Authors
A BLucy Caird
Speeches:
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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. -
Telemedicine for abortion care: the Highlands experience
Lucy Caird1, Sharon Cameron2, Tracy Hough1 1Raigmore Hospital, Inverness, UK, 23 Department of Reproductive and Developmental Sciences, University of Edinburgh,, Edinburgh, UK - lucy.caird@gmail.com
In NHS Highland we provide an abortion service in a geographically challenging environment especially in terms of providing care within the context of the UK Abortion Act. Travel time to and from our service will be a consistent barrier to providing early medical discharge with those excluded consistently at around 35%. Our aim was to improve care by streamlining care with fewer visits and thus remove some inequity in providing abortion care in our remote and rural area. To reduce visits we offer a telephone consultation option with information sharing that affords women the chance to reflect on their choices and for us to 'one stop' their visit especially where flights or ferries are involved. Women from further away have to choose either day case medical or surgical abortion in hospital and this has resource implications for the gynaecology service. Manual vacuum aspiration can offer women the advantages of same-day treatment and as with all surgical abortion the easy insertion of intrauterine contraception chosen by 55% of the women having MVA. In this paper we discuss how we have developed new ways to deliver this service remotely and have aimed to make it as streamlined as possible for women.
Cait Calcutt
http://www.childrenbychoice.org.au
Speeches:
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Children by Choice - an Australian counselling, information and
education service on issues relating to unplanned pregnancy.
Abstract: Since 1972, Children by Choice has provided counselling, information and education services to women experiencing unplanned pregnancy. We are a unique service in Australia, as we provide the only specialist pro-choice counselling, information and referral service on all unplanned pregnancy options. (There are many anti-choice pregnancy counselling services in Australia). Our service has also assisted women to access abortion through financial subsidies and travel arrangements. Children by Choice has a proud history of activism on abortion law reform and expanding women's access to abortion services. This poster presentation will outline the history and services provided by Children by Choice, and discuss the current status of abortion access and laws in Australia.
Cait Calcutt, Coordinator
Sharon Cameron
Speeches:
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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. -
Integrating abortion within a community sexual and reproductive health service: a qualitative study of the experiences of women and health professionals
Carrie Purcell1, Sharon Cameron1 ,2, Anna Glasier1, Julia Lawton1, Jeni Harden1 1University of Edinburgh, Edinburgh, UK, 2NHS Lothian, Edinburgh, UK - carrie.purcell@ed.ac.uk
Background: Abortion in Scotland has historically been provided in a hospital setting. The availability of early medical abortion (EMA), and the possibility for women at early gestations choosing to go home to pass the pregnancy (soon after receiving misoprostol form the abortion service), have enabled the provision of abortion from an integrated community sexual and reproductive health (SRH) service. However, little is known about the impact of the clinical setting on the experiences of staff involved in the EMA service. This paper presents findings from the staff experience arm of a qualitative evaluation of EMA provision in both SRH and hospital settings. Objectives: - To examine the experience of nurses, nursing aides, doctors and sonographers involved in EMA provision. - To explore whether, and in what ways, the clinical setting shapes this experience - To highlight areas for good practice/ improvement Method: Qualitative interviews (N=35) were conducted with staff involved in EMA provision at one SRH-based and two hospital-based abortion services in central Scotland, between October 2013 and April 2014. Interviews were coded using NVivo 10 software and analysed thematically. Results: Staff in both settings emphasised the importance of team working and cited the quality of care offered as a success of the EMA service. They also described experiencing challenges, including: boundaries between roles, training, resource constraints, adjustment to change, and the perceived marginalisation of abortion services. Relative differences were identified between clinical settings, for example: nursing staff in the SRH setting described greater involvement with post-abortion contraceptive uptake; nursing aides in the SRH context expressed more negative views on their work role. Conclusions: There are many similarities of experience across staff groups and between clinical settings. Differences between the settings reflect the benefits and the challenges of the new SRH service.
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Is there a reduction in abortion rates?
Sharon Cameron (Scotland)
University of Edinburgh, Scotland
sharon.cameron@ed.ac.uk
Emergency Contraception (EC) can prevent pregnancy. Effectiveness of EC has been based upon estimates of the risk of pregnancy depending on the timing of unprotected intercourse within the menstrual cycle. Research demonstrated that the main barriers to use of EC were lack of knowledge of EC and difficulty in obtaining EC.
It was anticipated therefore that increasing the availability of EC would lead to a reduction in unintended pregnancies, reflected in lower abortion rates. In some countries, EC is available without prescription at pharmacies. In the UK and France, cross sectional surveys have shown that this has led to more women obtaining EC from the pharmacy rather than other sources.
However, increased use of EC has not been associated with a reduction in abortion rates in UK or Sweden. This may be because abortion is linked to other social, economic and political factors.
A Cochrane database systematic review of RCT’s that examined effects of advance provision of EC (women supplied with EC to have rapid access in case of need) compared to standard access, showed increased use of EC but no difference in unintended pregnancy rates. In those cycles resulting in pregnancy where women with EC did not use it, this was mostly due to a misperception that they were not at risk of pregnancy.
Encouraging use of more effective methods of contraception before or during sex may be a more effective strategy to prevent unintended pregnancies than use of EC.
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Outcomes for women based on psychological background
Sharon Cameron (Scotland)
University of Edinburgh, Scotland
sharon.cameron@ed.ac.uk
It has been claimed that the decision to terminate an unwanted pregnancy can lead to mental health problems for women. However, childbirth can be a physically and emotionally demanding time for mothers and many studies have demonstrated an increase in depression and anxiety post-partum. There has been a lack of research on the long term mental health of women choosing an abortion. Of those studies which have been published, many have suffered from methodological problems or failed to account of possible confounding factors.
Recently, a systematic review of the literature relating to mental health of women following abortion, was conducted by the American Psychological Association. This concluded, based upon the available evidence, that among adult women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single first trimester abortion, than if they deliver that pregnancy.
Whilst there may not be a causal link between abortion and mental health problems, nevertheless some women do experience negative psychological responses including depression and anxiety. Risk factors that have been identified include ambivalence about the decision to have the abortion, whether the pregnancy was originally intended, lack of a supportive partner, a psychiatric history and membership of a cultural group that considers abortion to be wrong. Some of these risk factors are also predictive of mental health problems following childbirth.
Further, more robust and definitive research studies are required on mental health after both abortion and alternative reproductive outcomes such as childbirth or miscarriage
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Outcomes of very early medical termination of
pregnancy at ££6 weeks of gestation
Heller, R; Cameron, S
NHS Lothian, UK
Background and methods: In 2010 the termination of pregnancy
(TOP) service at The Royal Infirmary of Edinburgh, Scotland, UK
introduced a protocol that allowed women at very early gestation
without ultrasonic evidence of an ongoing intrauterine pregnancy,
but who fulfilled certain criteria (£6 weeks of gestation by dates,
eccentric placed intrauterine gestational sac of £3 mm, decidual
reaction, no risk factors for ectopic) to proceed directly
with medical TOP, without the need for further investigations
or ultrasound scans. Follow up consisted of routine
telephone follow up with home low sensitivity urine pregnancy
(LSUP) test.
A retrospective audit of the management of this group of
women attending in 2011 was conducted. Hospital computerised
records and case notes were used to determine the number of
visits made, investigations performed and outcome of the
pregnancy.
Results: Five hundred and eighty women attended over the audit
period requesting a TOP at £6 weeks of gestation. Of these
women 3.7% (n = 21) had a serum hCG performed prior to TOP,
and 2% of women (n = 12) had more than one ultrasound before
TOP. Seventy-three percent of women (n = 414) had routine
follow up (telephone follow-up with LSUP) only, 24.4% (n = 138)
had one post-TOP ultrasound, and 1.5%, (n = 9) returned for
more than one post-TOP ultrasound. At follow up ultrasound,
two women were found to have ongoing pregnancies (0.3%).
There were no ectopic pregnancies.
