Edinburgh, 19-21 octobre 2012: „Unwanted pregnancy - A fact of life“
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09:00-
10:30Aspects juridiques/éthiques de l’avortement, PentlandChair:- Bernard Dickens, CA
- Sam Rowlands, GB
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- Teresa Bombas, PT (all speeches)
- tabombas@sapo.pt
Going ForwardThe prevalence of contraceptive use and the
abortion rate are very different among countries.
We know that the abortion rate is high in
countries where the prevalence of use a modern
contraceptive method is low. Combined hormonal
contraceptives (COC) are one of the most popular
methods of birth control. This is a reliable form
of contraception, having a theoretical failure
rate of 0.1% and, due to problems related with
compliance an actual failure rate of 2-3%. The
pill use is very different among countries. It will
be important to try to understand why these
differences exist. Despite the safety of current
COCs, fears of adverse metabolic and vascular
effects and possible oncological effects remain.
Misperceptions and concerns about side effects,
especially those affecting menstrual cycle, fertility
and body weight increase, are often reasons for
discontinuation. Making contraception available
is not enough to prevent abortion: women should
be able to choose a contraception method that
suits their personal expectations - only then
will unwanted pregnancies be successfully
avoided and the abortion rate will decrease. For
contraceptive efficacy, a woman’s/couple’s free
and informed choice is required. -
- Audrey Simpson, GB (all speeches)
- audreys@fpa.org.uk
The situation in Northern
Ireland
Abortion is legal in Northern Ireland but only in
very restricted circumstances. Rape, incest and
fetal abnormality are not grounds for an abortion.
Women and girls resident in Northern Ireland with
a crisis or unplanned pregnancy who decide to
end their pregnancy have to travel to England
and other European countries and pay for a
private abortion. Despite being UK citizens they
are not entitled to a free abortion in Britain unlike
women resident in Britain. This presentation will
explore the financial, practical and emotional
consequences of this denial of sexual rights and
the political dynamics which underpin this denial. -
- Natalie McDonnell, IE (all speeches)
- danat@hotmail.com
The Situation in the Republic
of Ireland This presentation will set out the basis of
abortion in law in Ireland and examine recent
developments pertaining to the manner in which
Ireland’s constitutionally enshrined ban on
abortion operates. The application of international
human rights norms and standards reveal the
manner in which the ban – and the failure to
attain legal clarity in relation to its operation –
provides real opportunities for change. One
such opportunity arose in the context of A, B,
C v Ireland, the case taken to the European
Court of Human Rights in which the Grand
Chamber of the Court, in 2010, found a breach
of the Convention in the case of C, due to the
lack of clarity and the illusory nature of the right
to access a termination under Irish law where
there is a real and substantial risk to the life of
a woman. The options available to the State to
ensure compliance with the judgment will also be
explored in this presentation. -
- Ruth Fletcher, GB (all speeches)
- r.fletcher@keele.ac.uk
Travelling for Abortion:
A Framework for Future
Advocacy and Research This presentation will discuss the ways in which
the Irish Crisis Pregnancy Programme (formerly
the Crisis Pregnancy Agency) has developed
public governance of cross-border abortion
care. In doing so my aim is to think more about
the limits and potential of abortion travelling
as an option for women living with restrictive
abortion regimes. The governance of abortion
travelling does seem to have the negative effect
of consolidating the non-development of local
lawful abortion services. But the Programme
has also had the effect of providing publicly
subsidised support for women who travel,
enabling the reporting of extra-territorial abortion
rates as national abortion rates, and of promotingabortion after-care on return. These public health
measures, limited as they are, provide evidence
of some public support for abortion use and may
provide future resources for tackling domestic
resistance to abortion provision.
In analysing the Crisis Pregnancy Agency’s
administration of an outward flow for abortion care,
I identify its 4 key technologies of governance as
the non-development of local abortion services,
provision of support for exit, reporting of extra-
territorial abortion rates, and promotion of aftercare
on return. These technologies illustrate how state
agencies may actively mobilise ‘the peripheral’
as they claim to address local needs through
participation in the regulation of cross-border
healthcare. In so doing they configure a conception
of the peripheral that does not want to become
core and participates in transnational networks on
its own terms. Secondly, this peripheralism is not
constituted by the core, but cultivates dependency
on core provision of healthcare in other
jurisdictions. Thirdly, this peripheralism comes into
being by focusing on marginal healthcare services
(information, counselling, check-ups) on the fringes
of abortion provision.
