2002), no compulsory counselling except by the doctor himself, no „cooling off period“, no parental consent necessary for minors. Explicit mention of severe mental distress as a legally accepted reason for later abortions, without compulsory second medical opinion. Cantons have to designate clinics and doctors authorized to perform abortions.
Particularly successful strategies used.
- Personal contacts with the media, giving them regular and factual information,
- networking, building alliances with women’s, youth, political and professional organizations, mobilizing and briefing them,
- lobbying of parliamentarians, intensive personal contacts with some of them,
- formulating legislative texts and amendments for members of parliamentary committees,
- pragmatism, readiness to compromise, using moderate language and adapting our arguments to the changing situation.
Other reasons for our success.
- Decreasing influence of religion,
- changing role of women in society,
- growing open-mindedness in matters concerning individual lifestyles and sexuality.
In conclusion. Strategies must adapt to the situation, to political and religious forces present in a country and to the strength of pro choice mobilisation. Our experience: every time a broad public debate arose, some progress resulted. But: the battle for women’s right to decide whether and when to become a mother is hard and long. It needs dedication and perseverance. But in the end, I think, we have the better arguments.
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Since 1942, abortion has been authorised if the woman’s life is in danger. A
certificate signed by 2 doctors is required. The law is strict in theory, but very
flexible in its application. Terminations are performed in hospitals, in clinics
and private practice.
John Reynolds-Wright
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Introduction: Increasing proportions of womenwho access abortion services in Europe choose to have an early medical abortion (EMA) (<= 9 weeks). Provision of quality information on EMA(medications, process, confirmation of success of the procedure and signs/symptoms after the procedurethatnecessitate medical review) is important. However, the quality of information provided to women on EMA may be variable and provider dependent. There is some evidence that audiovisual information (e.g. film or animation) can be an effective way of providing information about abortion. Objective To evaluate an audiovisual animation as a method of information provision on EMA for women seeking EMA in four European countries.
Method: We developed a short animation (3 mins) about EMA that summarises the key steps in theEMA process but is also adapted to reflect subtle differences in EMA practice and law in Scotland, France, Portugal and Sweden. Fifty women choosing EMA in each country (total 200 participants)will be randomisedto information provision on EMA delivered by the animation(n=35) versus a face-to-face consultation with a provider (n=15). Outcomes include information recall on EMA and womens acceptability of provision of information on EMA by the animation.
Results: The study is ongoing. Preliminary data (one country) indicate high levels of acceptability and utility of the animation and comparable levels of information recall to face to face consultations. Free text responses from women indicate that they feel positive about the diversity of female characters depicted in the animation.
Conclusion: Provisional data suggests that even a short audiovisual animation might adequately and acceptably deliver key information about EMA. If shown to be acceptable in the other countries, then this intervention could be used routinely to provide standardised and high quality information to women seeking EMA throughout Europe.
Ana Rita Pinto et al.
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Medical abortion efficacy at 8 and 9 weeks
Ana Rita Pinto, Inês Vaz, Alfredo Gouveia, Rute Magarinho, Paulo Sarmento (Portugal)
Centro Hospitalar do Porto – Unidade Maternidade Júlio Dinis, Portugal
anapinto@gameover.pt
Objective. Abortion by request is allowed in Portugal if carried out within the first 10 weeks since April 17 2007. It implicates a minimum of a 3-day introspection period and the availability of psychological counselling, as well as support from social services technicians and women are given the choice between medical and surgical procedures. This law is a response to illegal abortions and to the need of eradicating its practice, as they are often carried out without the required conditions and with high risks to the sexual and reproductive health of the women involved. Most studies carried out on this subject are related to medical abortions within the first 49 days. This study, however, aims at evaluating the efficacy of medical treatment in abortions after the first 7 weeks.
Design and Methods. Retrospective study reviewing 380 cases related to abortion by request between July 1 2007 and February 29 2008. The variables analysed were gestational age, treatment methods (medical vs. surgical), dosage administered, treatment efficacy, need of additional intervention as a follow up to protocol and the need for curettage as an aid to uterus emptying completion.
