Edinburgh, 19-21 October 2012: „Unwanted pregnancy - A fact of life“
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09:30
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10:00-
11:00Abortion: a part of life , PentlandChair:- Sharon Cameron, GB
- Mirella Parachini, IT
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- Bernard Dickens, CA (all speeches)
- bernard.dickens@utoronto.ca
Conscientious commitment
Freedom of conscience is a human right
recognised in the Universal Declaration of Human
Rights of 1948. Accordingly, the U.N. International
Covenant on Civil and Political Rights provides
that “Everyone shall have the right to freedom
of thought, conscience and religion” (Art.18(1)).
Conscience is thereby expressed as separate
from religion. Individuals may, of course, base
their conscience on their religious beliefs, but
the Covenant establishes that religion has
no monopoly on conscience. A common
invocation of conscience regarding abortion is in
conscientious objection to participation, which isoften based on religious convictions.
Conscientious commitment is the reverse of
conscientious objection. It arises when healthcare
providers feel conscientiously committed to
offer patients advice and services to which
administrators of their healthcare facilities such
as hospitals are opposed in principle, for religious
or comparable reasons. Institutions such as
hospital corporations cannot claim human rights
such as conscientious objection. Health facility
administrators must accommodate service
providers’ rights of conscience, such as to
recommend and offer services the providers
conscientiously consider to be in their patients’ best
interests, and, with patients’ consent, to provide,
or refer patients for, such services, including lawful
abortion, without discrimination, in the same way
that facility administrators must accommodate
providers’ rights of conscientious objection. -
- Alberto Stolzenburg, ES (all speeches)
- alberto.ginecenter@gmail.com
Recent developments in Spain
Recent events and the legal, police, political
and social developments that have taken place
in Spain in recent years are part of a global and
conservative campaign and have generated in the
new political context of this country vast concern
for the rights of women regarding equality and
sexual and reproductive health.
The various recent historical stages are
discussed, from the Second Republic (1936-
1939) and the military dictatorship of Franco
(1939-1975) to democracy (1975-2012)
in relation to the legislation and practice of
induced abortion, in particular highlighting the
achievements and shortcomings of the Abortion
Law of 1985 and the current Law on Sexual and
Reproductive Health and Voluntary Termination of
Pregnancy, in force since July 2010.
The current political situation is described, with a
Conservative Government and absolute majority
in Parliament, and the statements of its main
representatives regarding the change of the current
law until end of year. Furthermore, we also present
the upcoming trial of professionals from an abortion
clinic in Barcelona and the attempt by retrograde
sectors and anti-choice groups to use this case to
put pressure on the Government and public opinion
in favour of a radical restriction of the right to abortion. -
- Ann Furedi, GB (all speeches)
- ann.furedi@bpas.org
We often voice our support for
abortion because it is necessary.
Necessary as a back-up to
contraception, as a ‘second-chance’ method of
birth-control when contraception fails or we fail to
use it. And necessary when a pregnancy becomes
no longer wanted - because something changes
in our lives or about how we feel.
We present abortion as an unfortunate fact of life.
When our opponents claim abortion is evil, we often
reply that it is a necessary evil. Our opponents take
the moral stance, and we claim to be of the ‘real
world’: pragmatic realists considering health risks
and benefits and not what is ‘right’ and ‘wrong’.
But there is a moral case to be put for freedom
of choice. There is an argument that it is wrong
to deny women that freedom – because to
take away our capacity to make decisions for
ourselves, is to take away what makes us human.
The right to choose is more than a matter for
women; it’s a matter for humanity.
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11:00-
11:30
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11:30-
12:45Contraception: Thinking outside the box, PentlandChair:- Anna Glasier, GB
- Andreja Štolfa Gruntar , SI
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- Ali Kubba, GB (all speeches)
- AliAKubba@aol.com
De-medicalising contraception
Access to contraception is a reproductive health
right. While sex ‘just happens’, women need to
go through several hoops to obtain contraception.
Regulations, protocols and guidelines drive
service provision but do affect the perceptions
of both users and providers. Evidence-based
de-medicalisation of contraception may remove
personal and systematic barriers to effective use of
family planning methods. Emergency contraception
is a case study in this area. Other models of care
have emerged in the last decade. These include
over and under the counter oral contraception,
vending condoms and emergency contraception
and web based services. Themes emerging
from such models suggest that research, service
provision and advocacy schemes should aim to
push the boundaries of contraceptive regulation
towards user-friendly non-medicalised care. -
- Christian Fiala, AT (all speeches)
- christian.fiala@aon.at ,http://www.gynmed.at
Contraceptive development has taken place in
3 milestones:
1. Discovery of the fertile days by Knaus and Ogino
in the 1920s. – For the first time ever, women
were able to understand what was happening in
their bodies and roughly identify the fertile days.