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10:30-
11:30
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11:30-
12:45Atelier 6 Atelier: L’utilisation de l’échographie dans l’avortement, TintoChair:Atelier 7 Sujet d’actualité: L’avortement tardif, Pentland- Christian Fiala, AT
- Matthew Reeves , US
Chair:Atelier 8 Atelier interactif : les praticiens comme cibles et causes des stigmates de l’avortement , Carrick- Marge Berer, GB
- André Seidenberg, CH
Chair:Atelier 9 Session de l’ICMA/EEARC: L’avortement à risque en Europe de l’Est, Harris- Thea Schipper, NL
- Anne Vérougstraete, BE
Chair:Atelier 10 Session ESC, Ochil- Rodica Comendant, MD
- Gabriele Halder, DE
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- Rodica Comendant, MD (all speeches)
- comendantrodica@yahoo.com
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.
Chair:- Johannes Bitzer, CH
- Anibal Faúndes, BR
- Kristina Gemzell-Danielsson, SE
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12:45-
14:00Déjeuner de travail la contraception d’urgence, TintoChair:- Elisabeth Aubény, FR
- Teresa Bombas, PT
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- Anna Glasier, GB (all speeches)
- anna.glasier@ed.ac.uk
Bridging Hormonal emergency contraception prevents
between one half and two thirds of pregnancies.
Traditional on-going methods of contraception are
far more effective. A consultation for emergency
contraception (EC) should therefore be regarded
as an opportunity to provide women with an
on-going method of contraception which will
prevent pregnancy more effectively than repeated
use of EC. The on-going method is best started
immediately to prevent pregnancy immediately
including those resulting from further acts of
unprotected sex in the cycle in which EC was
used (so-called bridging).
In most European countries most women now
get EC from pharmacies over (or behind) the
counter. Pharmacists are unable to provide
on-going effective contraception without a
doctor’s prescription and a mystery shopper
study undertaken in Edinburgh demonstrated
that most pharmacists give little or no advice
about bridging. Even when EC is issued by a
health professional who can provide an on-going
method, a disappointingly low number of women
are provided with an effective bridging method.
Strategies to enhance bridging from EC to an
effective on-going method need to be developed
and tested. -
- Linan Cheng, CN (all speeches)
- linanc2@163.com
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.
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14:00-
15:30Atelier 11 Atelier : Avancées dans l’avortement du 1er trimestre, PentlandChair:Atelier 12 Atelier: L’objection de conscience , Harris- Rodica Comendant, MD
- Andreja Štolfa Gruntar , SI
Chair:Atelier 13 Sujet d’actualité: Les séquelles de l’avortement: mythes et réalité , Carrick- Kelly Culwell, US
- Maria Francès- Kircz, NL
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- Mirella Parachini, IT (all speeches)
- mparachini@gmail.com
Examples from Italy
ABSTRACT TEXT
The Italian law no.194 approved in 1978, is often considered one of the most advanced inWestern Europe. An abortion may only be carried out in a public hospital and there are no special abortion clinics inItaly. The conscience clause is partially responsible for many of the difficulties in availability of services. The Article 9 provides for the non-participation of staff of any level who work in hospitals and do not want to participate in abortions for reasons of conscience. The objectors are freed from activity specifically directed to the interruption of pregnancy but not from assistance before or after the abortion. It is the responsibility of the hospital to ensure the procedure is efficient and the Region is responsible for the to the provision of the services. This brings to remarkable differences from one region of the country to another. For example the Region of Emilia Romagna, where social and medical facilities are easily available, offers better services with access to medical abortion. Conscientious objection is a major limiting factor in the implementation of the law. According to the Secretary for Health’s last report, at a national level nearly 71 % of the gynaecologists are conscientious objectors and in some regions this percentage reaches 80-85%. Medical abortion has been approved since 2009, but only within 49 days of amenorrhea, in spite of the European mutual recognition procedure. In all cases, with only two regional exceptions , a compulsory hospitalization is requested. So far the medical procedure is not readily accessible in all localities. Restrictions in access to abortion and lack of having the choice between a medical or a surgical procedure are currently the major problems.