Results. From the 380 women who underwent abortion, the gestational age in 151 (39,7%) was over 49 days; 7 (4,6%) underwent surgical procedure and 144 (95,4%) medical procedure. Initially, 46 women were administered 200 mg of Mifepristone orally and 800 µg misoprostol orally 36 hours later. From October 1 2007 protocol was changed and in 98 (68,1%) women were administered 600 mg Mifepristone orally and 800 µg misoprostol orally 36 hours later. In the initial procedure, 69,6% (n=32) had a complete abortion although 4,3% (n=2) failed to appear for follow-up. 4 (8,7%) were evolutional pregnancies, 1 (2,2%) had a missed abortion and in 7 cases (15,2%) emptying was considered incomplete, 3 (6,5%) of which needed curettage to aid uterus emptying. In the following procedure, 61,2% (n=60) had a complete abortion although 7,1% (n=7) failed to appear for follow-up. 14 (14,3%) were evolutional pregnancies, 3 (3,1%) were missed abortions and in 14 (14,3) cases emptying was considered incomplete, 1 (1,0) of which needed curettage. Overall, medical treatment was administered to 144 women. Abortion was complete in 92 (63,9%) cases, 18 (12,5%) were evolutional gestations and 25 (17,4%) were incomplete abortions. Defining the presence of live embryo after medical cycle as medical abortion failure, it is calculated as 12,5%.
Conclusions. Medical abortion had an 87,5% efficacy rate for the absence of live embryo at the time of ultrasound control. In our service the efficacy rate in the same period of time of medical treatment for any gestational age was 91,9%. Although scientific evidence of efficacy of medical treatment relates mainly to pregnancies within the first 49 days, the authors conclude that its use in cases of higher gestational ages is highly efficient, thus contributing to a lower number of surgical abortions.
Monica Roa
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Access to safe legal abortion in developing countries
Anibal Faundes (Brazil)
afaundes@unicamp.br
Maternal Mortality is almost 100 times higher in some developing countries than in the developed world and unsafe abortion is one of the main contributors to maternal death in developing countries where abortion is not legal. Maternal Mortality due to unsafe abortion depends on the rate of induced abortion, the proportion of induced abortion that are unsafe and the severity of the risk. There are no major differences in induced abortion rate between developed and developing countries, except that the largest rates are observed in Eastern Europe and the lowest in western Europe. The large difference is in the rate of unsafe abortion, which is around 30 per 1000 women in fertile age or over in developing countries and negligible in Western Europe and North America. Even greater is the difference in the risk of dying as a consequence of unsafe abortion. While one out of every 130 women with induced abortion die in Eastern Africa and one out of every 120 in Western Africa, the risk of dying after an induce abortion is practically nil in developing countries.
The main determinants of unsafe abortion, apart of the rates of unplanned, unwanted pregnancies, are the legal situation of abortion in each country and the the access to safe abortion in the full extent of the law. While more than 90% of abortions are legal and safe in developed countries, less than 50% are legal in the less developed world. Moreover, even women who fulfill the requirement of restrictive laws do not have access to abortion due to administrative, professional economical and health system barriers. The lack of access to safe abortion and its social and health consequences for women in developing countries is one of the most unfair imbalances between rich and poor countries. The society in general cannot remain indifferent to the suffering of so many women and as physicians, it is our responsibility to fight against this injustice. FIGO is assuming its part through the Initiative for the Prevention of Unsafe Abortion, currently including 54 countries with high induced abortion and unsafe abortion rate.
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Different strategies to legalize abortion: Successes and lessons from Colombia
Monica Roa (Colombia)
m.roa@womenslinkworldwide.org
Sexual and reproductive rights have slowly been recognized as founded on mainstream human rights. There is no question regarding the recognition and legitimacy of these rights on paper; however, we have found that those in charge of applying rights to real life cases base reasoning and decisions on biases and prejudices when interpreting and applying the law. These intermediaries are the decision-makers at courts and tribunals (mostly judges). Our goal is to make gender equality an irrefutable measure by which law must be interpreted, applied and enforced.
Based on this premise, in April 2005, Women's Link Worldwide launched a bold and innovative challenge to the Constitutional Court of Colombia, asking the judges to liberalize the country's abortion law, which outlawed the procedure under all circumstances.
On May 10, 2006 the Constitutional Court issued a historic decision. The Court ruled that abortion should not be considered a crime under three circumstances:
- when the life or health (physical and mental) of the woman is in danger,
- when pregnancy is a result of rape or incest,
- when grave fetal malformations make life outside the uterus unviable.
The Women's Link's case was the first to challenge Colombia's abortion law using international human rights arguments. The Colombian Constitution explicitly states that international human rights treaties ratified by Congress take precedence over national laws. Not only is the decision historic for women’s rights but also the language utilized by the Court is groundbreaking in the acknowledgement of women’s reproductive rights and the implementation of international human rights standards in a national context.