But they were not able to control their fertility.
2. Controlling fertility according to the individual
desire and possibilities (pill and IUD) in the
’60s. - The dream of humankind came true:
separate fertility from sexual activity. For the
first time ever, women were able to control their
fertility themselves and make their own choices
concerning the number of children. Regular
menstruation, however, continued. Even in
women who take the pill and thus have no
ovulation have their monthly bleeding.
3. Limiting menstruation to the fertile cycles by
continuous intake of oral contraception or the
intrauterine system. – Women can effectively
control both their fertility and menstruation
according to their own wishes and limits.
Currently we are in the process of making the 3rd
milestone widely accessible and a free choice for
women. The medical knowledge and technology
are there. But social acceptance is a slow process,
which will accompany us for some time to come. -
- Satu Suhonen, FI (all speeches)
- Satu.Suhonen@hel.fi
Post-abortion contraception:
start immediately
Contraceptive failure - unprotected sex or failure
in use of the chosen contraceptive method or use
of an ineffective method - leads to unintended
pregnancy. Most women choose abortion in this
situation. Avoiding the same incident in future, that is
reducing the risk of repeat abortion, is in the interest
of the woman and also the society both medically,
psychologically, socially and economically. Including
contraceptive counselling in post-abortion care is
important and emphasized also in recent guidelines
(WHO, RCOG). However, counselling itself has not
been shown to have a beneficial long-term effect on
contraceptive use and risk of repeat abortion.
Recovery of ovarian function after abortion is
rapid, ovulation occurs within the first month after
abortion in most women. Thus contraception
should be started as early as possible after
abortion. Immediate start of both hormonal
(pill, patch, ring) and also long-acting reversible
(LARC) methods (implant, injection, intrauterine
contraception) is recommended in the above
mentioned guidelines. After medical abortion
LARC using implants, injections can be started on
the day of abortion, intrauterine contraception as
soon as an on-going pregnancy is excluded. There
is evidence that if after abortion a LARC method
is chosen, the risk of repeat abortion is reduced.
Well-functioning, easy-access contraceptive
services are important in the follow-up. -
- Régine Sitruk–Ware, US (all speeches)
- regine@popcbr.rockefeller.edu
Update on contraceptive
developments Although contraceptive use showed a steady
increase worldwide, the needs of a significant
percent of couples have not yet been met, as
unscheduled pregnancies increased.
While implants and IUDs require a health provider
for a proper insertion, vaginal rings, a mid-acting
method, have the advantage of being user-
controlled. While long-acting methods seem
preferable for women with compliance issues,
daily transdermal gels or sprays have shown high
acceptability as the methods can be used privately.
Progesterone receptor modulators (PRMs) to be
used within 120 hours of unprotected intercourse
have a definite role as emergency contraceptives.
Continuous low-dose administration of a PRM
from a vaginal ring has been shown to block
ovulation and induce amenorrhoea.
Contraceptives combined with other agents
should provide dual protection against both
pregnancy and another preventable conditions.
Dual protection methods are tested as vaginal
gels or rings delivering both a contraceptive and
an agent active against HIV transmission. In
addition, the potential of PRMs to prevent breast
cell proliferation or the neuroprotective effects
of progesterone and derived molecules are new
areas of research for contraception with added
medical benefits. These dual-purpose methods
may increase users’ compliance, thus reducing
failures and unwanted pregnancies.Men now tend to accept responsibility for the
couple’s fertility control, leading to a growth in male
contraceptives needs. Non-hormonal methods
for men target the maturation of germ cells, or the
sperm motility and activity. Novel approaches in
women target meiosis as well as genes involved
in follicular rupture. These methods will hopefully
enter clinical testing during the current decade.