Chair:Atelier 14 Session de l’OMS: Informations concernant les recommandations basées sur les preuves, Tinto- Jean-Jacques Amy, BE
- Sam Rowlands, GB
Chair:Atelier 15 Communications libres, Ochil- Marc Bygdeman, SE
- Anna Glasier, GB
Chair:- Lena Marions, SE
- Allan Templeton, GB
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- Syed Mustafa Ali, PK (all speeches)
Termination of pregnancy services in Pakistan –
a confiscated right
Ali, SM; Rizvi, A; Mahmood, N; Khanum, A
Rahnuma, Family Planning Association of Pakistan- an affiliate of
IPPF
Objective: The aim of the study was to highlight the various
factors which control women’s right to access to termination of
pregnancy (TOP) services.
Methods: Data from 400 women aged 18–60 years seeking TOP
and general services from clinics of the Family Planning
Association of Pakistan (FPAP) in Lahore and Karachi was
obtained through a structured questionnaire over 3 months and
descriptive analysis of data was done using SPSS version 17. The
questionnaire was administered by clinic counsellors and covered
key themes of knowledge on access to safe TOP, TOP-related
stigma, reasons for seeking TOP service, decision-making on
family size and demographic data.
Results: During the study it was found that a majority of the
TOP clients (59.8%) coming to six service delivery points had a
family monthly income of less than PKR 10 000. The average age
of TOP clients was 30 years (SD 6). Similarly, the average number
of children of TOP clients was 3 (SD 1.9). A large number of
TOP clients (39.5%) were illiterate and only 5% of TOP clients
had 16 years of education while 33.7% of their husbands were
illiterate and 4.2% had 16 years of education. When knowledge of
clients on the legal status of TOP was assessed it was found that
out of 400 clients, 49.3% considered TOP to be illegal. The
knowledge level between general clients and TOP clients was alsoobserved as 62% of general clients considered TOP to be illegal in
Pakistan while 36% of clients, who had availed themselves of TOP
services, considered it illegal. Out of 200 TOP clients, 54.2%
associated stigma with TOP by not telling others that they had
sought TOP services. The reasons for seeking the TOP service
were: cannot afford another child (28.4%), mothers’ health
concerns (27.9%), last child too young (18.9%), contraceptive
failure (16.9%), too many children (5.5%), unmarried (1.9%) and
separation from husband (0.5%). Out of 400 clients, 47.2% were
not asked about their wish to have children and 48.2% were not
involved in the decision about birth spacing. Moreover, the need
for family planning had not been met by 18% of TOP clients as
they had used TOP services more than once.
Conclusion: Controlled access to family planning services, stigma
attached to TOP and low educational and economic status are the
factors which interfere with the right of women to seek TOP
services. Moreover, there is also a need to further study this
phenomenon and better understand how each of the factors
(stigma, low education etc) affects access to and uptake of safe
TOP services. -
- James Trussell, US (all speeches)
Fatal flaws in a recent meta-analysis on
termination of pregnancy and mental health
Steinberg, J; Trussell, J; Hall, K; Guthrie, K
Office of Population Research, Princeton University, USA
Similar to other reviews within the last 4 years, a thorough review
by the Royal College of Psychiatrists, published in December 2011,
found that compared to delivery of an unintended pregnancy,
termination of pregnancy (TOP) does not increase women’s risk
of mental health problems. In contrast, a meta-analysis published
by Coleman in September 2011 in the British Journal of
Psychiatry claimed to find that TOP increases women’s risk of
mental health problems by 81% and that 10% of mental health
problems are attributable to TOP. Like others, we strongly
question the quality of this meta-analysis and its conclusions.