The case of Colombia reactivated a regional debate which has shown a particular trend: "Whether you win or lose in parliament, the very next day, someone will go bring a challenge in court," she said, highlighting how the abortion battle has decamped from the political to legal arena”.
A 12 minute video with details on the different strategies developed in the case of Colombia will be shown by the presenter.
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The legal framework for abortion in Latin America: going forward and backwards
Monica Roa, Programme Director of Women’s Link Worldwide, Mexico
The legal regulation of abortion continues being a highly debated topic in Latin America. Even though the discussion did not move for years, two milestones in 2006 gave a renewed strength to those that want to promote or restrict access to legal and safe abortion in the region. One of the milestones takes place in Colombia on May 2006, when the Constitutional Court declared that the total criminalization of abortion is a violation of women’s rights to life, health, integrity, dignity and non-discrimination. The Court recognized women have the right to have an abortion performed at the public health system, when the woman’s life or health (physical or mental) is in danger, when pregnancy resulted from rape or incest, and when there is a diagnosis of a malformation incompatible with life outside the uterus.
The other milestone occurs in Nicaragua in October 2006 when the legislative assembly eliminated therapeutic abortion, leaving a complete ban on abortion in force. Since then, debates in favor and against abortion regained force and paved the road for advances and regressions that could be characterized in the following manner:
Revision of current laws and promotion of the Health exception:
- Case KL vs Peru at the Human Rights Committee
- Abortion on the ground of mental health
Using the health exception already existing in many latin american criminal codes:
-Processes to liberalize abortion on the woman’s demand during the third trimester
- Mexico City – law declared constitutional by the Supreme Court
- Uruguay – President Tabare Vasquez’ vetos a law approved by Congress
- Argentina – currently discussing a law at the national legislative
Processes to give constitutional protection to the right to life from the moment of conception:
- El Salvador: pioneering the movement to legally recognize the fetus as a human person
- Mexican states (18): the conservative reaction to the liberalization in Mexico City
- Republica Dominicana: the constitutional protection of life from the moment of conception
- Kenya: importing the strategy to Africa
- National laws to declare the day of the unborn
Criminal prosecutions:
- El Salvador: women condemned to 30 years for homicide
- Guanajuato: women condemned to 30 years for homicide
- Brasil: process against 10.000 women whose medical records were removed without due process
- Argentina: judges and attorneys working to implement legal abortion are being prosecuted for promoting
the commission of crimes
Disrupting the implementation of legal abortion:
- Colombia: conscientious objection as a weapon to sabotage legal abortion
- Argentina: fetous ombudsmen try to impede the provision of legal abortions
- Peru: not adopting regulations and protocols for the provision of legal services
Interim measures at the Inter American System for HHRR:
- Case X and XX vs Colombia: protection for the physical and mental Health of a minor who was denied a
legal abortion
- Case Amalia vs Nicaragua: protecting the life of a woman who was denied treatment for cáncer due to
her 10 weeks of pregnancy.
Pascale Roblin
Speeches:
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Contraception before and after abortion at home
Pascale Roblin, Claire Ricciardi, Aubert Agostino and Raha Shojai, France
Objective: In France, despite a wide range of highly effective, easily accessible and reimbursed contraceptive methods, the rate of abortions remains high and one third are repeat procedures. We analyzed womens’ contraceptive path surrounding a medical abortion.
Methods: A retrospective study of 450 women who had medical abortion at home before 7 weeks was realized in a community care office in Marseille between 2006 and 2010. All women were seen at the post abortion visit and had received contraceptive counselling before and after the procedure with emphasis on long acting reversible contraceptives (LARC). The last declared failed contraceptive method leading to the unwanted pregnancy and the method finally adopted by the patient at the immediate follow-up visit were noted.
Results: Before abortion, 43 (9,5%) used no contraception, 92 (20,5%) used natural methods and 244 (54,2%) used condoms. Women declared using COC in 71 cases (15,8%) and the vaginal ring in one case. None had an IUD or an implant. After abortion, 37 (8,2%) requested no prescription of contraception, 259 (58%) had COC, 15 (3,3%) used a vaginal ring and 12 (2,7%) opted for a transdermal patch. Following abortion, 31% of patients switched to LARC (121 IUD and 18 implants) and 37% to highly effective forgettable methods. Among the 244 pre-abortion condom users, 163 (73%) switched to COC. Among the 71 pre abortion COC users, 45% still maintained COC as their preferred method and 34% switched to IUD.