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12:45-
14:00Lunch session 1: IPPF European Network, CarrickChair:Lunch session 2: National clinical practice guidelines in abortion care, Tinto- Joanna Dec, PL
Chair:- Elisabeth Aubény, FR
- Nathalie Kapp, FR
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14:00-
15:30W01 Workshop: Women’s journeys, HarrisChair:W02 Debate: Surgical or medical 1st trimester abortion ‐ pro and con, Pentland- Gunta Lazdane, DK
- Sam Rowlands, GB
Chair:W03 Education and Training in abortion care, Carrick- Elisabeth Aubény, FR
- David Baird, GB
Chair:W04 Hot topic: Reproductive sabotage, Tinto- Teresa Bombas, PT
- Kristina Gemzell-Danielsson, SE
Chair:W05 Free communications, Ochil- Rebecca Cook, CA
- Kelly Culwell, US
Chair:- Rodica Comendant, MD
- Alberto Stolzenburg, ES
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- Helena Kopp Kallner, SE (all speeches)
- helena.kopp-kallner@ds.se
Acceptability of medical termination of pregnancy
up to 63 days of gestation with home
administration of misoprostol: assessment of
significant factors
Kopp Kallner, H1; Fiala, C2; Gemzell-Danielsson, K1
1 Department of Obstetrics and Gynaecology, Karolinska Institute 7,
Stockholm, Sweden; 2 Gynmed Clinic, Austria
Objective: The objective of this study was to identify significant
factors affecting acceptability of home administration of
misoprostol for medical termination of pregnancy (TOP) up to
63 days of gestation.
Methods: This study was conducted in a University Hospital
Outpatient Family Planning Clinic. Women who were in good
general health, above 18 years of age, with no contraindication to
medical TOP, requesting medical TOP with home administration
of misoprostol and with pregnancies up to 63 days of gestation as
evaluated by ultrasound were asked to participate. Women
received 200 mg of mifepristone in the clinic and were instructed
to self-administer 0.8 mg of misoprostol vaginally at home 36–
48 hours later. Women filled in questionnaires which were
answered after the TOP and at follow up. Patients also filled in
daily symptom diaries. Follow-up was 2 weeks later with physical
examination and low sensitivity urine-hCG according to clinical
practice. All factors extracted from the questionnaires which could
potentially affect acceptability were analysed using multivariate
logistic regression.
Results: In total, 395 women who opted for home administration
of misoprostol for medical TOP were recruited. We found that
the presence of a partner/friend during the TOP affected
acceptability in a positive direction (P = 0.021). In contrast,
having a positive low sensitivity urine hCG at follow up affected
acceptability negatively (P = 0.002), although most of these
women had a successful and complete TOP. In contrast to otherstudies on medical TOP, we could not find an influence of age,
gestational length or the requirement of extra pain medication on
overall acceptability of the procedure.
Conclusions: Home administration of misoprostol for medical
TOP up to 63 days of gestation is highly acceptable. Women
should be encouraged to have a partner/friend present during the
TOP if possible as this affected acceptability of the procedure in
this study. In order to further increase acceptability of home
administration of misoprostol, focus of future research should be
directed towards increasing the number of complete TOPs in a
shorter time frame. -
- Sharon Cameron, GB (all speeches)
- sharon.cameron@ed.ac.uk
Results: Two prospective cohort studies (n = 3821) and two
randomised controlled trials (RCTs) (n = 3821) were included.
Three thousand seven hundred and forty-nine women underwent
a procedure administered by an MLP and 3893 women underwent
a physician-administered procedure. Three studies used surgical
TOP with maximum gestational ages ranging from 12 to 16+
weeks; a medical TOP study had maximum gestational ages up to
9 weeks.
There was no difference in incomplete/failed TOP for
procedures performed by MLPs compared to doctors in RCTs of
surgical (OR: 2.00; 95% CI: 0.85, 4.68) and medical TOP (OR:
0.69; 95% CI: 0.34, 1.37). One prospective cohort study showed
increased odds of incomplete/failed TOP among MLPs versus
physician groups (OR: 4.03; 95% CI 1.07–15.28).
None of the included studies found a difference in the odds of
overall complications between provider groups.
Conclusions: Based on this evidence, there is no indication that
procedures performed by MLPs are less effective or safe than
those provided by physicians.Conclusion: Women undergoing a TOP who wish to avoid
another unintended pregnancy should consider immediate
initiation of either intrauterine contraception or the progestogen-
only implant. Service providers should be trained and supported
to provide these methods to women at the time of TOP. -
- Lucy Caird, None (all speeches)
FC1.03
Most women choosing termination of pregnancy
are certain of their decision and do not need more
counselling
Caird, L1; Cameron, S2; Glasier, A3; Hough, T1
1 Raigmore Hospital, NHS Highland, UK; 2 Chalmers Sexual and
Reproductive Health Centre, UK; 3 Department of Reproductive and
Developmental Sciences, UK
A self-administered questionnaire using a validated measure of
pregnancy intention (London Measure of Unintended Pregnancy)
was introduced as part of routine assessment for women
requesting a termination of pregnancy (TOP) at a NHS hospital
clinic in Inverness, Scotland, UK aimed at identifying those who
may need more discussion on their decision to proceed with a
TOP. We wished to determine the proportion of women for
whom the pregnancy was clearly unintended, the proportion who
were not certain of their decision and who would like more
detailed discussion, and the proportion who subsequently
proceeded with a termination of pregnancy.