Here we detail seven errors in this meta-analysis and three
significant shortcomings of the included studies because policy,
practice, and the public have been badly misinformed. These
errors and shortcomings render the meta-analysis’ conclusions
invalid. In this case there was a complete failure of the peer-
review process and editorial oversight. -
- Erika Troncoso et al. , MX (all speeches)
- troncose@ipas.org
First Tri deaths: the hidden patterns
Troncoso, E1; Schiavon, R1; Freyermuth, G2;
Ramirez, G2
1 Ipas; 2 Observatorio de Mortalidad Materna, Mexico
In Mexico, public health sector information systems have
significantly improved their record keeping and allow us to know
that termination of pregnancy (TOP) mortality accounts for
around 10% of maternal deaths in the last 10 years. Given the
high mortality ratio, maternal deaths are analysed carefully every
year in the Ministry of Health. The goal of this project was to
better understand the 2010 TOP related mortality files.
During 2010, 9.27% of maternal deaths were due to TOP
(92 cases). Almost 75% of deaths were among women aged 15 to
34 years, younger than those dying from other causes. Twenty-six
percent were single compared with 15% for the other causes.
Ninety percent of women received health care before the death.
The quality of the information of the TOP cases was poor,
regularly a maternal mortality case was 11 elements for the
comprehensive analysis into their file. In the case of TOP deaths,
only 66% of the files had verbal autopsies, 23% a necropsy report,
and no one had an official declaration. In some cases, women
were not aware of their pregnancy, and the diagnosis did not
consider pregnancy.
Despite the interest in maternal mortality, TOP has not been
adequately addresed in the current framework and more questions
remain after the revision of the files. TOP-related deaths require
an adequate response from the health systems. -
- Wye Yee Herbert, None (all speeches)
FC1.01
Our love affair with misoprostol over the last
20 years
Herbert, WY
The Queen Elizabeth Hospital Pregnancy Advisory Centre, Australia
TheQueen Elizabeth Hospital Pregnancy Advisory Centre in
Adelaide, South Australia is agovernment-funded clinic established
in 1992,providing over 2500 surgical terminations eachyear.
Four papers published over the last 20 years document our
implementation of misoprostol use, showing significant
improvements in service delivery, as well as reduction in
complication rates.
Our first study published in 1999 showed that adding
misoprostol to osmotic dilators at 17–20 weeks of gestation to
increase passive dilatation of the cervix, markedly reduces the risk
of perforation of the uterus.
Our second study published in 2009 compared the outcomes
of four different peri-operative misoprostol regimens for first
trimester surgical terminations. Compared to no misoprostol
regimen, the regimen of 200 lg of oral misoprostol 3 hours
pre-operatively plus 200 lg of misoprostol vaginally at the end of
the surgical procedure showed: 90% reduction in difficult cervical
dilatations, 60% reduction in rate of D&C treatment of retained
products of conception and 71% reduction in incidence of
women requiring post-operative contact for concerns.
In 2011, our third study demonstrated that adding 200 lg of
oral misoprostol 3 hours before two tablets sublingually every
half-hour for three doses at 13–16 weeks of gestation further
reduced difficulty of the operation.
In 2002, we adopted medical management with misoprostol,
as first-line treatment for retained products following surgical
termination. Our study published in 2009 showed that the
regimen of 200 lg of misoprostol orally or sublingually three
times a day for six doses was 93% effective, and reduced the
D&C rate by 79.6% from 1.18% to 0.24%. -
- Rebecca Gomperts, NL (all speeches)
- info@womenonwaves.org
Regional differences in surgical intervention
following medical termination of pregnancy
provided by telemedicine
Gomperts, R1,2; Jelinska, K1,2; Sabine, S1,2;
Gemzell-Danielsson, K1,2; Kleiverda, G1,2
1 Women on Waves; 2 Department of Obstetrics and Gynaecology,
Karolinska Institutet, Stockholm, Sweden
Objective: Analysis of factors influencing surgical intervention
rate after home medical termination of pregnancy (TOP) by
women in countries without access to safe services using the
telemedical service ‘Women on Web’.
Design: Cohort study.
Setting: Women with an unwanted pregnancy <9 weeks pregnant
who used the telemedicine service of Women on Web between
February 2007 and September 2008 and provided follow-up
information.