Conclusion: Most unwanted pregnancies occurred with the use of male condoms. Immediately after abortion, the majority of women opted for combined oral contraceptives. On the short term, peri-abortion contraception counseling may however encourage women to switch to more effective and forgettable methods (IUD or implant).
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Does a previous abortion modify womens’ contraceptive choice?
Pascale Roblin, Lisa Tichane, Sylvie Camil, Aubert Agostini and Raha Shojai, France
Objective: Care givers often expect that women with a previous abortion are more likely to use highly effective contraceptive devices to prevent further unwanted pregnancies. We assessed the failed contraceptive method used before an abortion between women with and without a previous abortion.
Methods:In a series of 450 women requesting a medical abortion at home before 7 weeks in a community care center in Marseille, France, there were 157 (35%) patients who had a history of at least one previous abortion. We realized a case –control study to compare the failed contraceptive method leading to an unwanted pregnancy between 157 women with a previous abortion and 293 women without a previous abortion. Chi-2 test was performed and considered significant for p<0.05.
Results: The rate of women using no contraception, natural methods or condoms were similar in both groups. The rate of COC users was 16% in the group of patients with a previous abortion vs 14,7% in the control group (p=0,8). None of the patients used IUD or implants in both groups.
Conclusion:The contraceptive profile of women with an unwanted pregnancy is similar between women with and without a previous abortion. In our population, a history of abortion did not modify womens’ contraceptive choice towards more effective methods.
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IUD after medical abortion: Should it remain underused?
Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)
University Hospital of Marseille, France
pascaleroblin@yahoo.fr
Objective. Immediate post-abortum IUD insertion remains an underused option in daily practice. We evaluated the safety and acceptability of IUD insertion shortly after medical abortion at the office.
Patients and Methods. In a prospective series of 300 women who underwent medical abortion in a private office before 49 days, we observed the incidents that occurred among the 104 patients (34,6%) that opted for an insertion of IUD shortly after abortion. Uterine vacuity had been controlled by ultrasound between the 8th and 12th days post abortum. IUD were inserted between the 8th an 30th day following abortion. None of the patients had received prophylactic antibiotics. 62 (60%) patients had hormonal IUD and 42 (40%) had Copper IUD.
Results. Women’s mean age was 31 years, 26% were nulliparous and 37% had already had previous abortions. None of the patients had long term reversible contraceptions before requesting an abortion and only 5 (1,6%) had used emergency hormonal contraception. 72% of IUD were inserted at the control visit on the 8th day. When uterine vacuity seemed incomplete, IUD insertion was postponed but for 90% of our patients insertion was possible before day 30. No mechanical (expulsion or perforation) and no infectious complications were registered. At insertion, the mean pain score on an analogical visual scale was 2/10. Mean duration of bleeding following IUD insertion was 6.5 days. With a follow up of 24 months in our database, 8 patients (7,7%) requested IUD removal : in 2 cases because of pelvic pain but no evidence of pelvic inflammatory disease, in 2 cases for excessive bleeding and in 4 cases for desire of pregnancy.
Conclusion. Our preliminary findings suggest that IUD may be offered shortly after an induced medical abortion before 49 days. When such method is chosen by the patients, safety and continuation rates seem high. Proposing an IUD immediately after a first trimester abortion at the office may help reduce repeat abortions.
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Medical abortion in France. The benefits of a complex procedure
Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)
University Hospital of Marseille, France
pascaleroblin@yahoo.fr, raha.shojai@ap-hm.fr
Objective. Medical abortion in an ambulatory setting is possible in France since 2004. However, many physicians have been reluctant to use this new option at the office because of the complexity of the protocol. Our aim was to evaluate the feasibility of this procedure in a private practice and to show it’s benefit in terms of contraception counselling.
Patients and methods. A prospective study was realized among 300 consecutive women, with gestational age less than 49 days, choosing a medical abortion at a general practionner’s office. Under the French law, patients had to undergo five supervised visits (V). The first visit (V1) was to inform patients on the procedure and proposition to encounter a social worker for alternatives to abortion. V2 was for medical examination, cervical cytology, screening for IST and counselling on contraception. After a reflection period of seven days, the third visit was for administration of 600mg of mifepristone under the physician’s supervision. The fourth visit was for administration of 400µg of oral misoprostol at the office. Medications were bought by the physician at the pharmacy. Women were not obliged to remain under supervision and could depart within minutes of receiving medications but were not given the possibility to take the medications themselves at home. They had access to a 24-hour hotline and walk-in emergency service. The fifth visit was for post-abortion control at 10 days with HCG and/or sonography.