Discussion and conclusions: Most women at early gestation
(£6 weeks) without definite evidence of a viable intrauterine
pregnancy can proceed to medical TOP without the need for
additional pre-TOP or post-TOP ultrasonography -
Post-abortal infection - prevention strategics
Dr. Sharon Cameron, United Kingdom
The reported incidence of post -abortal infection (in countries where abortion is legal ranges from 1% to10%, depending on the population, diagnostic criteria used to define infection, use of peri-abortal antibiotics and the method used. Prospective comparative studies have suggested that medical abortion may be associated with an overall lower risk of infection, possibly because it is less invasive procedure. The presence of chlamydia, gonorrhoea or bacterial vaginosis in the lower genital tract at the time of abortion has been shown to be associated with an increased risk of post-abortal infection. Strategies for preventing post- abortal infection include (i) a screen-and-treat policy (ii) universal antibiotic prophylaxis or (iii) a combined approach, of both screening and prophylaxis. Meta-analysis of randomised trials have shown that antibiotic prophylaxis at the time of abortion is associated with a reduction in the risk of subsequent infection of around 50%. Furthermore, antibiotic prophylaxis has been shown to benefit women who have negative pre abortion genital swabs and is less costly than the other strategies. However, failure to test for sexually transmitted infections pre-abortion and to identify infected women, perpetuates the risk of re-infection by an infected partner. This is important since it is believed that re-infection with chlamydia may increase the likelihood of complications such as tubal infertility.
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Self-assessment of success of early medical
termination of pregnancy: a service evaluation
Cameron, S1,2; Glasier, A1,2; Dewart, H1,2;
Johnstone, A1,2; Burnside, A1,2; Paterson, B1,2;
Hunt, L1,2; Rahimi-Rizi, J1,2
1 NHS Lothian, UK; 2 University of Edinburgh, UK
Introduction: In a recent study, we demonstrated that telephone
follow- up with a self-performed low sensitivity urine pregnancy
(LSUP) test was effective to determine the success of early medical
TOP (<9 weeks of gestation). In the latter study, one half of
women surveyed stated that they would have chosen self
assessment (without a telephone call), if available. We
subsequently introduced self-assessment with a self-performed
LSUP test to our hospital TOP service in Edinburgh, Scotland.
Women choosing this option were given detailed information on
symptoms that may indicate an ongoing pregnancy and advised to
contact the service if symptoms or LSUP suggested ongoing
pregnancy.
Methods: Ongoing service evaluation of self assessment with
LSUP test as a method of follow up after early medical TOP,
consisting of review of the proportion of women choosing this
follow-up, contacting the service, and the efficacy for detecting
ongoing pregnancies.
Results: To date, out of a total of 89 women having early medical
TOP, 66 have opted for self-assessment (74%), 18 for telephone
follow-up (20%) and four for a clinic follow up with ultrasound
(4%). Only three of the first 66 women (4.5%) choosing self
assessment have contacted the service, because of pain/bleeding
(n = 1), discharge (n = 1) and a positive LSUP (n = 1). To date
there have been no known ongoing pregnancies in the self
assessment group.Conclusion: Initial findings suggest that self-assessment with a
LSUP test is a popular choice for women. Few women contact the
service, suggesting that women are confident in managing follow-
up in this way. -
CS05.2
Quick starting after emergency contraception (EC
Sharon Cameron
NHS Lothian, Edinburgh, UKMeta-analyses have shown that women who have further episodes of unprotected sex in the same cycle after taking oral EC have a two- to three-fold higher risk of pregnancy than women who do not. This raises the importance of quick starting a regular method of contraception immediately after EC is used. Guidelines advise that when quick starting a hormonal method after taking levonorgestrel for EC, that women use barrier methods/ abstinence for the standard numbers of days until contraceptive effectiveness of the method if achieved (e.g. 7 days for combined hormonal methods, 2 days for progestogen only pills- POP). Since Ulipristal acetate (UPA) is a progesterone receptor modulator, quick-starting a hormonal method after UPA could in theory alter the effectiveness of hormonal contraception by competition at the receptor site or vice versa. Two RCTS have addressed this. One examined the effect of UPA followed by COC on ovarian quiescence and suggested that UPA does not affect the contraceptive efficacy of COC. This study was not designed to examine a potential impact of COC on UPA. The other study examined UPA followed by POP (desogestrel) and also suggested that UPA does affect the contraceptive action of POP. However, this study indicated that commencing a POP 24hrs after UPA can prevent the ability of UPA to delay ovulation. In view of this, women who wish to commence hormonal contraception after UPA for EC are advised not to quick start. Interim guidance from the Faculty of Sexual and Reproductive Healthcare UK, advise that women wait at least 5 days after UPA before commencing hormonal contraception.
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From hospital to community
Sharon Cameron1,2 1NHS Lothian, Edinburgh, UK, 2University of Edinburgh, Edinburgh, UK - sharon.cameron@ed.ac.uk
There is growing recognition that termination of pregnancy (TOP) services should be able to offer both high quality contraceptive advice and provide women with the most effective methods of long-acting reversible of contraception (LARC), to start immediately after the TOP. Women who choose to start LARC immediately post TOP have a significantly reduced risk of having another TOP than counterparts choosing less effective methods. In many countries, TOP services are traditionally delivered from hospital departments of obstetrics and gynaecology where staffing of the labour ward usually takes priority. Junior medical staff delegated to undertake the consultations of women requesting a TOP may be disinterested in TOP care and may lack specialist contraceptive knowledge and training to insert the most effective LARC methods. In contrast, staff working in specialist contraceptive services (family planning/ sexual and reproductive health) in the community possess the knowledge and skills to offer the most effective methods of contraception. Furthermore, early TOP can clearly be delivered from the community setting. This raises the question of whether higher LARC uptake rates and as a consequence, fewer subsequent TOPs could be achieved if more TOP care was delivered from the community specialist contraceptive setting.
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FC17
Preferred terminology amongst women seeking abortion : A British survey
Sharon Cameron1, Patricia Lohr2, Roger Ingham3
1NHS LOTHIAN, Edinburgh, UK, 2BPAS, London, UK, 3University of Southampton, Southampton, UKObjectives: Some controversy exists as to whether or not women find the term ‘abortion’ distressing and would prefer alternatives such as ‘termination of pregnancy’. There is a lack of evidence to substantiate any change in terminology. We conducted a study to determine views of women seeking abortion on terminology used.
Methods: A cross-sectional study of the views of 2,259 women presenting for abortion in Britain was conducted over four months in 2015. Self-administered anonymous questionnaires were distributed at 57 abortion services in Scotland, England and Wales. The questionnaire asked for women’s views on preferred terminology and collected basic demographic data.
Results: The mean age of respondents was 27 years (range 13-51), 51% had children and 36% had previously undergone abortion. Most women did not find the words ‘abortion’ or ‘termination of pregnancy’ distressing. 35% (n=738) indicated that they found 'abortion' distressing vs 18% (n=399) who felt 'termination of pregnancy' was distressing (p<0.000). Significantly more respondents stated a preference for 'termination of pregnancy' than 'abortion' (n= 1009; 45% vs n=263; 12% respectively p<0.0001). This preference was not affected by demographic characteristics (e.g. age, reproductive history, residence).
Conclusions: Most women do not find either ‘abortion’ or ‘termination’ to be distressing. However, a relative majority might favour 'termination of pregnancy' and abortion care providers should be sensitive to this when communicating with women.
Ana Campos
Speeches:
Leslie Cannold
Speeches:
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Experiences of decriminalising abortion in Victoria
Dr Leslie Cannold, author, medical ethicist and the President of Reproductive Choice Australia and Pro-
Choice Victoria, grass-roots community groups that have played key roles in reforming Australian laws
In Australia, abortion is regulated by the states, most of which maintain abortion in the criminal code. In 2008, after a brutal political battle within and outside the Parliament, the Government’s Abortion Law Bill 2008 was passed into law without amendment. The new law removes abortion from the Crimes Act. Up to 24 weeks gestation, it is now regulated like all other medical procedures. After 24 weeks, doctors maintain control of the decision, two of whom must judge it as “appropriate in all the circumstances.” Subsequent efforts to reform laws similar to Victoria’s in NSW and Queensland, where a young woman is currently being prosecuted for the crime of procuring her own abortion, have so far been unsuccessful. Based on my involvement in successful law reform efforts nationally (in removing restrictions to the i mportation of RU486) and in Victoria, NSW and Queensland (in attempts to reform state abortion laws), I will identify factors vital to successful law reform efforts.