Methods: A retrospective review was conducted of the outcome
of the pregnancies amongst women attending the service between
January and July 2011.Results: One hundred and eighty-five women with a viable
pregnancy completed a questionnaire. The pregnancy was clearly
unintended in 166 (90%) cases. One hundred and sixty-seven
women (90%) stated that they were certain of the decision to
have a TOP and 150 women (81%) did not want further
discussion about this decision. One hundred and sixty-three
women (88%) proceeded with a termination of pregnancy.
Conclusion: Most women referred to a clinic requesting an
induced TOP have a clearly unintended pregnancy, are certain of
their decision and do not wish further counselling. Subjecting
women to compulsory counselling about their decision to have a
TOP is in conflict with their wishes and would waste resources. -
- Lucy Michie, None (all speeches)
Review of telephone follow-up of women having
early medical termination of pregnancy
Michie, L1,2; Cameron, S1,2; Johnstone, A1,2;
Dewart, H1,2
1 NHS Lothian; 2 University of Edinburgh, UK
Introduction: Telephone follow-up2 weeksaftermedical
terminationofpregnancy(TOP)(£9 weeksofgestation)withaself-
performedlowsensitivityurinepregnancy(LSUP)test,was
introducedatahospitalTOPserviceinEdinburgh.Womenwho
screened‘positive’attelephonefollow-up(ongoingpregnancy
symptoms,scantbleeding,orLSUPresult)subsequentlyattended
foranultrasound.Apreviousserviceevaluationconfirmedthatthis
waseffectivefordetectingongoingpregnancyandhadgoodfollow-
uprates.Wesoughttodetermineifthismethodoffollow-up
continuedtobesuccessfulduringtheyearfollowingitsintroductionMethods: Retrospective computerised database review of outcome
of telephone follow-up of women having a medical TOP
(£9 weeks of gestation) over 12 months (March 2011–February
2012).
Results: One thousand and eighty-four women of mean age
25 years had a medical TOP during this period. One hundred and
twelve women were scheduled to attend the clinic for follow-up
and three women did not require follow-up as complete TOP was
confirmed on the day of treatment. Ten women (out of 969)
attended hospital before the planned telephone contact (1%). Of
the 959 requiring telephone follow-up, 656 (68%) were
successfully contacted. Two of those who were not contactable
had ongoing pregnancies. Five hundred and seventy-three (87%)
of those contacted, screened ‘negative’ with no false negatives
occurring. Of the 83 (13%) who screened ‘positive’, three had
ongoing pregnancies. The sensitivity of follow-up was 100% and
specificity was 88% (95% CI 84.9–90.1).
Conclusion: Although slightly lower follow-up rates were obtained
in the 12 months following initial introduction, telephone follow-
up with LSUP was shown to be effective for detecting ongoing
pregnancy. -
- Ellen Wiebe, CA (all speeches)
- ellenwiebe@yahoo.com
Women’s perceptions of viewing ultrasound before
termination of pregnancy: comparing first and
second trimester
Wiebe, E; Trouton, K
University of British Columbia, Canada
Objectives: The purpose of this study was to gain a better
understanding of women’s choices, perceptions and experiences of
viewing the ultrasound before having a first or second trimester
termination of pregnancy (TOP).
Methods: A questionnaire was offered to women prior to their
ultrasound asking if they wished to view it. For women who chose
to view the ultrasound, a second questionnaire asked them about
their experience. Women in the first trimester (up to 12.0 weeks
by ultrasound) were compared to those in the second trimester.
Results: There were 234 women who completed the first
questionnaires: 172 first trimester and 62 second trimester. Of the
first trimester patients, 50% (86) and of the second trimester
patients 47% (29) wanted to see the images (NS). More second
trimester women were unsure about how they would feel about it
(P = 0.01). There were 77 first trimester and 27 second trimester
patients who completed the second questionnaire. When asked if
viewing the ultrasound made it harder emotionally, 21% (16/77)
of the first trimester patients and 44% (12/27) of the second
trimester patients said ‘yes’ (P = 0.01).