Results.Among the 300 patients, 10 (3%) were lost at follow-up. The rate of complete abortion with no major complications among the 115 patients with a known outcome was 97%. Four patients (3,5%) required surgical aspiration : 2 for haemorrhage, 1 for incomplete abortion and 1 for continuation of pregnancy. Seventy-six women (63%) fully adhered to the protocol and came to the 5 scheduled visits. The mean number of visits at the office was 4,1. An unscheduled visit was required in 7 cases (6%) for repeat administration of misoprostol and 19 patients (16%) phoned for advice. The reflection period of seven days was not possible to respect in 55% of cases because of the time limit of 49 days but all patients had at least 48 hours to confirm their decision. None of our patients requested to encounter a social worker. Concerning contraception, 75% had no use of birth control methods and only 2 women used emergency hormonal contraception. At the control visit, 46% opted for oral contraception and 38% for a long term reversible method (IUD or implant). Overall rate of satisfaction for the method was 78%.
Conclusions.Our findings confirm that medical abortion in a general solo practice is a safe and acceptable procedure. A complex procedure based on five visits at the office may be a shortcoming and considered as a setback in the era of increased patient autonomy. In our view it improves patient-doctor relationship which is essential for counselling in post-abortion contraception.
Sarah Robotham
Speeches:
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Women’s experience of the abortion process - a semi-qualitative survey
Sarah Robotham, Julie Porksen and Helen Axby, Marie Stopes International UK
Background: Marie Stopes International is the largest UK provider of abortion services outside of the NHS, performing over 50, 000 procedures in 2003. UK clients come to Marie Stopes through NHS referrals or privately, whilst others are private clients from overseas. Differing timescales in the process leading up to having an abortion are reported, however no systematic study of client experiences has been carried out.
Objectives: This survey explores women’s experiences of the abortion process in order to: determine preferences in regards to abortion service provision; understand the timescales women experience; determine the acceptability of the latest clinical guidelines for women accessing termination of pregnancy services.
Design and Methods: Information was gathered from c.100 clients accessing termination of pregnancy services at MSI centres in the UK. A mix of interviewer administered questionnaires and self-completion questionnaires were used. Open questions were analysed by content analysis.
Results: Results will be available end of August, 2004, and will cover the following areas: decision making; experiences of NHS vs private clients; client preferences; obstacles faced; opinions on clinical guidelines.
Conclusions: To follow from results.
Eva Rodriguez
Speeches:
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Advantages of the Implementation of a Quality Control System in a Abortion Clinic
Rodríguez, E.; Gómez, M.; Serrano, J.; González, M.; Martin, M. Rubio, C.
Clínica El Sur, Sevilla, Spain
Quality control programs are being used more often to promote business . Since they have
been proved to be very effective we believe that they could also be implemented in the
medical sector, specifically in interruption of pregnancy. After four years of quality control
program which we have implemented in our clinic it has been succesfull. In colabaration
with other specialist we have brought this poster so that it might encourage others to
introduce this program in their clinics.
The supervision, and certification of a quality control program by an international
enterprise which specialises in QUALITY CONTROL means describing, documenting and
making protocols with regards to all the practices in that business, establishing a
consensus on the standards at all levels.
The main objective of our quality management program is client satisfaction. It involves
establishing mechanisms in order to obtain a continuos improvement in the service which
we offer i.e. performing abortions. It also involves monitoring the results of these
standards. In order to achieve this we plan the objectives of organization, formation of our
personal, control and analize our desviations that occur so that we can rectify them and
hence securely value the most important areas of our enterprise, suppliers, products,
maintance of our equipment, infrastucture, the satisfaction of our clients etc. -
Misoprostol with and without mifepristone in advanced pregnancy cases
Eva RodriguezMD, ACAI – Sevilla, Spain
Objectives To establish the effect of mifepristone on pharmacological late abortion (more than 16 weeks) performed with misoprostol and the effect of factors such as misoprostol dosage.
Subjects and methods: Retrospective study (753 subjects) comparing fails and time of induction in two groups, with (325) and without (428) mifepristone by means of survival analysis and the effect of others factors by means of non-parametric tests.