Sample: Women who used medical TOP with a known follow up.
Methods: Information from the online consultation, follow-up
form and emails was used to analyse the outcome of the TOP.
Main Outcome Measures: Ongoing pregnancy, reason for surgical
intervention, perceived complications and satisfaction.
Results: Of the 2323 women who did the medical TOP and had
no ongoing pregnancy, 289 (12.4%) received a surgical
intervention. High rates were found in Eastern Europe (14.8%),
Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in
Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%;
P = 0.000). More interventions occurred with longer gestational
age (P = 0.000). Women without a surgical intervention more
frequently reported satisfaction with the treatment (P = 0.000).
Conclusions: The large regional differences in the rates of
reported surgical interventions after medical TOP provided by
telemedicine cannot be explained by demographic factors or
differences in gestational length. It is likely that these differences
reflect different clinical practice and local guidelines on
(incomplete) abortion rather than complications that genuinely
needed surgical intervention. Surgical interventions significantly
influenced womens’ views on the acceptability of the TOP. -
- Thoai D Ngo, GB (all speeches)
- thoai.ngo@mariestopes.org.uk
Safety and effectiveness of termination services
performed by doctors versus midlevel providers: a
systematic analysis
Ngo, T1,2; Park, MH1,2
1 Marie Stopes International; 2 London School of Hygiene & Tropical
Medicine, UK
Objective: We review the evidence that compares the effectiveness
and safety of termination of pregnancy (TOP) procedures
administered by mid-level providers (MLPs) versus doctors.
Methods: We conducted a systematic search of published studies
assessing the effectiveness and/or safety of TOP provided by MLPs
compared to doctors. The Cochrane Central Register of
Controlled Trials, EMBASE, MEDLINE and Popline were searched
for trials and comparison studies. The primary outcomes were:
(i) incomplete or failed TOP and; (ii) measures of safety (adverse
events and complications) of TOP procedures administered by
MLPs and doctors. Odds ratios and their 95% confidence intervals
(CIs) were calculated for each study.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. -
- Mandira Paul, UG (all speeches)
Task sharing in post-termination of pregnancy care
at district level in Uganda; healthcare providers’
perception on safe TOP, post-TOP care and
contraceptive counselling – an exploratory study
Allvin, MK1; Paul, M1; Gemzell-Danielsson, K1;
Kiggundu, C2
1 Department of Obstetrics and Gyanecology Karolinska Institutet,
Stockholm, Sweden; 2 Mulago University Hospital, Kampala, Uganda
Background: Termination of pregnancy (TOP) is restricted in
Uganda and poor access to family planning results in unwanted
pregnancies forcing women to have unsafe TOPs and thus posing
a great burden on the Ugandan health system. Post-TOP care is
implemented and unofficial task shifting is taking place as a
pragmatic response to the workload.Objective: To explore the healthcare providers’ perception on
post-TOP care, with regard to professional competences, medical
and surgical methods, contraceptive counselling and task shifting/
sharing in post-TOP care.
Methods: In-depth interviews (n = 27) with healthcare providers
participating in post-TOP care were conducted in seven health
facilities in the Central region of Uganda. Data was organised
using thematic analysis with an inductive approach.
Results: Post-TOP care was perceived necessary, however
controversial, and together with poor conditions it provoked
frustration, mainly among the midwives. Task sharing was
generally implemented and midwives were identified as the main
providers. Different uterine evacuation skills were recognised and
midwives would sometimes perform interventions not approved
by hospital guidelines, due to absence of doctors. Misoprostol was
rarely used or accessible at district level, however those with
experience perceived it efficient and safe. An overall demand and
need for further training was identified.
Conclusions: Developing policies and service guidelines in order
to implement evidence based use of misoprostol in post-TOP care
as well as provision of in-service training is recommended.