Roch Cantwell
Roch.Cantwell@glacomen.scot.nhs.uk
Speeches:
Josep Lluis Carbonell Esteve
Speeches:
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J. CARBONEL (Spain) uses this method, with 3 doses of 8OO µg misoprostol
alone. The rate of success ranges from 90 to 92% in pregnancies up to 63
days of amenorrhoea (LMP). This technique is less expensive than that using
mifepristone -
INDUCED ABORTION IN GESTATIONS FROM 19 TO 24 WEEKS OR MORE WITH 200 mg of MIFEPRISTONE + MISOPROSTOL + OXITOCIN
*J.LL Carbonell Esteve, *L. Várela, et al
*Clínica Mediterránea Medica Valencia, Castelló (Spain)
INTRODUCTION: Although some authors perform the D and E up to 22-23 weeks gestation, it is not advisable to use it beyond 19-20 weeks, since the risks and difficulties increase considerably with gestation. To determine a suitable protocol with maximum possible safety and efficacy is one of the burning scientific topics in termination of pregnancies of second late trimester and third trimester. Without any doubts mifepristone and misoprostol are indispensable in such protocol.
MATERIAL AND METHODS: They were administered mifepristone 200 mg orally 24-48 hours before vaginal administration of 800 µg of wet misoprostol + 2 dilapan shafts according to cervical conditions. 3-4 hours later the cervix was evaluated and if shafts were loose, a second dose of 600 µg of vaginal misoprostol was inserted or it was performed an artificial rupture of membranes (dilation 2-3 cm) and oxitocin infusion was established (6-8 drops by minute in a solution of 500 cc of ClNa with 30 U.I. of oxitocin). In an hour basis the cervix was examined and several medications were used to relieve pain and ripening the cervix. General sedation was used at expulsion. A complete hemogram with fibrinogen and TPTA 2 hours late were performed. Patients with cesarean section or previous uterine scar were not excluded.
RESULTS: 90 subjects between with 19 to 23.5 weeks gestation were successfully interrupted with the above protocol; 2 of them (20,4 and 20,5 weeks gestation) were failure cases at 32 and 31 hours, respectively, and were terminated by D and E. Only 30% of the cases received mifepristone before 24 hours. They were malformed 52.4% and 47.6% were voluntary abortions. The most frequent malformation was Down’s syndrome. The mean expulsion time was 5.5 hours, range 1.30-25 hours. There was a moderate hemorrhage by an atone uterus and the patient was discharged the following day, and an uterine rupture that forced to perform an urgent hysterectomy in a patient with a 19 years old cesarean section.
DISCUSSION: The use of mifepristone previously to the administration of prostaglandins improves significantly the cervical conditions and reduces in 50% the mean expulsion time, allowing that more than 60% of the cases can be discharged 6 hours post expulsion of the fetus and therefore to spend the night at home. Patients with previous cesarean section should be object of a different protocol, perhaps with less and maybe repeated doses of misoprostol. In the international bibliography there is reported a case of uterine rupture using a single 200 µg dose of vaginal misoprostol. It is urgent to determine with randomized clinical trials a proper dosing protocol for cases with previous uterine scar.
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IS SPAIN A DEMOCRATIC COUNTRY CONCERNING RIGHTS TO ABORTION?
J.LL Carbonell Esteve
Clínica Mediterránea Medica Valencia, Castelló (Spain)
The answer without a doubt TO this question is NO. Given that, in 98,99% of the abortions in our country, the woman should be authorized by a psychiatrist to carry out her abortion. The supposition of serious danger for the woman's psychic health that contemplates the Spanish law of abortion is the “legal strainer” for which is carried out more than 90% of those almost 70.000 annual abortions of social character or for free will of the woman. Therefore, this not is tinged since in the practice the legal strainer that supposes an insult and confiscation of the sovereignty and the woman's freedom, allows that in the reality the abortion in our State is practically FREE as in other countries of the truly democratic Europe. Also, more than 60% of the cases the woman should pay the cost of her abortion.
More than 2.500 judicial diligences have opened up crime of illegal abortion of course and more than 20 trials have taken place so far for the same reason, since the promulgation of the abortion law in 1985. In the last sentence of the Supreme Tribunal of the year 2003, after 10 years of judicial prosecution and provisional freedom for 2 doctors from different clinics and for the own woman that aborted, and concluded that the abortion was “legal” although a psychiatry specialist did not authorize it but by a general doctor Specialist in Public Health (Dr. J. Carbonell). The woman was acquitted and alone the doctor that practiced the abortion was condemned (Dr. J. Vives) for a supposed crime of professional negligence.
It is hope that this serious situation changes with the new abortion law that the PSOE, at the moment in governs has committed openly as necessary to promulgate, so that it puts an end to this situation of serious artificial lack of defense, so much for doctors as for women themselves.
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MIFEPRISTONA 200 MG + 600 µg OF SUBLINGUAL VERSUS VAGINAL MISOPROSTOL FOR SURGICAL ABORTION BETWEEN 12 TO 20 WEEKS GESTATION.
J.LL Carbonell, L. Várela, et al.
Clínica Mediterránea Medica. Valencia, Spain
INTRODUCTION: The use of vaginal misoprostol for ripening the cervix before second trimester abortions performed with the technique of Dilation and Evacuation (D and E), has represented a significant advance in the practice it of such procedure. Few carried out studies exist, using 200 mg of mifepristona before the administration of misoprostol. One of the legal indications of mifepristone is its use as a sensibilizing agent to the action of prostaglandins for second trimester abortions. To study the efficacy of sublingual versus vaginal misoprostol was the object of this study.
MATERIAL AND METHODS: 600 women with gestations between 12 to 20 weeks were randomly allocated to receive 200 mg of oral mifepristone and 15-48 hours later 600 µg of sublingual or vaginal misoprostol. Vaginal misoprostol (group 1) was inserted by doctors into the vaginal fornix and the buccal tablets (group 2) were placed by subject themselves sublingually and the other tablets inside the cheeks. In both groups, D and E was performed between 1 and 1.30 hours after the administration of misoprostol. Patients with previous cesarean section were not excluded. It was measured: 1) effect of mifepristone 2) achieved dilation, 3) side effects of misoprostol, and 4) duration of post abortion bleeding. The effect of mifepristone was assessed, before and after treatment, by means of vaginal exam detailing: position, length, consistency and dilation of the cervix.
RESULTS: So far they 200 women were treated with this protocol. In 91% of patients, the cervical conditions were improved after the administration of mifepristone. There was not any side effect of interest. The mean dilation reached was of 12 and 13 mm, in groups 1 and 2, respectively. Nausea, vomiting, chills/fever were present in 7,8% and 15%, vomiting 3% and 4,5%, fever/chills 30% and 36%, in groups 1 and 2, respectively. These signs and symptoms were always of moderate and acceptable intensity as referred by 91% of patients. After the administration of misoprostol and before the D and E there were 4% and 5% in groups 1 and 2, respectively, of spontaneous expulsions, that is to say pharmacological abortions.
DISCUSSION: Comparing with the well-known experience the fact of administering mifepristone 200 mg previously supposes an important advance in what concerns to the improvement of the cervical conditions for the realization of a D and E, so that once administered the misoprostol the necessary time of wait to perform the D and E decreases in about f 50%, otherwise they begin to take place pharmacological abortions. The reached dilation is very superior to the one obtained with the administration of misoprostol alone, being the dilation softer and physiologic, also shortening the surgical and anesthetics times. The sublingual route has practically demonstrated to be as effective as the vaginal one, that which represents a considerable advance in what concerns to the patient's comfort. More studies should be carried out in order to demonstrate the efficacy and safety of sublingual administration of misoprostol that presents fewer incidences of side effects due to the elimination the enterohepatic course and with similar dilatory efficacy as the vaginal route.
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Mifepristone 10 mg for emergency contraception up to 144 hours after an
unprotected intercourse
Carbonell JL,* García R,† Breto A,† Llorente M,* Marí JM,* Sánchez E,* Salvador I,*
Guillén S.*
†Eusebio Hernández Gyneco-Obstetric Teaching Hospital, Havana, Cuba.
*Mediterrania Medica Clinic, Valencia, Spain.