Results: Lesser time of induction was observed in the group with mifepristone (rate of finalization 0,0634, statistically different from rate of control group: 0,0906), without more adverse effects. Lesser time of induction with misoprostol each 3 hours and greater in primipara.
Conclusions: The late pharmacological abortion goes better adding mifepristone to misoprostol. The dosage of misoprostol each 3 hours is slightly better than the use each 4 hours. -
Termination is allowed up to 22 weeks of amenorrhoea, with no requirement
for a waiting period. 97.3% of terminations are done for psychological reasons;
15% concern adolescents.
The private sector performs 97% of terminations. Although the law is
restrictive, access to termination is good. There is a need, however, for fairer
legislation. The present reporting system is insufficient. -
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.
Maria Rodriguez
Speeches:
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In recent years, conflict, violence and disasters have brought a dramatic rise in the number of displaced people, both within and across national borders. There are an estimated 26 million women and girls of reproductive age living in emergency situations, all of whom need sexual and reproductive health (SRH) information and services. The average length of time an individual now spends displaced is 20 years, and three quarters of countries with the highest maternal mortality ratios are fragile states as defined by the Organisation for Economic Co-operation and Development. Sexual violence is also prevalent. A recent Global Review demonstrated that significant gaps remain in access to safe abortion and reproductive health care in humanitarian settings.
Providers are an essential component of safe abortion care globally. In humanitarian settings providers have unique needs to provide safe, competent care. To support providers in offering safe, evidence-based reproductive health care, the WHO has recently developed a process for adapting reproductive health guidelines to the humanitarian setting, and developing provider tools. This process was developed following a review of the literature, and in consultation with experts in guideline methodology, emergency response, SRH and rights, epidemiology, implementation research, and program managers. The methodology has been applied to the Medical Eligibility Criteria for Contraceptive Use, and a tool of the adapted guidelines developed and field tested. Similar efforts may further provision of safe abortion care in the humanitarian settings.
Pascale Rogie
Svetlana I. Rogovskaya
Robin Rothrock
Speeches:
Sam Rowlands
Sam is the UK representative on the Board. He was Secretary-General from 2008 to 2012. He was a member of the Scientific Committee for the 2008, 2010 and 2012 Congresses. He was a member of the local organising committee for the 2012 Congress in Edinburgh
Sam was a general practitioner for 17 years and later has been a clinical lead for community contraception services. After conducting research in London, he continued research in his practice and using the General Practice Research Database. He received a doctorate from the University of London in 1999. From 2003 to 2005 he was Clinical Director of bpas, a large abortion charity. Formerly he was an Associate Professor at Warwick Medical School and taught on the MSc in Sexual & Reproductive Health at the University of Warwick.
Since 2011 he has been senior physician in community sexual and reproductive health in Bournemouth. He is a Visiting Professor at the School of Health & Social Care, Bournemouth University.
He was Vice President of the Faculty of Sexual & Reproductive Healthcare from 1995 to 1997 and President of the Royal Society of Medicine Sexuality & Sexual Health Section from 2003 to 2005. He is a member of the Editorial Advisory Board of the Journal of Family Planning and Reproductive Healthcare. He is Chair of the Faculty Clinical Effectiveness Committee.
He is a Member of the Expert Witness Institute and regularly prepares expert reports for the assistance of the civil courts. In 2009 he completed a Masters in Medical Law from the University of Northumbria, Newcastle-upon-Tyne. The title of his dissertation was Human rights aspects of abortion law. He maintains a list of world abortion laws on the FIAPAC website.
He was a member of the guideline update group of the 2004 Royal College Guideline on the care of women requesting induced abortion. He gave both written and oral evidence in 2007 to the UK House of Commons Select Committee on Science and Technology inquiry into scientific developments relating to the Abortion Act 1967. He has published more than 70 papers in peer-reviewed journals.
He is currently editing a book entitled Abortion Care due to be published by Cambridge University Press during 2014.