Implementation of official task shifting in post-TOP care would
further be a systematic approach to improve quality of care and
accessibility of services in order to reduce TOP-related mortality
and morbidity. -
- Marijke Alblas, ZA (all speeches)
- malblas@iafrica.com
Training midwives and doctors in post-termination
of pregnancy care in Gabon and Cameroon
Alblas, M; Ndembi, AP; Pheterson, G; Mbia, C;
Mekui, JE
Middle Africa Network for Women’s Reproductive Health: Gabon,
Cameroon and Equatorial Guinea
The NGO Middle Africa Network for Women’s Reproductive
Health: Gabon, Cameroon and Equatorial Guinea – GCG is
devoted to research, education and training to understand
obstacles to better health care. This presentation focuses on one
central part of the mission: training midwives and doctors in
post-termination of pregnancy (TOP) care, mainly manual
vacuum aspiration. After a needs assessment initial field trip in
2009 it became clear that the morbidity and mortality among
women due to unsafe TOP is high in rural areas in Northern
Gabon, southern Cameroon and eastern Equatorial Guinea.
When complications from back street TOP arise, women arrive
late (or never) for emergency hospital care because they know
TOP is illegal and highly stigmatised, and often they have no
money either for transport to the hospital or for the medical aid
they need. If a doctor is present, he/she can do a sharp curettage
under general anesthesia, but this is expensive and in the more
rural areas often there is no doctor. Pregnancy and birth are
typically the domain of midwives, but they are not trained in
treating TOP-related complications since procedures such as MVA
or misoprostol use are not institutionally recognised, and only
doctors perform D&Cs.
Recently one of our trained midwives has been appointed by
the Ministry of Health to train all the midwives in the country in
post-TOP MVA. In the last 3 years this network has made asignificant first step in demonstrating that also in a country where
TOP is illegal, one can build capacity, mobilise attitude change
and enlist institutional support.
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15:30-
16:00
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16:00-
17:30Medical abortion 1st trimesterChair:- Christian Fiala, AT
- Anne Vérougstraete, BE
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- Beverly Winikoff, US (all speeches)
- bwinikoff@gynuity.org
Alternative ways for follow up Women who choose outpatient medical abortion
are typically given an appointment for a follow up
visit several days to two weeks after they have
used the medications. Yet almost no women
require intervention or additional treatment at
such follow up visits. Providers and women have
sought safe ways to reduce the number of women
who need to return to the clinic. This presentation
discusses strategies to reduce the need for
universal return visits, including telemedicine, use
of various electronic media, and the development
and promise of semi-quantitative pregnancy tests,
including data from recent research. -
- Joke Vandamme, BE (all speeches)
- JokeL.Vandamme@Ugent.be
Counselling: How do women
feel about it? One of the differences regarding abortion laws
worldwide, concerns the presence of a pre-
abortion counseling session. The necessity of
this counseling for women seeking first-trimester
abortions has been extensively debated.
Professionals often hold strong opinions on thisissue while the opinion of clients themselves is
not heard. Our study, performed in Flanders (i.e.
the Northern part of Belgium), asked 971 women
how they experienced this session. Results
showed that despite initial resistance towards
the session and high decisiveness regarding
the abortion, women valued the counseling
and felt significantly better afterwards. Besides
making an informed decision, non-directive
and client-centered counseling sessions - as
they are organised in Flanders - can have other
advantages for women seeking an abortion.
Examples of these are: the provision of correct
information about the procedure and its
consequences, the consolidation of an already
made decision, receiving emotional support for
the choices made… As a result, we support the
continuation of this pre-abortion counseling in
Flanders, in addition to the existing medical care. -
- Kristina Gemzell-Danielsson, SE (all speeches)
- Kristina.Gemzell@ki.se
Increasing access to safe
abortion servicesMedical abortion with mifepristone and a
prostaglandin analogue was developed into a
safe and effective method for induced abortion
in the 1980’s. Today the prostaglandin analogue
of choice is misoprostol and medical abortion
is a safe option for termination of pregnancy
at all gestational lengths. However, several
barriers remain that limit global access to safe
abortion services. Simplifying medical abortion
could potentially contribute to increased access
and acceptability. Possible approaches include
the option to self-administer misoprostol at
home. Another possibility is task sharing with
midlevel providers to allow these health care
professionals to be more involved with the care
of healthy women undergoing medical abortion.