Conclusions: About half of the women in this study wanted to see
the ultrasound before the TOP. Second trimester patients were
more likely to be unsure about what to expect and were more
likely to find it harder emotionally. It is important that we
prepare our second trimester patients more carefully for the
experience of viewing the ultrasound. -
- Andreja Štolfa Gruntar , SI (all speeches)
Women’s preference for medical or surgical
method of termination of pregnancy at 9–12 weeks
of gestation
Dewart, H1; Johnstone, A2; Cameron, S2
1 Royal Infirmary of Edinburgh, UK; 2 Chalmers Sexual and
Reproductive Health Service, UK
Background and methods: Medical termination of pregnancy
(TOP) at less than 9 weeks of gestation and in the second
trimester, using mifepristone and misoprostol is well established
in Scotland. Although there is good evidence to support the
efficacy, safety and acceptability of medical TOP in the late first
trimester (9–12 weeks), it is not widely available. The TOP service
in Edinburgh, Scotland, UK currently offers only a surgical
method at this gestation band. A survey of women presenting to
this service at 9–12 weeks of gestation was conducted to
determine whether these women would choose a medical method
if this were available.
Results: Questionnaires were completed by a convenience sample
of 77 women over 5 months, representing 49% of all women at
this gestation during the study period. Women were of mean age
24.7 years (range 15–42). Most women (n = 51; 66%) stated that
they would choose a medical TOP if able to do so and a further
10 (13%) were unsure about preference of method. Most women
(n = 43; 56%) stated that they would still choose the medical
method, if they had to travel to another hospital (40 km away) to
have this. The commonest responses (out of 46 given) for
preferring a medical method was a perception that it was safer
(37%), easier (30%) and less invasive (28%).
Discussion and conclusions: Most women in our survey at 9–
12 weeks of gestation would in theory choose a medical method
of TOP, if this were available. Consideration should now be given
to offering this method to women as an alternative to surgery.
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16:00-
17:30Abortion: an update on the global situationChair:General Assembly of FIAPAC (members only)- Christian Fiala, AT
- Helena von Hertzen, CH
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- Rebecca Cook, CA (all speeches)
- rebecca.cook@utoronto.ca
Stereotyping in Reproductive
Health Gender stereotyping refers to the treatment
of the sexes according to social and cultural
constructions of women and men, due to their
different physical, biological, sexual and social
functions, not according to their individual
attributes. This presentation will examine how
wrongful stereotyping of women harms their
dignity and prevents them from accessing abortion
services according to their own individual needs
and circumstances. It will explain how international
and regional human rights treaty bodies and
national constitutional courts are holding states
legally accountable for failing to eliminate harmful
gender stereotypes. In conclusion, it will explore
what implications the evolving law against harmful
gender stereotyping might have for abortion laws
and policies more generally. -
- Susheela Singh, US (all speeches)
- ssingh@guttmacher.org
Trends in induced abortion Background: Abortion levels and trends often
mirror patterns in the incidence of unintended
pregnancy. We present estimated safe and unsafe
abortion levels globally and in all the major worldregions and subregions for 2008, the most recent
year available, and trends in abortion incidence
between 1995, 2003 and 2008. We also explore
the association of the legal status of abortion with
the abortion rate. Finally, we examine abortion
rates and the distribution of abortion by age, and
variations in these measures across geographical
areas and over time.
Select Findings: The global abortion rate was
steady between 2003 and 2008 following a period
of decline between 1995 and 2003. Worldwide,
49% of abortions were unsafe in 2008, compared
to 44% in 1995. About one in five pregnancies
ends in abortion. Restrictive abortion laws are not
associated with lower abortion rates. Adolescents
account for a smaller share of abortions than their
population size would predict in most countries
with data. The proportion of abortions obtained
by adolescents is higher in North America than
in Europe, though Northern Europe resembles
North America in this respect. Findings and their
implications will be discussed in greater detail. -
- Bela Ganatra, GB (all speeches)
- ganatrab@who.int
Update on unsafe abortion Despite technological advances, unsafe abortion
continues as a public health problem and
important cause of maternal mortality globally. As
per WHO’s recent estimates, currently, about 22
million unsafe abortions occur every year—98%
of them in the developing world. The global rate
is 14 unsafe abortions per 1,000 women 15-44
years, but there are wide disparities acrossgeographic regions, with Eastern and Middle
Africa having the highest rate of unsafe abortion
at 36 unsafe abortions per 1,000 women aged
15-45. Adolescents and poor women also bear a
disproportionate burden.
Sexuality education, access to affordable,
effective contraception and to lifesaving care to
treat complications can all help to reduce the
unintended pregnancies or the morbidity and
mortality from unsafe abortion, but access to
safe, legal abortion care remains central to
dealing with the problem. Barriers include health
system, finances, regulations, and policies,
stigma and the ways existing laws and regulations
are interpreted and implemented.
Effective interventions do exist and progress
has been made in recent years, as is evidenced
by a decrease in case-fatality rates from unsafe
abortion. The Safe Abortion: Technical and
Policy guidance for health Systems (WHO, 2012)
presents the public health and human rights
based evidence to address the issue.
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