Speeches:
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CS04.1
Improving access to abortion care
Sam Rowlands
Bournemouth University, Bournemouth, UKThe following ways of overcoming barriers to access to abortion will be presented: Elabouration by Health ministries as to precisely what the abortion law allows; Exemptions or reimbursement in jurisdictions in which women have to pay for abortions; Drafting by professional societies of country-specific abortion guidelines or dissemination of international guidelines for the benefit of health care professionals; Advocacy by clinicians for improved clinical standards in abortion care; Wide dissemination of information about abortion services to allow choice for women; Availability of medical and surgical methods of abortion at all legal gestations; More first trimester procedures offered within a primary care setting; The option of making appointments via a centralised booking system; Delivery of services as close to women’s homes as possible; Special arrangements for women who live far away from cities or towns; Seamless care pathways for the whole of a woman’s journey; Greater participation in all elements of abortion procedures by staff other than doctors; Tightly regulated and monitored conscientious objection; Information and postabortion care provision by clinicians in jurisdictions in which self-administered abortion is prevalent.
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Risk management in abortion care
Sam Rowlands (Great Britain)
University of Warwick, Coventry, United Kingdom
The aim of risk management is to identify potential risk and thereby reduce untoward events and the loss and harm that may result. An error in management of a client which leads to an adverse event can be termed an incident. An incident that is narrowly avoided can be termed a near miss. Near misses occur at higher frequency than actual incidents, yet with limited impact; they are rich learning material. Examples of incidents are: procedure performed on the wrong client, wrong procedure performed, inaccurate gestational assessment leading to commencement of inappropriate procedure, IUD inserted/not inserted after abortion in error, anti-D given/not given in error, client intercepted at clinic entrance by protestors.
It is necessary to create a no-blame culture in the workplace. Errors are the result of human failure, but there is often a systems component in the background. Self-reporting of errors (one’s own or other people’s) is encouraged. This should be done at the time of the incident by filling in a specially-designed form. During discussions about incidents, the anonymity of those who have reported incidents should be preserved. When harm has been done, it is good practice to give a detailed explanation of what went wrong and to say sorry to the client; this is not admitting legal liability. General ways of reducing risk include: designing procedures to counteract error and taking complaints seriously. Specific ways of reducing risk include: adequate consent procedures, routine ultrasound scanning, having a low threshold for transferring a client to hospital from a free-standing clinic if events deviate from the normal pathway, supplementary security measures (for instance access control system, panic buttons, police liaison).
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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
- Ambivalence
- 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
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The development of a nationwide central booking service for abortion
Sam Rowlands, Clinical Director bpas and Visiting Senior Lecturer, University of Warwick (UK)
bpas is a national abortion charity in the UK that provides around 48,000 procedures each year to UK residents and women from other countries on a not for profit basis. Central booking services have been proven to facilitate access to abortion services. City-wide models have previously been described. A nationwide central booking service has been developed in the UK.
Methods
A nationwide central booking service was introduced in 1993. Initially a manual booking system was used. In 1996 the appointment system was computerised.
Results
More than ¼ million calls are now received each year. The highest demand weekday is a Monday. The volume of calls peaks at mid-morning. There is a 36% increase in calls between December and January. More than a quarter of calls originate from mobile phones.
Conclusions
The computerised central booking service has radically improved the efficiency of the organisation. Waiting times can be actively managed using data from the system.
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Parental authorisation of abortion
Sam Rowlands1,2 1Bournemouth University, Bournemouth, UK, 2Dorset HealthCare, Bournemouth, UK - srowlands@bournemouth.ac.uk - www.samrowlands.net
Parental authorisation/notification requirements operate in 34/203 jurisdictions around the world; in the USA 38/50 states require parental involvement. Most of the abortion laws requiring parental involvement insist on one parent giving their consent; some require only that a parent is notified. The age threshold for parental involvement is usually either 16 or 18. Young people usually achieve mental capacity to consent to treatment by the age of 14. Adolescents have the same reproductive rights as adults. Health care professionals have a duty to protect young people from exploitation. Adolescents should expect to have their confidentiality respected and be free to make their own decision about whether or not to continue a pregnancy. A young person’s decision to involve their parents/guardian should be determined by the quality of the family relationship, not by laws. Compulsory parental notification is a strong barrier to a young person’s access to abortion care. Coercion to continue a pregnancy has an adverse psychosocial impact on young people. Breaching confidentiality risks violence and abuse in non-supportive families. Introduction of parental involvement laws in US states has been shown to result in out-of-state travel of young people and an increase in second trimester abortions in this age group. Based on scientific evidence and on basic human rights for young people, those sections of abortion laws insisting on parental involvement should be repealed.