Background: Mifepristone 10 mg has proved to be an effective emergency contraceptive
when administered up to 120 hours after unprotected coitus. We assessed whether the
same effectiveness can be achieved if mifepristone is administered in a longer postcoital
interval (144 hours). Methods: Between May 2003 and February 2005, in the Eusebio
Hernández Gyneco-Obstetric Teaching Hospital in Havana, Cuba, we conducted a single-arm trial to evaluate the effectiveness of 10 mg mifepristone for emergency contraception
up to 144 hours (6 days) after unprotected coitus, A total of 635 women who requested
emergency contraception after a single act of unprotected intercourse were included in the
study. Results: After treatment there was a total of 7/635 (1.1%) pregnancies, 95% CI 0.4
– 2.3%. The prevented pregnancy fraction was 88.0% with 95% CI 77.1 – 95.1%. The
most common side effects reported by subjects were dizziness (6.1%) and nausea (4.9%);
vomiting was only reported by 0.6%. In 38/635 (6.0%) women menstruation was delayed >
7 days. Conclusions: Mifepristone 10 mg administered after unprotected sex can be an
effective method in emergency contraception with an acceptable profile of side effects, but
bigger studies are necessary to verify that it could be administered up to 6 days (144
hours) after an unprotected intercourse. -
Misoprostol for cervical priming: Vaginal vs sublingual
Carbonell J. LL.,* Llorente M,* Barambio S.,† Sánchez E.,* Varela L.,* González G.,*
Sánchez C.
*Clínica Mediterrania Médica, Valencia, España
† Clínica Tutor Médica, Barcelona, España
Objectives: to assess the effectiveness and safety of mifepristone 200 mg 48 hours before
administering misoprostol 600 µg, vaginal versus sublingual route, prior to D&E in 12-to-
20-week pregnancies.
Design: Controlled randomized clinical trial. Setting: Clínica Mediterrania Médica,
Valencia, Spain.
Subjects: Women with 12-to-20-week pregnancies wanting a voluntary abortion under the
requirements of serious danger for the mother’s mental health and/or fetal malformations,
between 9 July 2004 and 9 February 2006.
Methods: 900 women were randomized to be included in one of the following 4 groups: I)
sublingual mifepristone 200 mg plus misoprostol 600 µg before D&E, II) vaginal
mifepristone 200 mg plus misoprostol 600 µg before D&E, III) sublingual 600 µg
misoprostol before D&E, and IV4) vaginal misoprostol 600 µg before D&E.
Main outcomes measured: The degree of cervical dilation achieved before D&E, surgical
time necessary to terminate the pregnancy and side effects of misoprostol.
Results: The average cervical dilation in the mifepristone groups was 12.5 ± 2.8 mm (IC
95% 12.3 – 12.8), versus 8.5 ± 3.2 mm (IC 95% 8.2 – 8.8) in those receiving only
misoprostol. Surgical time in the mifepristone sublingual misoprostol group was 11.9 ± 4.3
minutes versus 13.0 ± 5.3 in the sublingual misoprostol group without mifepristone,
(p=0.007); in the mifepristone vaginal misoprostol group the average surgical time was
12.3 ± 5.0 minutes, versus 13.0 ± 6.2 in the vaginal misoprostol group without
mifepristone, (p=0.031).
Conclusions: administering mifepristone before D&E with misoprostol in second-trimester
abortions makes surgery easy and, to a certain extent, lessens the risk of cervical injuries,
especially in D&E in advanced gestational periods. -
Sublingual versus vaginal misoprostol 400 µg for cervical priming
Josep Lluis Carbonell1, J. Marí1, F. Valero2, M. Llorente1, I Salvador1, L Varela1, P Leal1,
A. Candel1, A Tudela1, M Serrano1, E Muñoz1,1Clinica “Mediterrania Medica”, Valencia, Castelló, Spain. 2Clínica “Ginemur”, Murcia,
Murcia Capital, Spain.
Objective: To compare the sublingual and vaginal administration of misoprostol for
cervical priming before first trimester surgical abortion. Design: Open, multicenter,
randomized trial. Locations: Four clinics in Spain: Valencia, Castelló, Murcia and Murcia
Capital. Participants: 1424 healthy pregnant women with amenorrhea ≤ 84 days who
voluntarily decided to terminate their pregnancies. Methods: Women were randomly
assigned to receive a single dose of 400-µg misoprostol sublingually or vaginally 1 to 3
hours before aspiration. Outcomes assessed: The cervix dilation before surgery and
surgical time needed for aspiration. They were also evaluated the incidence of side effects
such as nausea, vomiting, diarrhea, fever/chill and parestheses. Results: The mean
cervical dilation achieved was 6.8 ± 0.8 mm and 6.7 ± 0.9 for sublingual and vaginal
groups, respectively. Mean surgical time for the sublingual group was 7.0 ± 2.8 minutes
and 7.4 ± 2.5 for the vaginal group. Nausea, vomiting and diarrhea were more frequent in
the sublingual group. Conclusions: Both regimens had similar efficacy; however, the
sublingual route caused more side effects. -
VAGINAL MISOPROSTOL 800 µG EVERY 12 HOURS FOR SECOND TRIMESTER ABORTION.*
J.LL. Carbonell Esteve,a J. Rodríguez,b et al.
aClínica “Mediterránea Medica”, Valencia Spain.
bHospital Docente Gineco-Obstetrico “Eusebio Hernandez”, Havana, Cuba
INTRODUCTION: Since Bugalho et al. published in 1992 the first study using doses of 800 µg of misoprostol for second trimester abortion, so far numerous studies have been carried out using different dose and administration intervals. Some of them have used 200 mg of mifepristone 48 hours before misoprostol and they have obtained significantly shorter expulsion times. An appropriate protocol to carry out abortions of more than 12 week gestation regarding efficacy and safety is yet to be determined.
MATERIAL AND METHODS: Subjects with a previous uterine scar were excluded. A total of 269 women between 12 and 20 weeks gestation received 800 µg of vaginal misoprostol every 12 hours up to a maximum of 3 doses. Side effects, duration of bleeding, expulsion time, etc. were measured. Success was defined as the complete expulsion of the fetus and placenta without curettage after expulsion.
RESULTS: Complete abortion occurred in 245/269 (91.1%, 95% CI 87%-94%). After the first misoprostol dose aborted 66,5% of subjects; 19% of subjects aborted after the second misoprostol dose; and 5,6% aborted after the third dose, totalling 91,1%. There were 24 (8.9%) failure cases according to protocol. Mean vaginal bleeding time was 15.7 ± 4.1 days. Chills, nausea and vomiting were the most frequent side effects, all of them mild and transient. There 13 blood transfusions due to vaginal bleeding.
CONCLUSIONS: Of the 13 transfusions, only 1.1% were correctly indicated, the rest of them were unnecessary according to hemoglobin values. The administration of 800 µg misoprostol doses every 12 hours could be to valid alternative for abortion beyond 12 weeks gestation, especially in those countries where mifepristone is not yet available.
Morin Carlos
Speeches:
Mara Carvallo
Speeches:
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And after the Referendum?
Matilde Salta, Mara Carvalho, Vasco Freire (Portugal)
Médicos pela Escolha – Doctors for Choice in Portugal
medicospelaescolha@gmail.com
In Portugal, in the past 11th of February of 2007, a certainty became evident: that an important majority of the Portuguese society identified clandestine, illegal abortion like a Public Health problem, legitimizing the right to safe abortion by the woman’s request, as part of a plenum exercise of Sexual and Reproductive Rights, Universal Human Rights.
The new abortion law respects a person’s autonomy as an ethical principle, ensuring a free and universal access to safe abortion, a procedure performed by or with the help of qualified health care professionals. This new legal setting allows us to have concrete numbers about abortion, so that, by evaluating the numbers, we identify vulnerable groups, try to know its causes and consequences and provide the necessary support and interpret possible variations over the time, with longitudinal studies.
The DGS – Direcção Geral da Saúde (General Health Bureau in Portugal) predicted for the year after the implementation of the law 20000 abortions. In a study made by APF – Associação para o Planeamento da Família (the Family Planning Association) the number predicted was around 17000 abortions a year. Still awaiting annual results, in the first 5 months of law application, 6000 abortions were registered, and after eleven months the number was 12000, numbers a bit low when compared with the initial predictions. Why this happened and what can happen next are important discussions in terms of evaluating the effectiveness of the system and constantly, the level of information of the people.
Regardless of if the next annual numbers corroborate or not the tendency of the first eleven months, it is necessary to stretch the experience in other European countries where abortion is legal for several years: clandestine abortion tends to become almost absent with the legalization, but it’s a process with several years of evolution; the diminishing of the abortion rate and the raising of the women/couples doing effective contraception (to avoid unwanted pregnancies) is fundamentally related with the implementation of an effective Sexual Education and Health Care policies that improve the access to Family Planning and modern Contraception. In Portugal, one year after the implementation of the law, it’s still urgent to:
- Inform all the women that they have a new right of choice, an informed choice, with access to non-directive and specialized, support and care.