This possibility is likely to have major impact
to increase access to safe induced abortion in
countries were medical resources are scarce. A
simplified treatment regimen may also include
home self-evaluation of complete abortion, an
option which is currently being investigated. -
- Andrew Weeks, GB (all speeches)
- aweeks@liverpool.ac.uk
Misoprostol is an orally active prostaglandin
E1 analogue, which was first licensed for the
prevention and treatment of NSAID-induced ulcers.
Because of its ease of use and strong uterotonic
properties, it quickly found uses in reproductive
health for the induction and treatment of abortion,
induction of labour and in the management of
postpartum haemorrhage. The manufacturer of the
original brand (Cytotec) was reluctant to encourage
its reproductive use for fear of a back-lash
from the antiabortion lobby. It therefore remainsoff-label for reproductive health uses. This has
done little to stem enthusiasm for the drug with
protagonists pointing out that some of the most
important drugs in obstetrics (e.g. corticosteroids
to promote fetal lung maturity) remain off-label
for pregnancy use. Furthermore, the World
Health Organisation now considers misoprostol
an essential drug for a variety of gynaecological
indications. Clinicians are protected legally when
using it by the principle that doctors should act
according to ‘best practice’ as determined by
their peers. They should not be deterred by the
lack of licences, which were introduced to prevent
misleading claims by the pharmaceutical industry
rather than to guide clinicians’ prescribing. The
current situation is made easier by the widespread
production of generic misoprostol tablets, licensed
for reproductive health indications. -
- David Baird, GB (all speeches)
- d.t.baird@ed.ac.uk
About 15% of pregnancies
terminate spontaneously in the
first trimester .The majority of these miscarriages
are unrecognized clinically.. As the levels of
progesterone fall expulsion of the products of
conception occur spontaneously and resumption
of cyclical ovarian activity with 2-3 months.
Modern methods of medical abortion using
mifepristone and a prostaglandin simulate closely
the mechanisms which occur in spontaneous
abortion suggesting that it is likely that the
majority will resolve spontaneously without further
intervention(Baird 2002) . Blockage of the action
of progesterone with mifepristone results in
powerful uterine contractions which together with
an increased sensitivity to prostaglandin leads to
expulsion of the fetus and placenta.(Baird 2002).
Extensive research over the last 30 years has now
identified a simple regimen (Mifepristone followedby misoprostol) which is highly effective(on-
going pregnancy<1%), is free from serious
side effects and does not require sophisticated
facilities(WHO2003). Several studies have shown
that abortion can be safely delivered by relatively
unskilled health workers (mid-level providers
MLP) who have been trained to follow an agreed
protocol of treatment(Shannon &Winnikoff 2009
Warriner et al2011). By devolving provision of
abortion to MLP the access to abortion should
be greatly widened. As predicted in the original
report of medical abortion with mifepristone and
gemeprost that “this combination would have
particular application in countries where skilled
medical and surgical experience are in short
supply” (Rodger & Baird 1987 )
-
17:30-
18:00Chair:- Sharon Cameron, GB
- Sam Rowlands, GB
-
- Christian Fiala, AT (all speeches)
- christian.fiala@aon.at ,http://www.gynmed.at
Future perspectivesThe current situation in abortion care should be
improved on two levels: medical and social. On
both levels the focus needs to be the pregnant
woman rather than external factors.
On the medical level we need to give more
autonomy to the woman coming for an abortion.
The procedure still is very much controlled by
the medical system and women are forced to
follow the rules. There is a huge potential for
more autonomy especially in medical abortion,
which will be done at home in the future, only
the drug needs to be bought in the pharmacy
or drugstore, just like the pregnancy test. This is
already reality for example in India.
Also we urgently need better means to effectively
control pain associated with the medical and
surgical procedure and for medical abortion we
need to reduce duration of bleeding.
Equally important are improvements on a social
level: real self-determination. Women and couples
need the legal framework to freely decide on a
pregnancy and as well all necessary means to
execute their decision. We have made a huge
progress from archaic interdiction of abortion to the
current legal status. However there still are many
paternalistic remnants when it comes to abortion.
-
18:15-