Martyna Równiak
Speeches:
Dominique Roynet
Speeches:
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The satisfaction of treating patients Dominique Roynet, MD, Belgium Because I’m working there with young women, in good health, sexually active, even if it is very emotional, we are on the field of health and not on the one of pathology. If sometimes emotions, ambivalence, psychological difficulties may exist, in most cases, the woman shows her satisfaction, she feels relieved because her problem has been solved. Often I’m not mostly touched by the abortion itself, but more by the circumstances in wich the woman has to live her abortion (problems of couple,violence, loneliness, lack of money, social poverty, extramarital pregnancy, very young woman,..), and always by the guilty feeling and the loneliness wich accompanies so often those women ( in Belgium, catholicism is very present and influential on the mentalities) Because it’s a work that gives me personal valorisations. As a general practitioner, I have to perform several technical acts in other fields of medicine. I must say that no other work generates such a positive(valorisating) image of myself. Nowhere else I do recieve such a lot of small presents, flowers, post cards and thanks than after an abortion. And all those phrases women say to me: “ you have saved my life”, “I’ll never forget you”, “you are so kind”, “I never have been welcomed so warmely”... Because it’s work which contributes to my personale evolution. Listening to women asking for an abortion, it’s impossible not to doubt about our own certitudes, not to question our own prejudices. The motivations advanced by women make me often question myself about ethical issues (“Is it possible to abort just because of the gender of the fetus?”...) The sadness wich always comes with the determination to abort forces me to find the right tone, the right distance. The dignity of some women forces my respect. The indifference or the aggressiveness of others have sometimes induced my own aggressiveness. In front of those women who trust me (but do they really have a choice?), who confine in me their physical, psychic and emotional intimacy, I feel myself humble and modest. Finally, I must say that those women did teach me the biggest part of my present experience. I do thank them warmly. Because it’s work that gives me the opportunity to meet progressive, humanist, feminist colleagues, in a proportion much more important than between surgeons, urologists or other gynecologists and gastroenterologists. The experiences I lived, the tecnics I used, the difficulties of the legal context, the activities of other activists, the enconter with other mentalities, cultures, values..just make me more convinced than ever: “Abortion has to be a fundamental right of women and the access to abortion has to be free and without charge.”
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98% of abortions are carried out in non-hospital situations with very few medical
staff. The antibiotics prescribed are chosen in relation to the age, the sexual
precociousness and the number of partners.
The talk underlined the frequency of asymptomatic carriers , the increase in the
occurrence of Chlamydia 3%. Gonorrhoea tending to disappear.
The criteria for screening are thus defined:
&Mac183; More than 2 partners per year
&Mac183; Request for abortion
&Mac183; Before putting in an I.U.D.
&Mac183; Partner infected with a S.T.D.
&Mac183; The pill before 18
&Mac183; Abdominal pains
&Mac183; Screening for S.T.D.
Treatment : 200mg DOXYCYCLINE for 2 days.
Abortion postponed for a week in the case of Chlamydia
Sandra Rubio
C. Rubio et al.
Speeches:
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Clínica El Sur, a Socially Responsible Company
C. Rubio, E. Rodríguez, M. Gómez, J. Serrano, P. Hidalgo (Spain)
Clínica El Sur, Spain
info@atochaginecologica.es
The society is an integrated and interconnected body in which all parts have their role, their responsibility and are indispensable to build the necessary solutions to the challenges of its time.
The company, as key agent of the current society, has a strong influence on it since it is part of the richness generation process and distribution causing a too often negative impact on aspects as: environment, human rights, development… In turn, the presence of the society at the companies also rises and then appears a new COMPANY-SOCIETY equation in which companies of XXI century, by breaking the old triangular scheme (workers/customers/shareholders), have become complex structures which must include all its groups of interest (stakeholders): Shareholders, Governments, NGO´s, International Organizations, Mass media, Trade Unions, Employees, Consumers, Citizenship, Local administrations…
In this context, a new corporate culture appears: the Corporate Social Responsibility (C.S.R.).
As a result of the European Summit Conference hold in Lisbon in 2000, the “European Green Book on C.S.R.” is published. In this book it is stated “…not only benefits are important, but how you get them”. “Being socially responsible does not mean only meeting fully the legal duties, but also going further by making a higher investment in human capital, environment and relations with the interlocutors”.
Clinica El Sur (El Sur Clinic) and its staff feel fully identified with this new way of thinking and behaviour and then, since one year ago, we work in the implementation of a C.S.R. management system which we present you in our poster. This system mainly pursues:
- Active listening and dialogue with the stakeholders.
Promotion with the example of a management system more egalitarian, fair, caring and equitable which includes the social and environmental concerns.