- Implement consistent Sexual Education policies, with obvious medium/long term benefits in preventing other Public Health Problems, like all the STDs.
Improve the Family Planning and abortion network. For example: creating conditions so that medical abortion is accessible to women in all the public primary care health services; equip the national health system with more human and technical means that answer not only to the needs of the women that want to interrupt their pregnancies, but also to the ones related to requests for definitive chirurgical contraceptive methods; all the hormonal contraceptives should be freely distributed.
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Impact of legalizing abortion in Portugal in 2007
Mara Carvalho, Portugal
In Portugal, in the past February 11th of 2007, 59,3% of the Portuguese voted “Yes” to a new abortion law and a certainty became evident: an important majority of the Portuguese society identified a persons’ autonomy as an ethical principle, ensuring a free and universal access to safe abortion by woman’s request up to 10 weeks of gestation. This legal framework allows you to have real numbers on abortion, thereby being able to identify vulnerable groups, access the implications and interpretation of possible changes over time.
In this new setting, the estimated numbers were around 20,000 abortions per year, by woman’s request. In a study made by APF - the Family Planning Association - the number predicted was around 17 000. After the implementation of the law the number of abortions by woman’s request up to 10 weeks was similar to predicted (18 014 in 2008 and 18 951 in 2009), about 70% were performed in the public health system and, of those, the medical abortion was the method chosen in 96% of cases.
Over the past few years have been reported less severe complications (infection / sepsis and
uterine perforation) related to abortion5. It was recently made public the report of the Maternal Deaths 2001-2007. During this period, in 14 of 92 maternal deaths reported, the cause of death was associated with unsafe abortion. Are not yet published the data of maternal deaths in 2008 -2009, but preliminary analysis indicates that there have been no deaths related to abortion after the legalization.Analysing the data we conclude that the big majority of abortions since 2007 were performed in a legal and safe context, the portuguese public health system was capable to properly respond to the abortion requests and regarding the ratio between medical and cirurgical abortion, we realize that medical abortion is the elected method.
In Portugal, three years after the legalization, it’s still urgent to inform all the women that they have a new right of choice with access to non-directive and specialized support and care, to implement consistent Sexual Education policies and improve the abortion network, including medical abortion performed by family physicians.
Laura Castelmann
Speeches:
Paul Cesbron
Speeches:
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In France from 1990 to 1995 1,000,000 legal abortions were carried out. There
were 4 deaths linked without certitude to an infection, 1 0/00 peritonitus and
about 1% of minor complications with up to 12 weeks of amenorrhia There are
few long term post-infection effects.
Women with a history of pelvic infection run a real risk of infectious complications.
The speaker quotes an American study:
1/1400 abortion leads to hospitalisation.
1/4500 leads to a serious infection.
What antibiotic therapy: 1 dose of DOXYCYCLINE 200mg 2 hours before, 200mg
12 hours after.
To recap:
At the moment the incidence of infection is not known.
The majority of centres do not practise a systematic antibiotic therapy.
The discussion underlined the different medical practices. In Spain
DOXYCYCLINE is systematically used for 5 days, in Germany there is screening
for Chlamydia with treatment in positive cases.
The specific case of Russia where women under go a high number of abortions
shows a linked rise in the incidence of Chlamydia.
In conclusion: although this is a quantifiable field consensus is not possible
Kamheang Chaturachinda
Speeches:
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Progress in medical abortion in Thailand
Kamheang Chaturachinda, WHRRF, Thailand
Prior to 2002 Misoprostol was freely available over- the- counter in Thailand at a cost of US 40 cents each. In 2002 the Ministry of Health had the first ever female Minister. She was from an ultra- conservative religious right political party (Palang Dhama Party). This party viewed abortion as immoral and sinful. Misoprostol was therefore put on the restricted drug list that needed to be prescribed only in hospital by a physician. The cost of the tablet in the market rocketed from 13 Bahts (40 US cents) up to 2,500 Bahts (70 USD ) and even to 5,000 Bahts (160 USD ) per tablet. A combination of Mifepristone 200 mg and Misoprostol 800 microgram package (commercial name MEDABON) was introduced in to Thailand in 2009 by the Concept Foundation. This was first introduced in to 3 leading medical schools in Bangkok(and later in to Provincial medical schools) as a research project. The second phase research of the efficacy and effectiveness of MEDABON was launched by WHO and our Foundation (WHRRF) at Ramathibodi hospital in Bangkok in 2010. After the publication of this study, we vigorously pushed for the registration of the drugs in Thailand as well as listing in the essential drug list (EDL). Listing in EDL allows the National Health Security Office (NHSO) to obtain the drugs for use in the Women’s Reproductive Health Entitlement Package at a reduced price. Registration was successful in 2014 . And listing in EDL in 2016. Medabon is now bought by the NHSO at a reduced price for distribution and use in the Women’s Reproductive Health Entitlement Package free of charge (market price 500 B./package: NHSO price 230 B./package). Even though Medabon is registered for use to terminate pregnancy, Safe Abortion is still not universal available to women in Thailand. The main reason for inaccessibility of women in Thailand to medical termination of pregnancy is the negative attitude of the healthcare providers. WHRRF together with the Royal Thai College of Obstetricians and Gynaecologists are trying to overcome this obstacle by education and training.Progress in medical abortion in Thailand
Kamheang Chaturachinda, WHRRF, Thailand
Prior to 2002 Misoprostol was freely available over- the- counter in Thailand at a cost of US 40 cents each. In 2002 the Ministry of Health had the first ever female Minister. She was from an ultra- conservative religious right political party (Palang Dhama Party). This party viewed abortion as immoral and sinful. Misoprostol was therefore put on the restricted drug list that needed to be prescribed only in hospital by a physician. The cost of the tablet in the market rocketed from 13 Bahts (40 US cents) up to 2,500 Bahts (70 USD ) and even to 5,000 Bahts (160 USD ) per tablet. A combination of Mifepristone 200 mg and Misoprostol 800 microgram package (commercial name MEDABON) was introduced in to Thailand in 2009 by the Concept Foundation. This was first introduced in to 3 leading medical schools in Bangkok(and later in to Provincial medical schools) as a research project. The second phase research of the efficacy and effectiveness of MEDABON was launched by WHO and our Foundation (WHRRF) at Ramathibodi hospital in Bangkok in 2010. After the publication of this study, we vigorously pushed for the registration of the drugs in Thailand as well as listing in the essential drug list (EDL). Listing in EDL allows the National Health Security Office (NHSO) to obtain the drugs for use in the Women’s Reproductive Health Entitlement Package at a reduced price. Registration was successful in 2014 . And listing in EDL in 2016. Medabon is now bought by the NHSO at a reduced price for distribution and use in the Women’s Reproductive Health Entitlement Package free of charge (market price 500 B./package: NHSO price 230 B./package). Even though Medabon is registered for use to terminate pregnancy, Safe Abortion is still not universal available to women in Thailand. The main reason for inaccessibility of women in Thailand to medical termination of pregnancy is the negative attitude of the healthcare providers. WHRRF together with the Royal Thai College of Obstetricians and Gynaecologists are trying to overcome this obstacle by education and training.
Kate Cheney
Speeches:
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Objectives The time between one pregnancy and the conception of the next is the interpregnancy interval (IPI). Short intervals of less than 6 months are consistently found to be associated with a range of adverse maternal and neonatal outcomes including maternal anaemia, preterm birth and low birthweight and those less 12 months increase the risk of neonatal morbidity. Amongst women attending two maternity hospitals in Sydney Australia, we sought a random sample of women to examine the timing of their IPIs and their understanding about the optimal space between pregnancies. Methods A prospective questionnaire-based study was performed at two hospitals in Sydney, Australia between Sep 2016 and May 2017. We collected demographic data, previous obstetric history, interpregnancy interval, contraceptive use and perspectives on advice and timing of the current pregnancy and ideal birth spacing from consenting women attending their second antenatal visit or immediately postnatal. Results 316 women completed questionnaires of whom 195 women were pregnant following a live birth. Of these, 119 (61%) reported that neither the hospital nor their GP had provided advice about ideal IPIs, 46.2% had not used contraception between pregnancies and 38 (19.5%) had an IPI 12 months, significantly fewer women with an IPI of < 1 2 months had used contraception after the last birth (21.6% versus 59.9%; p < 0 .001) and significantly more believed that < 1 2 months was an ideal birth interval (73.9 versus 44.5%; p=0.031). Conclusion: Most women who completed a questionnaire following a live birth reported a lack of health provider information about ideal IPIs. Where optimal IPI was understood to be less than a year, women were more likely to have a short interval between pregnancies. Almost half of women did not use any contraception.
Linan Cheng
Speeches:
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IUD for EC
Dr. Linan Cheng
Shanghai Institute of Family Planning Technical Instruction, The International Peace
Maternity and Child Health Hospital, China Welfare Institute, Shanghai, PR China
Emergency contraception is defined as the use of a drug or device as an emergency
measure to prevent pregnancy after unprotected intercourse. From this definition it follows
that methods of emergency contraception are used after coitus but before pregnancy
occurs, and that they are intended as a back up for occasional use rather than a regular
form of contraception.
The first report by Lippes in 1976 indicated an effectiveness of >95% within 5 days of
unprotected intercourse. Askallani 1987 first compared Cu-IUD (Cu-T 200) insertion withexpectant management in women requesting emergency contraception within 4 days of
unprotected intercourse. There was a significantly higher number of pregnancies in the
expectant management group (RR: 0.09, 95% CI 0.03 to 0.26). The comparative
effectiveness of inserting an intra-uterine device has not been adequately investigated.
Whereas it might be difficult to conduct randomized controlled trials of intra-uterine devices
with other interventions with the woman as unit of randomization, cluster randomization
might overcome this problem. Although there are many barriers to using intra-uterine
devices for emergency contraception, data from nonrandomized studies that were all
conducted in China suggest that inserting Copper-IUDs for emergency contraception could
be effective in preventing unintended pregnancy (3 pregnancies/1470 women, failure rate:
0.20%). These findings are in line with the findings of the Askalani trial that compared IUD
insertion with nothing. In the review of the efficacy of the IUD used in emergency
contraception by Trussell and Ellertson a meta-analysis of 20 published papers of post-
coital IUDs showed a failure rate of 0.1%from more than 8400 insertions.
The postcoital insertion of an IUD is an option that can be used up to 5 days after the
estimated time of ovulation and can be left in the uterus as a long-term regular
contraceptive method. -
Methods – What’s new?
Linan Cheng (China)
linanc2@yahoo.com
Background. Emergency contraception is using a drug or copper intrauterine device (Cu-IUD) to prevent pregnancy shortly after unprotected intercourse. Several interventions are available for emergency contraception. Information on the comparative efficacy, safety and convenience of these methods is crucial for reproductive health care providers and the women they serve.
Objectives. To determine which emergency contraceptive method following unprotected intercourse is the most effective, safe and convenient to prevent pregnancy.
Selection criteria. Randomised controlled trials and controlled clinical trials including women attending services for emergency contraception following a single act of unprotected intercourse were eligible.
Data collection & analysis. Data on outcomes and trial characteristics were extracted in duplicate and independently by two reviewers. Quality assessment was also done by two reviewers independently. Meta-analysis results are expressed as relative risk (RR) using a fixed-effects model with 95% confidence interval (CI). In the presence of statistically significant heterogeneity a random-effect model was applied.
Main results. Eighty trials with 43,743 women were included. Most trials were conducted in China (70/81). There were more pregnancies with levonorgestrel compared to mid-dose (25-50 mg) (15 trials, RR: 2.01; 95% CI: 1.27 to 3.17) or low-dose mifepristone (<25 mg) (9 trials, RR: 1.43; 95% CI: 1.02 to 2.01). Low-dose mifepristone was less effective than mid-dose (20 trials, RR:0.67; 95% CI: 0.49 to 0.92), but this effect was no longer statistically significant when only high quality trials were considered (6 trials, RR: 0.75; 95% CI: 0.50 to 1.10). Single dose levonorgestrel (1.5 mg) administration seemed to have similar effectiveness as the standard 12 hours apart split-dose (0.75 mg twice) (2 trials, 3830 women; RR: 0.77, 95% CI: 0.45 to 1.30). Levonorgestrel was more effective than the Yuzpe regimen in preventing pregnancy (2 trials, RR: 0.51; 95% CI: 0.31 to 0.83). CDB-2914 (a second-generation progesterone receptor modulator) may be as effective as levonorgestrel (1 trial, 1549 women; RR:1.89; 95% CI: 0.75 to 4.64) but the confidence interval is wide and the result compatible with higher or lower effectiveness. Delay in the onset of subsequent menses was the main unwanted effect of mifepristone and seemed to be dose-related.
Reviewers' conclusions. Mifepristone middle dose (25-50 mg) was superior to other hormonal regimens. Mifepristone low dose (<25 mg) could be more effective than levonorgestrel 0.75 mg (two doses) but this was not conclusive. Levonorgestrel proved more effective than the Yuzpe regimen. The copper IUD was another effective emergency contraceptive that can provide ongoing contraception.
Catherine Chéry
Speeches:
Sophie Christin-Maitre
Speeches:
Sopen Chunuan
Speeches:
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Situations of abortion and criminal abortion in the southern part of Thailand
Chunuan Sopen, Ph.D., Asst. Prof. Faculty of Nursing, Prince of Songkla University, Thailand
Co-authors: Kosunvanna Siriratana, Sripotjanart Wattana, and Jitsai Lawantrakul (Asst. Profs,
Faculty of Nursing, Prince of Songkla University), Jitti Lawantrakul MD, Obstetrician & Gynecologist,
Hatya Hospital, Uaiporn Pattrapakdikul ,Nurse Specialist, Nursing Division, Songklanagarind Hospital
Abortion is a major public health concern in the developing countries. Accurate measurement of the type
of abortion has proven difficult in many parts of Thailand. Thai health care providers need information on the incidence of both legal and illegal abortion to provide the needed services and to reduce the negative impact of unsafe abortion on women’s health.
The purposes of this descriptive study were to:
1) survey the incidence rate of legal and illegal abortion in the southern part Thailand
2) identify causes, complications and impacts of abortion
3) explore the decision making before conducting unsafe abortion.
This study was carried out in 2007 in 6 governmental hospitals. The samples consisted of 402 women with abortion. In addition, twenty women with unsafe abortion were deeply interviewed about the decision making process before conducting abortion. The structural instruments were used for data collection. The content validity was judged by 5 experts. Descriptive and content analysis were used.
Results showed that more than one-third of women had unsafe abortion (35.7%). Forty-two percent of women with abortion were in young women under 24 years of age (n = 168). Causes of abortion were social problem (34.08%), family problems (26.12%), and women’s health problems (21.64%). Nearly one-third of women had severe abdominal pain (29.6%), fever (18.4%), and anemia (15.4%), and shock (4.5%). Half of women had only psychological problems (50.5%). The majority of subjects made their own decision to terminate their pregnancy (n = 119) and almost half of them performed unsafe abortion by themselves (n = 71).
Most women in the interviewed group would like to terminate their pregnancy as soon as possible (n = 14). After they had completed abortion they felt released and then they felt guilty. They suggested that the public hospital should provide safe abortion for women with unplanned pregnancy. These study findings indicated that most of women with unsafe abortion experienced psychological and economical problems; thus, health care providers should offer the counseling program to reduce women’s problems and to improve their quality of lives.
Kathryn Church
Speeches:
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Objectives: In Bangladesh, women undergoing menstrual regulation (MR) (an approved procedure to regulate menstruation in women at risk of pregnancy) are a key group to target with contraceptive services. We used a randomised controlled trial to evaluate an intervention delivered by mobile phone which was designed to promote contraceptive use among MR clients in Bangladesh.
Methods: In 2015/2016, we recruited 972 women after their MR procedure from 41 facilities, and randomised them to intervention or control groups. The intervention group were sent 11 automated, interactive voice messages with optional call centre counselling over 4-months post-MR. The primary outcome was self-reported LARC (long acting reversible contraceptive) use at four months post-MR; secondary outcomes were use of any effective modern method, subsequent pregnancy or MR and intimate partner violence (IPV).
We used Logistic regression modelling to calculate odds ratios, allowing adjustment for baseline differences between the groups among pre-defined variables. In 2017, we conducted in-depth interviews (IDIs) with 30 trial participants to explore the intervention effects/non-effects.Results: We interviewed 773 participants (80%) at 4-months. Full details of the results from the trial and IDIs will be presented at the conference. Many IDI participants reported that they learnt more about contraception from the intervention however some women faced barriers to accessing the automated content due to low phone literacy. IDIs indicated a high frequency of phone sharing and that women’s phone use is sometimes monitored or controlled by others in the home. The majority of IDI participants had told their husbands about the study and their MR.
Conclusions: These findings highlight the importance of considering familial contexts when designing interventions that reach into homes. The results of this trial will help us to understand whether this type of intervention can be successfully translated to the Bangladesh context.
Mara Clarke
Speeches:
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Objectives: This presentation is an intimate and sometimes stark look at the groups most negatively impacted by the abortion law and policy in Ireland and Northern Ireland using real life examples of those still struggling to access legal abortion and the hardships they are facing.
Methods: The presentation is based on the experiences of clients who have contacted Abortion Support Network (ASN). As ASN’s primary function is to provide financial assistance, the case studies will be of those who are marginalised, at risk, or otherwise without the financial means and support networks required to access abortion services without assistance.
Results: While those based in Northern Ireland are able to access free abortions if they travel to England, not all people are able to travel. In addition, ASN continues to be contacted by women who have no idea about the scheme allowing free abortions in England, which is obviously due to a lack of knowledge of the availability. Meanwhile, while the Republic of Ireland has repealed the 8th amendment, there has as of yet been no legislative change, and anyone who wants an abortion is still forced to take safe but illegal abortion pills or travel to another jurisdiction.
Conclusions: as an abortion fund ASN won’t be drawing any conclusions until our phone stops ringing so often due to in country provision. For now, the only conclusion is the one we already know – that the criminalisation of abortion has always and will always most adversely impact the poor.
Rosemary Cochrane
rosemary.cochrane@ntlworld.com
Speeches:
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Management of first trimester termination of pregnancy as an out-patient in Paisley – is it feasible, is it acceptable and is it worthwhile?
Rosemary Cochrane (Great Britain)
Crawford JH – Department of Obstetrics and Gynaecology, Royal Alexandra Hospital, Paisley, UK
rosemary.cochrane@ntlworld.com
Introduction. The earlier in pregnancy an abortion is performed, the lower the rate of complication. The RCOG recommends that ideally all women requesting pregnancy termination should undergo the procedure within 7 days of the decision to proceed being agreed. As a minimum standard, all women should undergo the procedure within 2 weeks of agreement, with no woman waiting longer than 3 weeks between initial referral to time of procedure. Medical termination of 1st trimester pregnancy (MTOP) has been shown to be effective, safe and acceptable if carried out on an entirely out-patient basis. It has therefore been suggested that a service to allow “home” MTOP might be beneficial, however patients would have to fulfil several strict criteria.
Method. To ascertain eligibility every patient attending the pregnancy termination assessment clinic was asked to complete a confidential questionnaire.
Results. 65 women completed the questionnaire (71% of those who attended). Of the 33 (51%) women opting for MTOP only 7 were eligible. 32 (49%) opted for a surgical TOP; of these, 12 would have considered a home MTOP if available but only 4 women were eligible. Reasons for ineligibility are discussed.
Conclusion. Overall 11 (16.9%) patients requesting TOP would have fitted the criteria if the service was available. On the basis of this small sample we were unable to demonstrate a significant need for a home MTOP service.
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Termination of pregnancy in Lothian: a health
needs assessment
Cochrane, R; Milne, D; Cameron, S
NHS Lothian, UK
Introduction: The rate of termination of pregnancy (TOP) in
Scotland remains high, with 12 681 TOPs performed in Scotland
in 2010.
Most TOPs are hospital procedures or early medical
termination. In 2011 a new centre for SRH (Chalmers) opened in
Edinburgh; most provision of early medical termination will be
delivered from here in the future. Some TOPs will continue to be
performed within hospitals.
Whilst much research has concentrated on the efficacy and
acceptability of TOP, little has been written about women’s
experience and the patient pathway.
How the current service is viewed by users and providers, and
the impact of future change to the service, was uncertain.
This health needs assessment aims to:
(i) describe population accessing TOP services in Lothian
(ii) describe current service
(iii) identify areas of delay in service provision
(iv) identify areas of unnecessary complexity in patient’s
journey
(v) elicit stakeholders views
(vi) consider evidence of and recommend effective intervention
to improve termination services
(vii) support planning for change from 2011.
Methods: Women attending TOP services were interviewed and
then telephoned approximately two weeks after TOP and
questioned about their views of the TOP service.
Staff members within the TOP service including management
were interviewed.
Results and conclusions: Seventeen women and 17 staff members
were interviewed. Difficulty with patient recruitment and follow-
up is discussed.
Patients overall were happy with the service; several pertinent
negative points were raised.
Staff have mixed feelings about the service, and useful ideas for
improvement were garnered, and form part of an action plan as
part of the Lothian Sexual Health and HIV Strategy.
Kate Cockrill
Speeches:
Pedro Peña Coello
Speeches:
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The role of the doctor
Pedro Peña Coello (Sp)
Clinica Campo de Gibraltar
San Roque Cádiz, Spain
The emergency contraception’s objective is to avoid a non-desired pregnancy in case of having had unprotected intercourse. We know that a large percentage of these intercourse’s end in non-desired pregnancies (NDP), which usually are terminated with an abortion, which we all intend to avoid.
The most frequently used molecule today as a contraceptive is the LEVONORGESTREL, a highly recognized and used drug, secure, functional and with almost no side- effects. How many over the counter drugs with these characteristics are available today?
The association which I represent (ACAI) believes unanimously that the benefits to any easy access to apc are larger than the risks.
We largely defend that APC could be recommended, given, or prescribed by any person with minimum health information about this subject, health agents, sexual educators, social workers, nurses, doctors, or pharmacists.
We believe that us doctors have a great responsibility; therefore, our role is an important one concerning the investigation, prevention, education, and care of the sexual and reproductive education, but not necessarily nor obligatory the APC should be given by medical authorization.
Rodica Comendant
Speeches:
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Current problems and solutions on abortion in Eastern Europe (EE)
Rodica Comendant MD,
Reproductive Health Training Center, Director, ICMA Coordinator, Chisinau, Moldova
Description of the problem: Despite the widespread availability of abortion on legal
grounds for 50 years in most of the EE countries, the quality of services remain poor: the
main method is D&C, no patient centered care concept. Unsafe abortions account for 24%
of maternal deaths in region. Abortion rates remain high, and is commonly used as a
primary means to regulate fertility. Access to abortion services has been challenged in
recent years. Concerns about declining birth rates, pressure from religious groups have
reduced support for family planning and abortion in the region.
MVA project: The goal of the project was to improve the quality of abortion care with of
institutionalization of Manual Vacuum Aspiration (MVA), and promote patient centered
care concepts within the framework of clinical safety and reproductive rights. This project
was initiated by NAF, funded by the Open Society Institute, and in collaboration with Ipas.
The seven selected countries included Moldova, Macedonia, Kyrgyzstan, Georgia,
Albania, and Russia. The training project was successful in the goals of introducing MVA
in the countries and presenting a model of comprehensive evidence-based abortion care
with a woman-centered approach.
Medical abortion implementation: Mifepristone is currently registered in 10 EE
countries, Misoprostol is used off-label in ob/gyn practice in whole region. But still the MA
method is expensive and unavailable for general population. Introductory studies, with
seminars and trainings for policymakers and health providers have been conducted by
Gynuity Health Project in the region, with the aim to offer practical clinical experience with
evidence-based protocols and provide useful data to revise existing guidelines and
protocols or to establish new one.
A need for creative, individual, country-level, sustainable strategies: Strategic
assessment of the contraception and abortion, currently taking place in some countries in
the region will assist in improving the quality of services. Trainings of providers;
development of standards and guidelines; IEC, targeting potential users, to increase the
demand for better and affordable services among women, advocacy campaigns forwomen right to the access to the fruits of modern science, could be listed.
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Eastern Europe: Turning back the wheel?
Rodica Comendant, Galina Maistruk, Irina Savelyeva (Moldavia)
Reproductive Health Training Center, Moldavia
comendantrodica@yahoo.com
Despite the widespread availability of abortion on legal grounds for more than 50 years, unsafe abortions account for 24% of maternal deaths in Eastern European (EE) region (WHO, 1998). Abortion rates remain high. Abortion is commonly used as a primary means to regulate fertility; the use of modern contraception methods remains low. Access to abortion services in EE has been challenged in recent years. Concerns about declining birth rates, pressure from religious groups have reduced support for family planning and abortion. The low quality of services is influenced by the lack of quality of care standards and quality control.
In this context, the recent registration of Mifepristone in many of EE countries, hasn’t much contributed to the improvement of the quality of abortion care. Medical abortion is still inaccessible for general population and remains an “elite” method for most of the women. The analysis of the access to medical abortion in several EE countries has showed the following common trends:
- Cost of the pills is prohibitive;
- statistic is virtually inexistent;
- low level of the awareness about the method in the population, low demand for comprehensive abortion care services, many existing myths;
- lack of providers motivation to use a new method, the misuse, low efficacy;
- unwillingness of the public health systems to take the necessary steps for the implementation of the medical abortion services, and unnecessary barriers imposed by their regulations.
Recently launched by the leading abortion professionals and women advocates from 10 EE countries network „European Alliance for Reproductive Choice“ , supported by ICMA, among other objectives, has decided to focus on developing strategies, to make MA technology accessible in practice in EE countries. Experience-sharing, information, education, communication (IEC) activities, targeting potential users, to increase the demand for better and affordable services among women, advocacy for women rights to the access to the fruits of modern science, the improvement of providers knowledge among providers, transforming them in women advocates, advocacy events to register and utilize medical abortion are some of the listed strategies to consider.
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Dr. Comendant holds a PhD as an obstetrician
gynaecologist. She is the Director of the
Reproductive Health Training Center (RHTC)
of Republic of Moldova, and since 2005 has
served as the Coordinator of the International
Consortium for Medical Abortion. In this capacity,
she successfully supported the development of
the ICMA regional networks in Latin America,
Asia, and Eastern Europe. Additionally, Dr.
Comendant is the National Coordinator of Safe
Abortion Programme of the Reproductive Health
Strategy of Republic of Moldova, an attendant
Professor of the Department of Obstetrics and
Gynecology of State University of Medicine
and Pharmacy of Moldova, a regional and
international trainer in safe abortion methods,
a senior consultant for Gynuity Health Project,
USA, and a consultant for the WHO Strategic
Assessment of Abortion in several countries.
ICMA: global, regional and national networking to
reduce the burden of unsafe abortion
In spite of increased attention to sexual and
reproductive health and rights, and particularly
to maternal mortality, in spite of the development
of effective technologies to make abortion very
safe, pregnancy-related deaths and unsafeabortion remain a major public health problem in
largeparts of the world.
There are many organisations working worldwide
to improve women’s access to safe abortion
services – through advocacy, law and policy
reform, capacity building, service delivery, training,
information sharing and networking. Everyone
feels there is a growing need to link together and
combine the efforts towards ensuring the right to
safe abortion in all the countries. It was agreed an
international movement is needed to challenge the
growing threat posed by conservative political and
religious forces who are seeking to turn the clock
back, block efforts to improve laws and provide
services, and exclude abortion from maternal
mortality reduction and family planning initiatives.
This is why representatives of several dozen
NGOs from all world regions, consulted and
called together by the ICMA and it’s four affiliated
regional networks (ASAP, EEARC, CLACAI and
ANMA), in 2011-12, decided to launch the
International Campaign for Women’s Right to
Safe Abortion in April 2012, which after only a few
months has been endorsed by more than 620
groups and individuals all over the world. -
CS08.1
Simplified medical abortion screening
Rodica Comendant1, Mark Hathaway2, Ginger Gillespie3, Elizabeth Raymond4
1Reproductive Health Training Centre, Clinical Hospital #1, Chisinau, Moldova, Republic of Moldova, 2carafem, Washington, DC, USA, 3Institute for Family Health, New York, NY, USA, 4Gynuity Health Projects, New York, NY, USAIntroduction: Currently, most providers perform an ultrasound or pelvic examination before medical abortion to assess the duration and location of the pregnancy. These evaluations are expensive, time-consuming and uncomfortable and they must be done by a skilled clinician in a medical setting. Our pilot study is designed to assess the safety and acceptability of offering medical abortion to selected women without either procedure.
Methods: We will recruit women requesting medical abortion in Moldova, the United States, and Mexico. To be eligible, a woman must be certain that her last menstrual period started within the prior 56 days, not have recently been using hormonal contraceptives, have no risk factors for or symptoms of ectopic pregnancy and not have had an ultrasound or examination in this pregnancy. Some sites exclude women with evidence of uterine enlargement on abdominal palpation. Each subject is treated with a standard regimen of mifepristone and misoprostol and followed until the abortion is complete.
Results: Up until May 2016 182 women had been enrolled at three sites. In Moldova 76% of all women having medical abortion at the study site have joined the study. In the United States the proportion is much lower; many abortion clients were ineligible because of irregular menses or contraceptive history and some prefer to have an ultrasound. Of the 175 subjects, with complete follow-up to date, 94% had complete pregnancy termination without additional treatment, 2% had surgical aspiration and 3% had extra misoprostol. No serious complications have occurred related to the absence of initial ultrasound and examination. Most subjects (89%) were pleased with omitting the screening ultrasound and pelvic examination. We will present updated data at the meeting.
Conclusion: Simplifying the screening procedures for medical abortion appears safe and could substantially increase access to this service.
Rebecca Cook
Speeches:
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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.
Michelle Cooper
Speeches:
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Objective: Provision of immediate postpartum intrauterine contraception (PPIUC) is known to be safe but not routinely practiced within the UK. Improving access to effective contraceptive methods during the postpartum period can reduce the risk of subsequent unintended pregnancy and short inter-pregnancy intervals. Our aim was to introduce an immediate PPIUC insertion facility within a large public maternity service in Scotland, UK.
Methods: Obstetricians and labour ward midwives were trained in PPIUC insertion techniques. Women received PPIUC information from community midwives during routine antenatal contraception discussion. They could choose to receive either a copper intrauterine device or levonorgestrel-releasing system at planned caesarean section (from July 2015) or after vaginal birth (from January 2017). Women received a clinical review at six weeks to confirm device placement followed by telephone consultation at three, six and 12 months. Data from the first 300 women to receive intra-caesarean PPIUC and the first 100 women to receive PPIUC at vaginal birth were analysed in relation to complications, continuation and patient satisfaction.
Results: The uptake rate of PPIUC at caesarean section was 13.3%. There were 9 cases of suspected endometritis (3.8%), no uterine perforations and a cumulative device expulsion rate of 8.0%. At 12 months, the follow-up rate was 84.3% (n=253) and 79.1% (n=100) had continued IUC use. Of the first 100 women receiving PPIUC at vaginal birth, 45 (46.9%) experienced partial or complete expulsion and 82.2% proceeded to have further IUC inserted. There were no uterine perforations and 7 cases of suspected endometritis. At 3 months, 74.0% had continued IUC use. Median satisfaction scores were 10 out of 10.
Conclusions: It is feasible and acceptable to introduce immediate PPIUC insertion within a public maternity setting. There is a low rate of complications and patient satisfaction and continuation is high. The expulsion rate after vaginal PPIUC is likely to improve with increasing provider experience.
Gilberto Corbellini
Speeches:
Dilys Cossey
Speeches:
Dustin Costescu
Speeches:
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Introduction: In 2015, mifepristone was approved in Canada, making it the 61st country to do so. Prior to mifepristone, there were only 60 physicians providing medical abortion in Canada. In anticipation of the commercial availability of mifepristone in 2017, clinicians prepared clinical practice guidelines and an online medical abortion training course. Health Canada mandated training prior to prescribing or dispensing mifepristone, however, in late 2017, the regulation was relaxed from “mandatory” to “recommended”.
Methods: We present participant data on the first 16 months of medical abortion training to provide an estimate of clinicians who are currently eligible and/or likely to provide mifepristone medical abortion across Canada.
Results: Overall, 167 Obstetrician/Gynaecologists, and 408 Family Physicians (which make up the majority of abortion providers in Canada) have completed the Medical Abortion Training Course. 1346 pharmacists have completed the course and are eligible to dispense the medication. 173 nurses (of which 112 are nurse practitioners with prescribing privileges), 6 midwives, and 151 medical students and residents also have been trained in medical abortion. There is a physician trained in every province and territory, however there is no pharmacist trained in Nunavut, a northern territory.
Conclusion: There is widespread interest and uptake of mifepristone medical abortion in Canada. Within the first year of availability of mifepristone, over 2000 medical professionals have completed the medical abortion training course. In contrast to pre-mifepristone, where very few physicians provided methotrexate-based medical abortion, there are at least 575 physicians currently eligible to prescribe, and 1346 pharmacists eligible to dispense mifepristone.
Kelly Culwell
Speeches: