Poster Sessions

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    Abortion providers' resilience to anti-choice tactics in the United States and Canada

    Maureen Paul1, Katharine O'Connell White2, Wendy Norman3, Edith Guilbert4, E. Steve Lichtenberg5, Heidi Jones6 1Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA, 2Baystate Medical Center/Tufts University School of Medicine, Springfield, Massachusetts, USA, 3University of British Columbia, Vancouver, British Columbia, Canada, 4Institut National de Sante Publique du Quebec, Quebec City, Quebec, Canada, 5Family Planning Associates Medical Group, LTD, Chicago, Illinois, USA, 6CUNY School of Public Health, Hunter College, New York, New York, USA - jodotter@aol.com Objectives: To estimate the prevalence of anti-choice tactics on abortion facilities and to evaluate abortion providers' experiences with stigma in the United States (USA) and Canada. Methods: We conducted a cross-sectional survey of abortion facilities identified via publicly available resources in the USA (N=705) and Canada (N=94) from June through December 2013. Clinic administrators responded to facility-level questionnaires; surgical and medical abortion clinicians responded to individual-level surveys which included a 15-item validated stigma scale. Results: 690 clinicians and 456 facilities participated; 54% of USA facilities and 83% in Canada. 83% of USA and 33% of Canadian facilities experienced at least one form of harassment in 2012, most commonly picketing without blocking (66%). These experiences were more common in private offices (88%) or ambulatory centres (83%) than hospital-affiliated facilities (29%). Only 7% of facilities (all in the USA) reported staff resignations due to harassment. 41% of USA-based clinicians and 18% of Canadian clinicians reported personally experiencing harassment in 2012. 99% disclosed being an abortion provider to their partner or close friend, 88% to a parent, and 74% to a child. The stigma scale showed high reliability with a Cronbach's alpha of 0.80. Only 1% had high stigma scores, 26% moderate to high, 65% moderate to low and 8% low, with no differences by facility type. One third reported always/often/sometimes feeling marginalized by other health workers, but 87% reported always/often feeling they are making a positive contribution to society. Conclusion: Abortion providers and facilities experience several forms of harassment, which is more commonly reported in the USA than Canada. However, providers demonstrate resilience to stigma in both settings.

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    A national campaign to de-stigmatize abortion in France: why?

    Danielle Gaudry, Marjorie Agen, Shiva Bernhard Le Planning Familial, Paris, France - d.gaudry001@wanadoo.fr

    Abortion and contraceptive methods are a fundamental part of Human Rights: women have a right to choose whether to be pregnant or not. WHO guidelines about safe abortions demonstrate that the legalization and improved safety and accessibility of abortion are essential for women's health: postabortion deaths disappear, postabortion complications, including accidental infertility, are reduced. In the August 2011 report to the UN "Right of everyone to enjoyment of the highest attainable standard of physical and mental health" the Special Rapporteur considers "the impact of criminal and other legal restrictions on abortion conduct during pregnancy; contraception and family planning and the provision of sexual and reproductive education and information. Some criminal and other legal restrictions in each of those areas, which are often discriminatory in nature, violate the right to health by restricting access to quality goods, services and information. They infringe human dignity by restricting the freedoms to which individuals are entitled under the right to health, particularly in respect of decision-making and bodily integrity." It is violence against women to oblige them to stay pregnant when they don't choose to be pregnant. In French society, as well as other European countries, the model of pregnancy and maternity in a heteronormative family is prevalent. Traditionalists, in the "la manif pour tous" movement, dream about a social standard where women are the complement of men and where equality between the sexes doesn't exist. The rejection of the Estrella report by the EU parliament and the "one of us" initiative have demonstrated easily that "obscurantism is at our doorstep" (Veronique Keyser). Some official decisions recently taken in France, including the 100% refund for abortion and the change of law on the reference to distress, are positive signs, and the campaign in Luxembourg for instance, contribute to lifting the taboo on the right to abortion. Many hospitals and abortion centres however have disappeared since 2001, with governmental budget cuts resulting in the merger of French hospitals. Women are obliged to wait two to three weeks for an appointment, often traveling 60 to 80 km to access surgical or medical abortion. These facts are real difficulties in the exercise of the right to abortion. For these reasons, it is critical to provide a communication platform to women, their relatives, and medical professionals, to allow a debate about abortion without prejudice or guilt. So, the Planning Familial has created a website where everyone can improve abortion rights, by answering a questionnaire, monitoring social networks and forums, sharing the poster and the site address. More than 1,000 questionnaires have been completed to date, since April 2014. We would like to present the site "l'avortement, un droit à defendre" to the FIAPAC.

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    Caring for women undergoing second trimester medical termination of pregnancy

    Inga-Maj Andersson, Kristina Gemzell-Danielsson, Kyllike Christensson Karolinska Institutet, Stockholm, Sweden - inga-maj.andersson@ki.se

    Objective: To explore the experiences and perceptions of nurses/midwives caring for women undergoing second trimester medical termination of pregnancy (MTOP). Method: Semistructured interviews took place at one gynaecological clinic in a general hospital in Stockholm. Twenty-one nurses/midwives with experience in second trimester abortion care were interviewed following a semistructured interview guide. The interviews were recorded, transcribed verbatim and then analyzed using qualitative content analysis to identify common themes. Results: The analysis revealed two themes: "The professional self," with six subthemes describing the experiences and perceptions described in terms of professional behavior: "Being familiar with the process", "Balancing objective information", "Finding ways for pain treatment", "Looking for the woman's needs", "Handling the fetus" and "Needing time for reflection". The theme "The personal self" has four subthemes containing the experiences and perceptions described in terms of personal values: "Conflicting duty and behavior", "Dealing with emotions", "Identifying oneself with the woman" and "Developing inner safety and maturity". Conclusions: Taking care of women undergoing second trimester MTOP is a task that requires professional knowledge, empathy and the ability to reflect on ethical attitudes and considerations. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. Mentorship from experienced colleagues and structured opportunities for reflection on ethical issues enable the nurses/midwives to develop security in their professional roles and also feel confident in their personal life situation. The feeling of supporting women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second trimester MTOP.

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    Community involvement in promotion of safe abortion among vulnerable groups in Kazakhstan

    Galina Grebennikova1, Bibigul Alimbekova1 1Kazakhstan Association on Sexual and Reproductive Health (KMPA), Almaty, Kazakhstan, 2International Planned Parenthood Federation EN, Brussels, Belgium - galina.kmpa@gmail.com

    Background: The initiative was aimed at improving access to high quality comprehensive abortion care for low-income women, including internal and external migrants, and youth. KMPA established cabinets in community clinical centres of two regions populated by low-income people. KMPA cabinets provided services within a comprehensive package of SRH services in the framework of national legislation to meet high standards of care. Services were oriented and based on client rights and providers needs model. KMPA provided educational workshops on safe abortion techniques, postabortion counselling and quality of care for service providers in respective centres with the following M&E for further dissemination of experience to other community medical centres. Objective: To improve awareness of low-income population, including migrants and the youth on their sexual and reproductive rights and availability of comprehensive abortion care in local healthcare facilities of pilot regions by the end of 2013. Method: Primarily KMPA selected volunteers among women working in the local trade markets to be trained on the following topics: advantages of safe abortion and accessing sites for obtaining of services. Trained volunteers distributed the information materials on safe abortion and contraception among vulnerable groups in the markets. Results: After training 20 volunteers actively working at Black Market and providing information about free safe abortion services and contraceptives in the pilot outpatient clinics, the number of requests for safe abortion at primary healthcare (PHC) level increased by 2.5 times. The outcome indicates an improvement of women's awareness of the available medical abortion services for free. Conclusion: Involvement of local community in education and dissemination of information and knowledge about safe abortion services at PHC level significantly improves the level of awareness and visits of vulnerable population of PHC outpatient clinics.

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    Comparison of two methods of late termination of pregnancy for fetal anomalies

    Urška Gruden, Barbara Šajina-Stritar, Nataša Vrhkar, Nataša Tul-Mandić Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia - urska.gruden@gmail.com

    Objective: To compare results of intra-amniotic injection of carboprost (IA method) with mifepristone-misoprostol oral/vaginal application (MI-MI method) for termination of pregnancy (TOP) for fetal anomalies after 22 weeks. Methods: We collected data from women requiring TOP after 22w for fetal anomalies from January 2011 to December 2012. After the maternal request and ethical committee approval, feticide was performed followed by IA injection of carboprost 4 ml or by application of mifepristone 200 mg orally and misoprostol vaginally 24-36 hours later. Mifepristone was optional. The first dose of misoprostol was 100 mcg vaginally, continued every 3 hours bucally with rising doses 100-400 mcg until labour started. We collected data about gestational age, parity, average time from beginning of procedure to labour and need for surgical evacuation of the placenta after TOP. We analyzed data using the statistical program SPSS. Results: We included 74 women, 24 in the IA group and 50 in the MI-MI group. Mean gestational age was 26w 2/7 (22w 1/7 -36w 2/7). Mifepristone was administered to 29 of 50 women in the MI-MI group TOP was successful in 24 (100 %) cases after IA and in 49 (98 %) cases after MI-MI. The average time from beginning of TOP procedure until labour was 24.8 hours in IA group and 17.4 hours after misoprostol application in the MI-MI group. Surgical evacuation of the uterus was done in 15 cases (65.2 %) in IA group and 13 cases (26 %) in the MI-MI group. In cases where mifepristone was combined with misoprostol the time interval from administration of vaginal misoprostol to labour was 5.5 hours, shorter than in cases where only misoprostol was used. Conclusions: Both methods are safe and effective, but the MI-MI method has more advantages. These are non-invasiveness, less surgical intervention for retained placenta, shorter interval from beginning of procedure to labour and lower costs.

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    Conscientious objection in Italy: is a ban the solution?

    Silvio Viale Sant'Anna Hospital, Turin, Italy - silvioviale@libero.it

    In Italy abortion can be performed only in public hospitals and only by gynaecologists working in public hospitals. In Italy you cannot obtain an abortion at outpatient clinics. So conscientious objection is the bottleneck of the service. According to the latest available data, in 2011 the number of public gynaecologists was 5,036 of which 3,490 were objectors (69.7%) and 1,546 were non-objectors (30.7%). Given that in 2011 there were 111,415 abortions, we can say that the mean annual number of abortion for each non-objector gynaecologist was 72. For comparison it is to be observed that the average annual number of deliveries for each gynaecologist was 110. The actual situation varies greatly by region, with the mean ratio of 60 abortions for gynaecologists in northern regions and 112 in southern regions, but in general has changed little over the last few years. In 1998 total gynaecologists were 5,285, of which 3,338 were objectors (64%) and 1897 non-objectors (36%), with 138,357 abortions and 73 for each non-objector. Both the number of abortions and the number of non-objectors have gone down together. Since we cannot expect a change in the law in order to allow abortions at outpatient clinics and by other categories of doctors, we must ask ourselves if 1,546 is a sufficient number for the needs. There is one non-objector gynaecologist for every 7,189 women aged 15-44 years, with an abortion rate of 9.4 per 1,000. Probably the answer lies in reducing the number of departments of obstetrics, that in Italy are nearly 600, and deciding to perform abortion in the biggest ones. The answer is to establish an annual threshold of at least 1,000 abortions with more then 50% of non-objectors in these departments. The author does not think that the answer is to ban conscientious objection.

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    Contraception after delivery: mothers should be better counselled about its need and alternatives

    Jenni Liikanen1, Satu Suhonen2 1Department of Social Services and Health Care, City of Helsinki, Helsinki, Finland, 2Centralized Family Planning, Department of Social Services and Health Care, City of Helsinki, Helsinki, Finland - satu.suhonen@hel.fi

    Objectives: Finland has low rates of induced abortions (8.6/1000 women aged 15-49 years, 2012). In Finnish guidelines of maternal care, contraceptive counselling at postpartum visits is emphasized. However, more than 10% of induced abortions are carried out in women who have given birth recently. Therefore the timing and content of this counselling can be questioned. The aim of this study was to examine women´s knowledge about return of fertility, options and use of contraception after delivery. Method: A cross-sectional questionnaire study was conducted 6 months after delivery at two maternity care units in the city of Helsinki, Finland. Results: 45 women returned the questionnaire during a 2 month period (response rate 55 %). Return of fertility after delivery in women not breastfeeding was poorly known. Only 16% (N=7) were aware of all the criteria of LAM (lactational amenorrhoea method) as a family planning method. From all available contraceptive methods most commonly only one was recommended. Condoms was the most popular contraceptive method (44.5%) used. Initiation of efficient contraception was delayed. The knowledge of the possibility of hormonal emergency contraception during breastfeeding was poor. Conclusions: Information about return of fertility, need for contraception, breastfeeding as a family planning method and available effective contraceptive methods is not given sufficiently after delivery. Thus there is an increased risk of unplanned pregnancy. Contraception after delivery and its need must be discussed and initiated early enough if a new pregnancy is not planned. The number of induced abortions during the postpartum period could be reduced if contraceptive counselling were to be improved, correctly timed and supported by the healthcare system. This promotes the psychological, physical, social and economical well-being of the woman and her family and is also cost-effective for the healthcare system.

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    Current medical and multi-sectoral challenges in sexual assault responses in Malta

    Flavia Zimmermann Three Cities Foundation, Vittoriosa, Malta - chairwoman@threecities.org

    The current legal and social framework in Malta poses a set of specific and compelling challenges for evidence-based medicine and service provision in the context of sexual violence and contraceptive care. This presentation aims to give an objective overview of facilities available to female victims of sexual violence in Malta. It will review services and interventions for underage and adult survivors of sexual assault, the circumstances (including withholding of emergency contraception) which affect standards of Care-and-Evidence in the medical, forensic and psycho-social sectors - along with the range of consequences on patients' health. A summary of critical or urgent issues to redress the effects of this significant public health crisis will be presented. It will also include victimology approaches for survivors' recovery. The main objective of this presentation is to initiate an ongoing discussion about viable reforms to develop an ethical, humane and effective multi-sectoral service. The evidence to be presented has been gathered and updated since 2010, as part of a previous Daphne-Cosai III-funded international project to assess and improve sexual assault services in Europe.

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    Death after medical abortion not linked to mifepristone

    Silvio Viale Sant'Anna Hospital, Turin, Italy - silvioviale@libero.it

    The death of a woman of 36 years with no previous known medical condtions after a medical abortion in Turin last April 9 attracted great attention in the media, . The headlines were "death after RU486", but the first report of the medical examiner appointed by the coroner said that RU486 was not responsible for the death . The protocol was mifepristone 600 mg on the first day and gemeprost 1 mg on the third day. On the third day ketorolac 30 mg IM for pain was also administered together with methylergometrine maleate 0.2 mg IM to reduce blood loss. Shortly after the expulsion the woman developed shortness of breath and loss of consciousness followed by cardiac arrest. The first cardiac arrest occurred at around 12:30 and the woman died at 22:45 in the ICU. From the first evidence the autopsy did not reveal any relevant items. Unfortunately, this is not the only death that has occurred in Italy in 2014 after an abortion. Two other women died recently after an abortion. One woman died in Nocera Inferiore, near Salerno, from abdominal bleeding after surgical abortion in a woman with myomas and previous caesarean section. The other woman died in Turin from acute liver failure two days after a surgical procedure for missed miscarriage. In the first case the media interest was mostly local. In the second case the media didn't known about it. These three deaths remind us that there is no zero-risk in pregnancy and that, though rare, it is possible to die during an abortion procedure even in countries with advanced health care systems. Regarding the death after medical abortion that occurred in Turin, we can say that mifepristone is not responsible in any way.

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    Deciding on the method and location for induced abortion: a Flemish survey study

    Joke Vandamme1, Ann Buysse1, Inge Tency2, Guy T'Sjoen1 1University of Ghent, Ghent, Belgium, 2KAHO Sint Lieven, Ghent, Belgium - jokel.vandamme@ugent.be

    Introduction The Belgian health insurance system prescribes that women who opt for medical abortion should stay at the abortion centre when using mifepristone and misoprostol. A lot of women currently decide for the more rapid surgical method under local anaesthesia. In this study, we map the process of deciding for one of the abortion methods along the different stages of information provision. Method. During a four month study period in four Flemish abortion centres, all Dutch-speaking adult women with a gestational period of less than 8 weeks were asked to participate. During the first visit, they were questioned about the sources they had consulted to get information on the abortion methods and were asked for their initial preference. Afterwards, they were shown a standardized videotape with accurate information on both methods and were asked for their preferences again. In a second video, women learned about the possibility of performimg the misoprostol phase at home and were questioned about their final preferences. Results. Preliminary results show that, when entering the abortion centre, the majority of women (>70%) preferred medical above surgical abortion. Most of the women (>60%) sought information on the official abortion centre website. However, one in three had visited other websites and one in four got information from external professionals. After the provision of standardized information, the percentage that prefers medical abortion drops to 50%. If the misoprostol at home option were available, only one in five would still prefer medical abortion with use of misoprostol in the abortion centre. Conclusion. Flemish women may have an inaccurate idea about the current medical abortion process. The misoprostol at home possibility would be a good alternative for the ones who would otherwise decide for the surgical method as well as for those preferring medical abortion.

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    Demographic characteristics of 400 women from Ireland and the Philippines who completed the online consultation form of the telemedical abortion service Women on Web

    Rebecca Gomperts, Marlies Schellekens Women on Web, Amsterdam, The Netherlands - mschellek@zeelandnet.nl

    The study analyzes the data of 200 women from the Philippines and 200 from Ireland who completed the online consultation form of Women on Web telemedical service in 2012. The study found that the geographical, cultural and political differences of Ireland and the Phillipines correspond to the demographic characteristics of women who completed the online consultation. For example average rates of contraceptive usage in the Philippines is 41% to 50% . On the other hand in Ireland contraceptives are widely available and accessible and 64.8% of people aged 18-49 use contraceptives. Our analyses found that more women from the Philippines reported that the unwanted pregnancy was caused because they did not use contraceptives compared to women from Ireland (70.5% vs 41.5%). Women in Ireland often already had children and reported failed contraception as a reason for their pregnancy (Table).

    Ireland Philippines p-value

    Total 200 200

    Mean age 28 26

    Reason for abortion:

    I am too young 20 (10%) 50 (25%) 0.0008

    Reason for abortion:

    I am too old 10 (5%) 2 (1%) 0.012

    Reason for abortion:

    family is complete 51 (25.5%) 14 (7%) 0

    Nulliparous 88 (44%) 106 (53%) 0.07

    No contraceptive use 83 (41.5%) 141 (70.5%) 0

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    Early, liberal provision of intrauterine contraception after first trimester abortion is not associated with an increased risk of postabortal adverse events or complications

    Elina Pohjoranta, Maarit Mentula, Satu Suhonen, Oskari Heikinheimo Helsinki University Central Hospital, Helsinki, Finland - elina.kuronen@helsinki.fi

    Objectives: We carried out a randomized prospective study to assess the effects of early provision of intrauterine contraception (either LNG-IUS or Cu-IUD) vs. routine practice of starting contraception following first trimester induced abortion. This is a secondary analysis comparing early (i.e. within 3 months) adverse events/complications in the two groups. Method: Altogether 756 women undergoing an induced abortion were randomized into two groups (378 in the intervention and 372 in the control group). In the intervention group, 70 (19%) women chose surgical abortion; 68 (97%) of them received an IUS/IUD at the time of abortion. Of the 308 women choosing medical abortion, 290 (83%) received the IUS/IUD at the follow-up visit 2-3 weeks after abortion, the remaining 61 (17%) later. The women in the intervention group had an appointment with the study nurse at 3 months after the abortion. For the control group, a follow-up and future contraceptive counselling was scheduled in primary health care, which is the normal practice. All women were advised to contact the hospital should complications arise. The hospital charts were reviewed for postabortal complications (i.e. bleeding, residual tissue, ongoing pregnancy or infection requiring treatment) within 3 months. Results: 58 (15%) women in the intervention group and 45 (12%) women in the control group were treated for an adverse event (p=0.196). The rate of complications among all women choosing medical abortion was 82 (13%) and 21 (15%) among those choosing surgical abortion. In the intervention group, 24 (41%) patients' complications were detected before the follow-up, 31 (53%) at the follow-up visit, and 3 (5%) at 3 months. Altogether 20 (5.3%) IUS/IUD expulsions occurred by 3 months, 7 (35%) of which were before 2-3 weeks. Conclusions: The early insertion of an IUD after first trimester abortion does not increase the overall risk of adverse events/complications nor cause extra visits to the clinic.

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    Effective strategies for improving access to quality care: Central Africa Network for Women's Reproductive Health

    Aimée Patricia Ndembi Ndembi1, Justine Ella2, Marie Irène Bena4 ,3, Marijke Alblas3 ,4 1ONG GCG, Libreville, Gabon, 2Association des sages femmes, Libreville, Gabon, 3Association des sages femmes, Douala, Cameroon, 4CSU/CNRS, Paris, France - ndembipatricia@yahoo.fr

    The Central Africa Network for Women’s Reproductive Health: Gabon, Cameroon, Equatorial Guinea (GCG) aims to enhance reproductive healthcare by facilitating exchange between countries in the region and conducting research, training and education to improve services and provisions pertaining to pregnancy accompaniment, pregnancy prevention and pregnancy termination. The network is committed to implementing feasible strategies for enhancing the capacities of local practitioners and for assuring access to quality primary and emergency care, particularly of rural, adolescent and migrant women. To reach our objective, we created a network of practitioners eager to work together to identify needs by analyzing obstacles to quality care. We then initiated: - Train the trainer programmes in manual vacuum aspiration (MVA) - Rap groups and radio programmes with expert speakers and facilitators in schools, villages and town centres Due to these training and education programmes, hundreds of midwives, obstetric nurses and doctors are now autonomous in bringing improved care to women with pregnancy-related complications. Quantitative evaluation documents a significant decrease in delays for emergency treatment due predominantly to midwife practice of MVA with local anaesthesia. Note that delays in emergency care have been shown to be a prime obstacle to preventing death from postabortion complications. Radio programmes and rap groups with adolescents and women are effective in spreading information about abortion, contraception and a range of sexual issues. In particular, information about IUDs has increased the acceptability of this contraceptive, especially in a rural zone where we have followed about 100 young women whose positive experience is influencing other women. We are currently working to apply this model developed on the border between Gabon, Cameroon and Equatorial Guinea to the border between Gabon and Congo-Brazzaville where people face similar realities.

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    Efficacy and tolerance of emergency contraception with levonorgestrel in a dose of 1.5 mg (Escapelle)

    Vera Prilepskaya, Elmira Dovletkhanova, Patimat Abakarova, Elena Mezhevitinova Federal State Budget Institution "Research Centre for Obstetrics, Gynaecology and Perinatology", Ministry of Healthcare of the Russian Federation, Moscow, Russia - eldoc@mail.ru

    Objectives: To assess efficacy and tolerance of levonorgestrel-containing contraceptive Escapelle in women for emergency contraception. Materials and Methods: We investigated 35 women, aged from 18 to 39 (mean age 23.4+/-1.1) coming to the Centre for emergency contraception. All women visited the Centre during 48-96 hours after the moment of unprotected sexual contact. Nineteen women (54.3%) had the 1st phase of menstrual cycle, 16 (45.7%) had the 2nd phase. To exclude contraindications for hormonal contraception we conducted examinations (clinical, ultrasound, pregnancy test). One dose of Escapelle containing 1.5 mg of levonorgestrel was indicated to all patients. Results: Efficacy of Escapelle made up 97.2%. Pregnancy occurred in one case (2.8%) that was associated with the time period of more than 96 hours since the intercourse. In the 1st group 11 (58%) out of 19 women were noted to have menstruation delay, 5 had heavy periods (26.3%). In the 2nd group five women (31.2%) had menstruation delay for 3-5 days, shortening of the cycle was found in four (25%) women, heavy periods were in two (12.5%). Side-effects were registered in six women (17.1%). Out of them sickness was noted in four (11.4%), vomiting in one (2.8%), breast tension in one case (2.8%). Conclusion: Escapelle is a highly efficient and well-tolerated method of emergency contraception. Taking into account the fact that side-effects in the form of menstrual cycle disorders were found more often in women using Escapelle during the 2nd phase of the cycle it is necessary to recommend planned hormonal contraception. Efficacy decreases with the time period since the unprotected intercourse.

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    ellaOne in practice

    Michael Rimmer, Victoria Sephton Brook Advisory Centre, Liverpool, UK - michael.rimmer@doctors.org.uk

    Objectives: To audit the day-to-day use of emergency contraception and compare the failure rates of levonorgestrel (previously the first line choice for emergency contraception) and ulipristal acetate (the new first line choice of emergency contraception) since implementation of new guidelines. Background: Unplanned pregnancy is a multifactorial problem affecting up to 7% of women each year. Despite emergency contraception (EC), many women still become pregnant and require termination of pregnancy (TOP). Increased effectiveness of EC and less reliance on TOP has positive benefits on a women’s social, mental and physical wellbeing. Studies looking at follicles close to ovulation have shown that levonorgestrel inhibits 14.6 % of follicles whereas ulipristal acetate inhibits 58.8% (Brache V et al, 2010). This suggests that ulipristal acetate works closer to ovulation, when risk of pregnancy is highest. This resulted in a change in guidance from the Faculty of Sexual and Reproductive Healthcare to offer ulipristal acetate (trade name - ellaOne) as first line of EC over levonorgestrel. Methods: An audit of women, receiving ulipristal acetate as 1st line (EC) was compared to a retrospective audit of women who received levonorgestrel as 1st line. Results & Conclusions: 662 women received ulipristal acetate of which 1 required a TOP; 1397 received levonorgestrel of which 5 required a TOP. This is shown below in the table with the failure rate.

    No. of women No. requiring TOP Failure rate Ulipristal acetate 662 1 0.0015106 Levonorgestrel 1397 5 0.0030157

    The odds ratio (of the failure rates) between ulipristal acetate compared to levonorgestrel is 0.50. (Calculation: Odds Ratio = 0.0015106 / 0.0030157 = 0.50091189). This demonstrates that the change in Faculty guidance is justified and that data from studies suggesting that ulipristal acetate is more effective than levonorgestrel is reflected in clinical practice.

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    How involved are partners in teenage girls’ abortions?

    Martine Aeby-Renaud1, Geneviève Sandoz1, Gaëlle Aeby2 1Hôpital universitaire de Genève, Unité de Santé Sexuelle et de Planning Familial, Genève, Switzerland, 2Collaboration, University of Lausanne, Lausanne, Switzerland - martine.aeby-renaud@hcuge.ch

    Voluntary termination of pregnancy is an important issue, in particular for teenage girls. However, less attention is paid to their partners, to who they are, whether and how they get involved in the process. This study investigates the involvement of male partners in the process of voluntary termination of pregnancy (VTP) for teenage girls up to ages 18 inclusive, who consulted with the "Sexual Health and family planning unit (USSPF)" (Geneva, Switzerland) in 2013. The final sample is composed of 43 teenage girls. Ages range from 15 to 18 years old. Prior to their pregnancy, around two thirds of the teenage girls had used one or more contraceptive methods. They mentioned male condoms (81.4%), emergency contraception (32.6%), the pill (30.2%), withdrawal (18.6%), calendar method (2.3). Nevertheless, 37.2% of them had not yet used any method. The great majority of teenage girls were in a relationship (86%). For the rest of them, it was either a one-night stand (9.3%), or sex with a friend (4.7%). The duration of relationships ranged from 2 months to 4 years. Age of partners ranged from 15 to 28 years old. On average, partners were older than the teenage girls with a mean of 2.91 years difference in age. Most of the partners were informed about the pregnancy (90.2%). Concerning their involvement in the VTP process, analyses were restricted to couples. We considered three variables: attendance at USSPF (yes: 41.7%), giving support (yes: 88.6%), and agreement with the VTP (yes: 93.9%). In summary, results showed that the majority of teenage girls were in a stable committed relationship that lasted at least several months. Partners were involved in the VTP process and provided support. Therefore, counsellors should more actively associate them in the VTP process for better prevention of contraceptive failure and experience of VTP.

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    ‘I know it's something to do with 28 days': young women's fertility knowledge

    Victoria Newton The Open University, Milton Keynes, UK - victoria.newton@open.ac.uk

    Objectives: This project sought to investigate what young women know about fertility and how this knowledge is interpreted at an individual level. Misunderstandings about fertility can result in some young women engaging in risk-taking behaviour (Williamson et al 2009, Hoggart et al 2010). The Department of Health Framework for Sexual Health (March 2013) identifies fertility perceptions and their influence on contraceptive use as an area for suggested action (Annex C). This project therefore addressed this need by exploring young women's awareness of their fertility in relation to menstruation, contraception and pregnancy risk. Methods: Ten semi-structured qualitative interviews were undertaken with participants aged 16-20. Topics explored include what young women know about their fertility; when they think they are most and least at risk of falling pregnant; to what extent they perceive themselves to be at risk of pregnancy; their contraception use and risk taking; their knowledge of STIs and other factors affecting fertility. Results: It was found that despite a blanket desire to avoid pregnancy, all participants took risks. Almost all had used emergency contraception.

    Although some participants had limited knowledge of when it is easier to get pregnant, there was no evidence that they were more careful during their fertile time. Conclusions: Young women may benefit from a greater knowledge and understanding of their fertility. A better understanding of their fertility may help young women to assess their risk of pregnancy, and when desiring to avoid pregnancy, to take extra precautions during their most fertile time. A greater knowledge may also empower them in the future should they wish to plan for a family.

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    Instability of misoprostol tablets stored outside the blister: a potential serious concern for clinical outcome in medical abortion

    Veronique Berard1, Christian Fiala2 ,6, Sharon Cameron3, Teresa Bombas4, Mirella Parachini5, Kristina Gemzell-Danielsson6 1ICB - CNRS, Division MaNaPI, Département Nanosciences, Université de Bourgogne, Dijon, France, 2Gynmed Clinic, Vienna, Austria, 3Chalmers Centre, NHS Lothian, Edinburgh, Scotland, UK, 4Obstetric Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 5San Filippo Neri Hospital, Rome, Italy, 6Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden - mparachini@gmail.com

    Objectives: Misoprostol (Cytotec®), is recognised to be effective for many gynaecological indications including termination of pregnancy, management of miscarriage and postpartum haemorrhage. Although not licensed for such indications, it has been used for these purposes by millions of women throughout the world. Cytotec® tablets are packaged as multiple tablets within an aluminium strip, each within an individual alveolus. When an alveolus is opened, tablets will be exposed to atmospheric conditions. The effect of prolonged exposure upon bioactivity of misoprostol and resultant clinical efficacy is unknown. Therefore, this study was undertaken to assess possible changes in tablets exposed to usual European temperature and humidity conditions. Design and Methods: To compare the pharmaco-technical characteristics (weight, friability), water content, misoprostol content and decomposition product content (type A misoprostol, type B misoprostol and 8-epi misoprostol) of misoprostol tablets Cytotec® (Pfizer) exposed to air for periods of 1 to 720 hours (30 days), to those of identical non-exposed tablets. Four hundred and twenty tablets of Cytotec® (Pfizer) were removed from their alveoli blister and stored at 25°C/60% relative humidity. Water content, and misoprostol degradation products were assayed in tablets exposed from 1 to 720 hours (30 days). Comparison was made with control tablets (N=60) from the same batch stored in non-damaged blisters. Results: By 48 hours, exposed tablets demonstrated increased weight, friability, and water content (+78.8%) compared to controls. Exposed tablets also exhibited a decrease in Cytotec® active ingredient (misoprostol) dosage (-5.1% after 48 hours) and an increase in the inactive degradation products (+ 25% for type B, +50% for type A and +60% for 8-epi misoprostol after 48 hours) compared to controls. Conclusion: Exposure of Cytotec® tablets to ‘typical' European levels of air and humidity results in significant time-dependent changes in physical and biological composition that could impact adversely upon clinical efficacy. Health professionals should be made aware of the importance of appropriate storage and handling of Cytotec® tablets.

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    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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    Knowledge and attitudes about contraception and abortion in women of five countries: US, Canada, UK, France and Australia.

    Ellen Wiebe1, Lisa Littman3, Janusz Kaczorowski2 1University of BC, Vancouver, Canada, 2University of Montreal, Montreal, Canada, 3Mount Sinai, New York, USA - ellenwiebe@gmail.com

    Objectives: The purpose of this study was to answer the following questions: 1. Do anti-abortion women differ from pro-choice women in their knowledge about health risks associated with abortion and contraception? 2. Which countries and demographic characteristics are associated with lower knowledge about abortion and contraception risk? Methods: We surveyed an on-line sample of women aged 18-44 from US, Canada, UK, France and Australia (at least 200 per country) in January 2013 using Survey Monkey Audience panel. The survey asked demographics, attitude to abortion and knowledge about risks of IUDs and abortion vs births. For the purpose of this study, women choosing the response, "Abortion should be allowed for ANY reason, because no one should be forced to continue a pregnancy" were categorized as "pro-choice" and those choosing one of other responses were categorized as "anti-choice". Results: Within two days, 1117 surveys were completed: 233 in Canada, 223 in the US, 230 in the UK, 221 in France and 210 in Australia. Almost half (47.1%) of the participants were classified as pro-choice because they indicated that women should be allowed to have an abortion for any reason in the first 3 months: 38.7% in Canada, 37.1% in USA, 42.0% in UK, 68.7% in France and 53.6% in Australia (p<.001). Women classified as having anti-choice beliefs were more likely to provide incorrect answers to all 10 knowledge questions about abortion and contraception (p=<.001). There were few differences in knowledge between the women from different countries. Conclusions: Women from these 5 countries were similar in terms of their knowledge about the risks of abortion and contraception. The majority of women gave incorrect answers to the knowledge questions. Women classified as anti-choice, in all five countries, were more likely to overestimate the risks of both abortion and contraception.

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    Late termination of pregnancy because of fetal anomaly complicated by placenta praevia: case report

    Vid Janša, Nataša Tul Mandić Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia - vid.jansa@gmail.com

    Introduction: The presence of placenta praevia totalis is an important cause of postpartum bleeding and can be a challenge for obstetricians in cases of late termination of pregnancy (TOP). Case report: A 35-year old woman, G4, P3, was referred to our hospital due to fetal heart anomaly and intrauterine growth restriction (IUGR). The previous pregnancies and deliveries were uncomplicated. The patient’s first antenatal visit in this pregnancy was at 28th week of amenorrhoea and ultrasound at 29 weeks revealed IUGR, complex heart anomaly (ventricular septal defect, double outlet right ventricle, pulmonary atresia) and placenta praevia totalis. A patient request for TOP was approved by the ethical committee. We wanted to avoid caesarean section. The risk of bleeding during TOP because of placenta praevia totalis became an important issue. A decision was made to proceed with selective uterine arteries embolization (UAE), which was performed in the Radiology department. 18 hours after the procedure fetal heart activity was absent. After 5 days of waiting for spontaneous onset of labour, we decided to continue with misoprostol and she received 100mcg vaginally, 3 hours later 100mcg buccally, followed by 200mcg and 400mcg buccally in 3 hourly intervals. The patient was transferred to the delivery room and placenta and stillborn fetus (770 grams) in breech presentation were delivered vaginally 15 hours after first application of misoprostol. After delivery karboprost was applied for prevention of bleeding and overall blood loss was less than 300ml. The patient was discharged in good condition the day after delivery. Fetal autopsy confirmed prenatal diagnostic conclusions. Discussion: The risk of heavy bleeding with vaginal delivery in cases of late TOP complicated by placenta praevia totalis can be reduced by UAE which has low complication rates, shorter hospitalization and avoids surgical risks as published. Embolization can be followed by misoprostol. Care must be taken to prevent postpartum bleeding.

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    Marie Stopes International UK Abortion Study: "I didn't think it would happen to me". Young women's accounts of pre- and post- abortion contraceptive use.

    Lesley Hoggart, Victoria Newton The Open University, Milton Keynes, UK - victoria.newton@open.ac.uk

    Objectives: The overall aim of the study was to explore the behavioural, social and service related factors that are associated with one or more unintended and unwanted pregnancy amongst young women (under 25 years). In this paper we explore, qualitatively, the narratives of young women who - for a multitude of reasons - have experienced unwanted pregnancy. Methods: A longitudinal investigation using in-depth qualitative interviews with 36 young women who have had one or more abortion. The study is funded by, and being undertaken in collaboration with, Marie Stopes International. Results: Participant's accounts of unintended and unwanted pregnancy highlight the diverse situational and behavioural scenarios in which women become pregnant when they do not want to be. Most participants in the study had been actively attempting to avoid pregnancy but had experienced a contraceptive failure due to improper use or a misunderstanding about the method. Other participants were sure they had used their method correctly and were uncertain how and why they became pregnant. For those women who were aware they were at risk of an unintended pregnancy, most did not seek emergency contraception. These women recounted finding it difficult to access emergency hormonal contraception (EHC), or being worried about having to pay for it. There was a clear lack of knowledge about the emergency IUD. For the few women who had accessed EHC, there was very little evidence of advice regarding the emergency IUD being given by their provider. Conclusions: An advance supply of EHC would enable women to have it to hand should the need arise. General awareness about the IUD as a method of emergency contraception needs to be raised. Providers should discuss the emergency IUD with women seeking EHC, especially for those who are close to the EHC time limit.

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    Medical abortion in Bulgaria: a happy-ending Cinderella story or a Little Match-Seller drama?

    Dimitar Cvetkov1, Svetlozar Stoykov2 1Women's Health Hospital Nadezhda, Sofia, Bulgaria, 2Medical University Pleven, Pleven, Bulgaria - cvetkoff@abv.bg

    Around the world, probably every medicine man possessed an "abortion recipe", and in Bulgaria too, the interruption of an unwanted pregnancy had its common place in traditional medicine. One of famous works of Bulgarian literature, Dimiter Talev's "The Iron Oil Lamp", gives a dramatic description of the terror of a mother who destroyed the life of her daughter by giving her an abortion potion to save her from the shame of unwanted pregnancy. Much has changed in Bulgaria since these times - the country is the sad leader in Europe's statistics on abortion/live birth ratio. When terminating pregnancy up to 12 weeks is in question, the only option regulation allows is surgical abortion. As early as 1994, there were efforts to introduce medical abortion into practice, but no development resulted, due to lack of interest and insecurity on the part of clinicians facing a new method. In 2010, following a symposium on medical abortion, the idea came back to life once more. After an active search for manufacturers and drugs, and even after a period of unregulated import, finally the pharmaceutical companies at last came to see the Bulgarian market as a rightful destination, and shortly after we saw the first registrations. Today, almost 4 years later, the Bulgarian drug market features Exelgyn, Sun Pharma, and Linepharma, in competition for affordable prices and a steady market share. Yet, at the seemingly happy end, we are facing a multitude of questions: regulatory sales regime; minimum age for abortion; reimbursing procedure costs for teenagers; training of clinicians and midwives. If we are not ready to adequately address these challenges and we do not arrive at viable solutions after a discussion among clinicians, the very method may be compromised and rejected, and a happy-ending Cinderella fairy-tale might turn into the Little Match-Seller sad story.

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    Medical abortion in Slovenia: where are we?

    Eva Macun General hospital Jesenice, Jesenica, Slovenia - eva.macun@sb-je.si

    Introduction: In Slovenia abortion is legal on demand up to 10 weeks of pregnancy. Later abortion can be done after approval of the Commission for abortion. It can be performed in 14 gynaecological departments. Slovenia has a national register of fetal death up to 500g. Institutions that perform abortions are obliged to report all known fetal deaths, with demographic data and procedure. Methods: We checked the fetal death database for method of abortion on demand for Slovenia for the years 2007-2011. We interviewed doctors in all Ob/Gyn departments. We asked them how many percent of abortion were medical in the year 2014. Possible answers were: <50%, >50% and >90%. We asked them also if women can be given misoprostol for home use. Results: In the year 2007 there were 5176 abortions on demand in Slovenia; 4660 (90%) were surgical and 123 (2.4%) were medical abortion and some other methods. In the following years the rate of medical abortions increased (Table 1). In year 2011 there were 4263 abortions ; 2153 (50.5%) were surgical and 1602 (37.6%) were medical abortions.

    Table 1: The rates of medical and surgical abortions in Slovenia, 2007 - 2011

    Year 2007 2008 2009 2010 2011

    Surgical

    Abortion number 4660 4099 3560 2604 2153 % 90.0 82.8 76.5 60.2 50.5

    Medical number 123 434 734 1345 1602

    Abortion % 2.4 8.8 15.8 31.1 37.6

    Results of interviews show that in year 2014 four Ob/Gyn departments use medical abortion in 50% or less. Four departments use it in more than 50% and less than 90%. Six departments use medical abortion in more than 90%. Three of the latter give misoprostol to women for home use. Conclusions: Use of medical abortion is increasing in Slovenia. There are departments that give misoprostol for home use.

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    • Marija Rebolj Stare Rebolj Stare , SI (all speeches)

    Medical abortion performed at home

    Marija Rebolj Stare University Clinical Centre Maribor, Maribor, Slovenia - mitzirs@gmail.com

    Introduction: At the University Clinical Centre, Maribor, the start of medical abortions was in the year 2006, with a full service from July 2007. With the recognition of its course and a lack of major complications, we decided to perform medical abortions up to 63 days of gestation in the outpatient clinic. A complete working plan was done, with exact briefings for all enrolled. Methods: On 24 February 2014 we started with outpatient medical abortions. At visit all reports (ultrasound report, blood haemoglobin level, blood type, Rh factor, ICT) and possible contraindications were evaluated. In case of uncertainty we repeated tests. Written explanation and patient consent, ambulance report, strict instructions were featured, for term and preterm control if needed. Analgesic therapy was prescribed. Oral intake of mifepristone 200 mg was followed, after 36-48 hours, with vaginal insertion of 4 pills of misoprostol 200 mcg. We advised attendance of adult and one week of sick leave. Two weeks later we performed follow-up. Results: Between 24 February and 3 April.2014, 47 patients aged 16.4-41.3 years, were enrolled. Average gestation was 52 (37-62) days. Seven didn't come to check-up; they probably had no problems. In 4 patients medical abortion failed and pregnancies were ongoing. Two had surgical abortion and 2 medical by extended protocol - one complete, one with curettage due to residua. For 36 patients medical abortion was successful. At 30 patients was complete, 6 had residua (15-31 mm) with high βHCG level (460-21164). Two were directed to hysteroscopy and 4 had curettage. Prophylactic antibiotic therapy was given once, prior to curettage. No transfusion was needed. Conclusions: Medical abortion at home proved to be safe for gestations up to 63 days of duration. Complications such as bleeding, residua or infection did not occur more often than at hospitalization. Failed medical abortions tended to occur; that confirms a need for a check-up some patients are avoiding.

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    Medical students' attitudes and perceptions on abortion: a cross-sectional survey among medical interns in Maharastra, India

    Susanne Sjöström1 ,2, Birgitta Essén2, Filip Sydén2, Kristina Gemzell-Danielsson1, Marie Klingberg-Allvin3 ,1 1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden - susanne.sjostrom@ki.se

    Introduction: Although abortion care as a procedure to prevent maternal death has been an established routine for decades in India, eight per cent of maternal mortality is attributed to unsafe abortion. Increased knowledge and improved attitudes among healthcare providers have a potential to reduce barriers to safe abortion care by reducing stigma and reluctance to provide abortion. Previous research has shown that medical students’ attitudes can predict whether they will perform abortions. The objective of our study was to explore attitudes toward abortion among medical interns in Maharastra, India. Study Design: A cross-sectional survey was carried out among 1,996 medical interns in Maharastra, India. Descriptive and analytical statistics interpreted the study instrument and significant results were presented with a 95% confidence interval. Results: A majority of the respondents rated their knowledge of sexual and reproductive health as good, but only 13% had any clinical practice in abortion care services. Most participants agreed that unsafe abortion is a serious health problem in India. However, many considered abortion to be morally wrong, one fifth did not find abortions for unmarried women acceptable, and one quarter falsely believed that a woman needs her partner or spouse’s approval to have an abortion. Conclusion: Despite good self-assessed knowledge of reproductive health, disallowing attitudes toward abortion and misconceptions about the legal regulations were common. Knowledge and attitudes toward abortion among future physicians could be improved by amendments to medical education, potentially increasing the number of future providers delivering safe and legal abortion services.

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    Medical treatment of abortion and missed miscarriage: what's the difference in results?

    Silvio Viale San'Anna Hospital, Turin, Italy - silvioviale@libero.it

    Objectives: We have compared the efficacy of medical treatment for abortions in women with missed miscarriages. The protocol was mifepristone 600 mg orally + gemeprost 1 mg vaginally two days after, eventually repeated once. Women didn't stay in hospital between mifepristone and gemeprost. Methods: Since April 2011, when mifepristone became available in Italy, until April 2014 we have performed 3545 medical abortions up to 7 weeks. Later we started to offer medical treatment also for blighted ovum and missed miscarriage up to eight weeks of development, regardless of the true gestational age. As at April 2014 we have performed 423 medical treatments of missed miscarriages and blighted ovum. Results: The overall success rate of medical management of abortion and missed miscarriage was 96.3%, with 147 surgical procedures out of 3968. For abortion the success rate was 96.5%, with 125 surgical procedures out of 3545. For missed miscarriage the success rate was 94.8%, a little less, with 22 surgical procedures out of 423. If we keep out the 32 cases in which the curettage occurred for failure in expulsion, 22 abortion and 10 missed miscarriage, the overall success rate rises from 96.3% to 97.1%. By doing the same for abortions and missed miscarriages we found that the success rate rise in both cases, from 96.5% to 97.1% for abortions and from 94.8% to 97.1% for missed miscarriage. Consequently, the rate of curettage drops from 3.5 to 2.9% for abortions and from 5.2 to 2.9% for missed miscarriages. Conclusions: The only significant difference is that medical treatment of missed miscarriage has a fourfold risk of failed expulsion compared to medical treatment of abortion, 2.4% versus 0.6%. With a success rate of 94.8% the medical regimen with mifepristone and gemeprost can be a routine alternative to surgical management of early fetal demise.

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    Meeting the needs of grieving families after induced abortion for fetal abnormality in Slovenia

    Vislava Globevnik Velikonja University Medical centre, Ljubljana, Slovenia - vislava.velikonja@guest.arnes.si

    The detection of fetal abnormalities in the first and second trimesters is increasingly common due to advances in technology. Parents need counselling to be prepared for the difficult decisions that must be made if their unborn children are diagnosed with a life-limiting condition. Termination after fetal anomaly forces parents to take an active part in the life and death of a nearly-viable fetus. Regardless of the option taken, they often experience intense grief reactions. Both giving birth to a child with a life-limiting condition as well as termination of pregnancy for fetal anomaly can be emotionally traumatic life events. Abortions for fetal abnormality are statistically rare, therefore there is little societal understanding and minimal support for those who experience them. The grieving family should be provided with assistance by professionals at multiple levels, aiming at reaching two main target groups: the grieving family by providing direct counselling and support in the hospital and in the community, and those assisting the bereaved by providing training and support. At our department both parents can be hospitalized together during the period of pregnancy termination. The possibility of seeing the dead baby, to hold it and to say farewell may help the parents afterwards. They are informed about cremation and the day of the funeral in a memorial park named Snowdrop Garden, about the mourning process and the possible psychosocial support during it. If the birth weight of the baby is over 500 grams, we use the protocol for perinatal death. Most parents are able to cope with the decisions they made. Feelings such as doubt, guilt, failure, shame, anger, relief, anxiety and depression are common during the process of abortion, the following weeks and sometimes even months. Only a few couples still need psychotherapeutic help and a support group after one year.

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    Menstruation and contraception: social and cultural issues on young women's decision-making

    Victoria Newton, Lesley Hoggart The Open University, Milton Keynes, UK - victoria.newton@open.ac.uk

    Objectives: This study examined the attitudes of young women (aged 16-21) towards menstruation and contraception. The study had two main research objectives: to document and investigate what young women think and feel about menstruation and contraception, and to explore young women's preferences regarding the intersection of contraceptives and bleeding patterns. Methods: A qualitative study in which twelve young women were interviewed in-depth, along with six focus group discussions. Results: Although participants held a broad view that menstruation can be an inconvenience, they did ascribe positive values to having a regular bleed. Bleeding was seen as a signifier of non-pregnancy and also an innate part of being a woman. A preference for a ‘natural' menstruating body was a strong theme, and the idea of selecting a hormonal contraceptive that might stop the bleeding was not popular, unless the young woman suffered with painful natural menstruation. Contraceptives that mimicked the menstrual cycle were acceptable to most suggesting that cyclic bleeding may hold a symbolic function for many women. Conclusions: When counselling young women about the effect of hormonal contraception on their bleeding, it would be helpful for practitioners to explore how the young women feel about their bleeding, and ask the young women to recall a ‘worst case scenario' in terms of their bleeding patterns with reference to how they might feel about it. It may also be helpful for practitioners to outline the therapeutic interventions available to alleviate breakthrough bleeding associated with some LARC methods, such as prescribing the COC pill, during their initial contraceptive consultation. Finally, the subjective understanding of the ‘natural body' as held by some women could be acknowledged more fully and in these cases practitioners could be encouraged to support them in their choice and seeking out of non-hormonal methods of contraception.

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    Modern contraception use and induced abortion rate in Slovenia

    Barbara Mihevc Ponikvar, Sonja Tomšič National Institute of Public Health, Ljubljana, Slovenia - barbara.mihevc@nijz.si

    Objectives: Knowledge about contraception, access to contraception and quality of family planning services influence induced abortion rate. With this analysis we want to present the current situation and the trends in induced abortions rate and contraception use in Slovenia. Methods: For this analysis we used the data from the national Information System on Fetal Deaths and Database on prescription drugs. These Information Systems contain data on all fetal deaths and all drugs that are prescribed in Slovenia. Results: Hormonal contraception is nowadays the most widespread form of contraception in Slovenia. Throughout the last decade the use remained rather stable but with changes in different age groups. An increase was observed in women aged 15-24 years and a decrease in the age group 30-39 years. In 2012 162 per 1000 women in the childbearing period used this contraception, most prevalently in the age group 20-24 years. 94 % of prescribed hormonal contraception was in the form of a contraceptive pill. Among contraceptive pills 92 % were combined hormonal contraceptives, most commonly with a combination of ethinylestradiol and drospirenone. Intrauterine contraception is gaining in importance in the last decade. The induced abortion rate in Slovenia reached its peak in 1982, since then the rate is steadily declining. In 2012 it was 8.7 per 1000. The highest abortion rate is among women in the age group 25-34 years. There are differences in abortion rates between regions and between women from different educational groups. Conclusions: In the last few decades patterns of use of contraceptive methods have changed significantly in Slovenia. The use of hormonal contraception is still increasing in younger women, but has fallen in women older than 30 years, which can be explained by increasing use of intrauterine contraception. Abortion rates have been declining since 1982 and reflect good availability and use of modern contraception.

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    MYA study: Observational study on cervical preparation prior to surgical abortion in real life conditions

    Aubert Agostini1, Philippe David2, Virginie Rondeau3 1Assistance Publique Hôpitaux de Marseille, Service Gynécologie, Hôpital de la Conception, Marseille, France, 2Service Gynécologie Obstétrique, Clinique Jules Verne, Nantes, France, 3INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France - aubert.agostini@ap-hm.fr

    Background: More than 200,000 abortions are performed yearly in France. Guidelines are available for medical and surgical abortion. However, clinical practices on surgical abortion and particularly on cervical preparation are not well known and not sufficiently documented. Study objectives: The main objective is to describe the different surgical abortion procedures especially the methods used for cervical preparation prior to surgical abortion including mechanical dilatation, therapeutic regimen, prescribed medications and conditions of administration. The secondary objectives assess the investigator's satisfaction with cervaical preparation, patient's feedback on surgery and identify associated factors with the chosen method of cervical preparation. Design: MYA is an observational, prospective study set up, in real-life conditions, in centres with at least 50% of their activity in surgical abortions and with a high number of abortions per year (N >500). In total, 132 centres were invited and 40 centres agreed to take part in the study from December 2013. A cohort of 600 women (older than 18 years) undergoing a surgical abortion at less than 14 weeks’ gestation, is expected. Women are enrolled during the visit prior the surgery after giving their oral consent. Data collection and outcome measures: Data will be collected by the investigator on 3 occasions: enrollment visit, during surgery and at the follow-up visit usually planned 3 weeks after surgery, including safety data. Patients will be asked to complete a questionnaire on acceptability one week after surgery. Cervical preparation will be described by the method used: medication prescribed or not, dosage and type of administration, interval between the medication administration and surgery and the rationale of this therapeutic regimen. Descriptive statistics of all variables will be performed to analyze the results. Conclusion: This study aims to provide additional information on the procedures of cervical preparation particularly for Western countries where these medical practices are poorly documented.

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    Nurse’s role in medical abortion up to nine weeks of pregnancy in a day hospital unit

    Jasmina Kostoski, Sanja Perić, Vlasta Slapničar University Medical Centre Ljubljana, Ljubljana, Slovenia - jasmina.kostoski@gmail.com

    Introduction: The Day Hospital is part of a Reproductive Unit which contains an operating room for aseptic interventions and three hospital rooms with 14 bed units. This is the main unit for all kind of abortions and minor operative procedures in gynaecology. The average annual number of patients is between 2500 and 2700. 1,232 abortions up to 10 weeks are performed, of which 766 medical abortions were recorded last year. Organization and workflow: Patients are coming to the Day Hospital with an already signed application for termination of pregnancy up to 10 weeks of gestation. A nurse will interview the patient in order to determine which kind of abortion will be the most appropriate (depending on the level of pregnancy, her expectations and any additional diagnosis). If medical abortion is appropriate, the patient is going back to the nurse who will give her a prescribed tablet of mifepristone. Together, they will make a plan for the further course of pregnancy termination considering the patient’s career and family responsibilities. The patient will not leave the hospital without having received all the needed spoken and written instructions from the nurse. Approximately 36-48 hours after taking the tablet, the patient is returning. After a brief interview in relation with the course of the first part of the medical abortion, the nurse will give the patient a tablet of NSAID and place the patient into the bed unit. After that the nurse or the resident will insert 4 tablets of misoprostol in her vagina. During that time, nurses are taking good care of the patient, helping to alleviate the possible pain and sickness by giving medications and controlling bleeding and pain. After 3 to 4 hours, the nurse is giving further instructions to the patient who will be able to safely leave the hospital.

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    Postabortion contraception in Ukraine: a pilot study

    Volodymyr Podolskyi1, Kristina Gemzell-Danielsson2, Lena Marions1 1Institute of Paediatrics, Obstetrics and Gynaecology, Kiev, Ukraine, 2Karolinska Institutet, Stockholm, Sweden, 3Karolinska Institutet, Stockholm, Sweden - podolskyivv@gmail.com

    Background: The abortion rate in Ukraine is high and the use of effective contraceptive methods is low. Aiming to explore women’s knowledge and attitudes towards modern contraceptive methods, we performed a survey among women undergoing surgical pregnancy termination in the first trimester. Material and Methods: A survey was provided in the Maternity House №6, Kiev Ukraine. The aim is to include 300 eligible women and the present data represent a pilot analysis of 30 women. The study was approved by the Ukrainian Ethical Committee, Kiev Results: Mean age was 27 years, 63% were married, 47% had graduated from college. A majority of the women (27/30) had given birth at least once. Only 2 women were pregnant for the first time. Seventeen women had performed at least one abortion earlier and almost half of the women (14/30) had experienced at least 2 abortions. Fourteen women wanted to have more children whilst the remaining 16 women stated they never wanted to have more children. Most women (26/30) had heard about contraceptive pills but only 13/30 were aware of intrauterine devices. Weight gain, future infertility were reported by the women as reasons for not using hormonal contraceptive methods. Previous experience of contraceptive methods included condoms (25/30), contraceptive pills (10/30) and IUD (5/30). Thirteen women had never heard about emergency contraceptive pills. Conclusion: Our pilot study indicates that Ukrainian women presenting with an unwanted pregnancy have an unmet need for long-lasting effective contraceptive methods. Repeat abortions were common among women included in our study. They showed insufficient knowledge regarding effective methods and expressed misconceptions regarding side effects of hormonal contraception methods. There is a need for education among fertile women and future studies need to explore whether insufficient knowledge also is prevalent among healthcare providers.

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    Psychological adjustment following induced abortion for fetal abnormality

    Lucija Pavse1, Vislava Globevnik Velikonja1, Robert Masten2, Nataša Tul-Mandić1 1University Medical Centre Ljubljana, Gynaecological clinic, Ljubljana, Slovenia, 2University of Ljubljana, Faculty of Arts, Psychology Department, Ljubljana, Slovenia - lucija.vidmar@gmail.com

    The purpose of this study was to explore the ways in which bereaved women perceive and cope with induced abortion for fetal abnormality. We examined the relative impact of major variables for predicting adjustment (in terms of depression, anxiety and grief) among bereaved women. 108 bereaved women who had had an induced abortion for fetal abnormality completed standardized self-report questionnaires measuring depression (Beck Depression Inventory–Short Form; BDI-SF), anxiety (State- Trait Anxiety Inventory; STAI-X1) and grief (Munich Grief Scale; MGS). More educated women had lower levels of depression and anxiety and felt less guilty. Women with more remaining children were more anxious. Women who had induced abortion at a higher gestation of pregnancy had higher levels of sadness and anger. Women with two or more induced or spontaneous abortions had higher levels of anger. These findings increase the understanding of the impact of factors associated with bereavement outcome following induced abortion for fetal abnormality. On that basis adequate intervention strategies should be established to identify and help mothers at high risk of poor psychological adjustment following perinatal loss.

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    Psychological assessment in Italian and immigrant women requesting TOP in two central Italian hospitals

    Marina Marceca1, Pietro Are2, Mirella Parachini3, Giovanna Scassellati Sforzolini4, Patrizia Facco5, Daniela Valeriani4, Gelsomina Orlando6, Cristina Francesca Damiani6, Paola Lo Pizzo6, Anna Pompili7 1San Giovanni Evangelista Hospital, Tivoli (Rome), Italy, 2ASL Latina, Latina, Italy, 3San Filippo Hospital, Rome, Italy, 4San Camillo Hospital, Rome, Italy, 5Sandro Pertini Hospital, Rome, Italy, 6San Giovanni Hospital, Rome, Italy, 7ASL RM E, Rome, Italy - marina.marceca@gmail.com

    During the last two decades the number of foreign citizens resident in Italy has been progressively increasing: in 1991 they were 625,000 (361,000 females), incresing to 4,570,317 in 2011 (7.5% of the Italian resident population). Females are 51% of them, about 4.5% of total resident female population. In Italy the induced abortion rate is lower than in other countries, but there are great differences between Italian and immigrant women resident in Italy: in 2009 the induced abortion rate among Italian women was 6.6/1000, compared with 24.1/1000 among foreign women. This study is part of a multicentre one, in press, performed in Italy between women requesting induced termination of pregnancy, in order to evaluate if there are differences in experiences of physical or psychological violence among Italian and immigrant women. Our data concern women who required TOP in Tivoli and Palestrina hospitals, two cities in central Italy, with high foreign populations. A group of 142 women (88 of which were Italians and 54 foreigners) received an anonymous questionnaire during the first visit before abortion. Comparing the results obtained we did not find significant differences between Italian and immigrant women regarding history of intimate violence, but the two groups showed different variables like education, number of children and moreover between repeated abortions.

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    Regarding medical abortions at the Gynaecological Clinic in Majorna

    Monika Axelsson Närhälsan Västra Götaland, Gothenburg, Sweden - monika.axelsson@vgregion.se

    We started the office with the idea of facilitating so-called early medical abortions that are terminated at home. After contact with and visits from the The National Board of Health and Welfare, in addition to hard work on routines and quality as well as medical safety, we finally managed to get the permit to open our doors. To summarize the results from the survey, the information given corresponds with the patients´ expectations. The patient receives sufficient analgesics to take home which is crucial. Measuring the level of pain is difficult but I have used a scale without numbers that goes from no pain to severe pain and most fall in the middle of the scale. 37% have chosen the lower end of the scale, meaning less pain, while 42% have chosen the higher end of the scale. 17% chose the middle of the scale. 82% thought they had received enough analgesics. 7% asked for emergency care during 4 weeks following the procedure due to bleeding, dizziness, pain, and so on. An interesting finding was the choice of contraception, where most patients have chosen combined birth control pills (32%) or no protection (22%). The conclusion is that we offer a good service at the gynaecology clinic in Majorna to women that wish to carry out an abortion. What could be explored further, and should be discussed, is the fact that such a high percentage of the women chose to use no contraception after abortion. One solution could be to offer an additional follow-up visit later on. However, important is to be able to offer abortions that are as good and safe as possible.

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    RU OK? Provider perspectives on follow-up with remote technologies after early medical abortion

    Lesley Hoggart1, Patricia Lohr1, Jeanette Taylor1, Chelsea Morroni1, Hillary Bracken2, Beverly Winikoff2 1bpas, Stratford Upon Avon, UK, 2Gynuity Health Projects, New York, USA - hbracken@gynuity.org Objective: Guidelines from the World Health Organization and Royal College of Obstetricians and Gynaecologists suggest that routine in-clinic follow-up is not required after early medical abortion. New diagnostic and communication technologies promise to allow women to assess their abortion outcome at home. Yet little is known about healthcare providers' attitudes and opinions about the elimination of clinic follow-up. Methods: Providers in 4 clinics in the bpas clinic network in the United Kingdom were interviewed after participating in a randomized clinical trial testing the feasibility of using remote communication technologies for follow-up after early medical abortion. Clinicians and non-clinical staff (N=10) at participating clinics and the bpas call centre participated in 3 focus group discussions guided by a qualitative researcher. Participants were asked about their perspectives on in-clinic follow-up and home follow-up by phone, text message or email. Focus group discussions were recorded, transcribed, and analyzed thematically by the authors. Results: Participants were open to alternative approaches to follow-up after medical abortion. Staff recognized the need to improve follow-up rates but were sceptical improvement was possible, and uncertain about how to balance time management issues with women's needs. Providers described a tension between two imperatives: to respect women's postabortion preferences and to ensure contact and knowledge of postabortion outcomes. Providers felt responsibility for follow-up was part of their duty of care; although some acknowledged that retaining this responsibility clashed with the bpas culture of trusting women to control their own bodies and reproductive lives. Conclusions: Overall, although there was an evident diversity of views, clinic staff felt that they had a responsibility to follow-up women after early medical abortion. Efforts to introduce home follow-up after medical abortion must be accompanied by training that addresses providers' concerns and ambivalence about allowing women to manage the procedure at home.

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    Scoring system avoids Chlamydia trachomatis over-screening in women seeking surgical abortion

    Vincent Lavoue1, Marie Catherine Voltzenlogel1, Camille Leonardon1, Jacques Minet1, Patrice Poulain1, Margaret Redpath2, Cyrille Huchon3 1Teaching Hospital of Rennes, Rennes, France, 2McGill University, Montreal (Qc), Canada, 3Université de Montréal, Montreal (Qc), Canada - vincent.lavoue@chu-rennes.fr

    Objective To develop and validate a predictive score to avoid unnecessary screening and prophylactic antibiotic use in abortion clinics by identifying a group of women who are at very low risk of Chlamydia trachomatis (CT) infection. Methods: This population-based retrospective study includes 1000 women who underwent surgical abortion between January and September 2010. The main outcome measure was the rate of CT infection among women seeking an induced abortion according to socio-demographic and clinical data. The score was developed by using 2/3 of the dataset as the derivation sample to identify the strongest predictors of CT. An ROC curve established cutoffs, and applied the score to the remaining 1/3 (validation sample). Results The rate of CT infection was 6.7%. Three criteria were independently associated with CT: gestation >10 weeks [adjusted odds ratio (aOR), 1.96; 95% confidence interval (95% CI), 1.06-3.64], not using contraception (aOR, 2.70; 95% CI, 1.41-5.16) and having 0 or 1 child (aOR, 3.46, 95% CI, 1.34-8.93). The CT score was based on these three criteria. The low risk group was derived from values of the score [probability of CT, 1.3% (95% CI, 0-3.0)]. Application of these criteria to the validation dataset confirmed the diagnostic accuracy of the score (probability of CT, 0%). Sensitivity was 100% and specificity 26.9% for the score in the validation dataset. Applied to the validation dataset, the score avoided 25.4% of CT tests and screened of 100% of CT-infected women before surgical abortion. Conclusions This easy-to-calculate score may prove useful for avoiding CT test in 25% of patients seeking surgical abortion.

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    Sex hormones and nuclear appendages

    Affaf Adda, Hassiba Lazreg, Nazim Bennaoum, Mohamed Brahimi Department of Haemobiology, EHU « 1er Novembre 54 », Oran, Algeria - ehu.adda@hotmail.com

    Introduction: Some nuclear neutrophils contain a small chromatin mass appended to one of their nucleus lobes. To date, their nature has remained uncertain. Some published data demonstrated that the frequencies and the distribution of these appendages were influenced by sex and by many other factors such as hormones, granulocytes metabolism, cell proliferation, and age. Objectives: This blind study was designed to check whether appendages are related to sex hormones and change with menstrual cycle phases or not. Method: Nuclear appendages were studied in ten women during different phases of menstrual cycle. Written consent was obtained from each individual. Ages of the individuals varied from 25 to 35 years old. None of them had a history of malignancy, severe systemic infection, pregnancy, recent transfusions, malnutrition, consumption of oral contraceptives or any other medication that affects the menstrual cycle. Peripheral blood samples were collected into EDTA tubes at different phases of the menstrual cycle (1st day, 7th, 14th and the 21st). At the time blood samples were taken, whole blood counts were studied. Blood smears were performed from each tube, stained then observed under immersion oil light microscope. Two hundred polynuclear neutrophils were examined for nuclear appendages for each sample and classified into four groups : neutrophils with form A (drumstick), form B (sessile nodules) or form C appendages (tag and hook) and neutrophils without any appendages. Results: The difference (A-C) was calculated for each slide. There were significant variations of the (A-C) during the menstrual cycle for each individual but these variations were not homogeneous from one woman to another. Conclusion: These results support the hypothesis that there is no relationship beteween oestrogen and appendages formation.

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    Sexual behaviour and knowledge on contraception and STIs among Slovenian secondary-school students: differences regarding type of school

    Bojana Pinter1, Tinkara Srnovrsnik1, Fani Ceh2 1Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia, 2The National Educational Institute, Ljubljana, Slovenia - bojana.pinter@guest.arnes.si

    Objective: To present the differences among secondary-school students on sexual behaviour and their knowledge on contraception and sexually transmitted infections (STIs), regarding type of school. Methods: The study was done on 969 randomly selected 3rd grade Slovenian secondary-school students of both genders by self-administered questionnaire in year 2012. Descriptive statistics and chi-square test were used. Results: Students were attending professional school, vocational school or gymnasium (12.6 %, 43.9 % and 43.5 %). Their average age was 17.5 +/- 0.7 years. Sexual intercourse have ever had was shown in 64.8 % of vocational-school students, 59.5 % of professional-school students and 47.2 % of gymnasium students (p < 0.001). Use of effective contraception (condom, hormonal contraception or double method) at last sexual intercourse was high (87.4 %) with no differences regarding type of school. Self-assessment of knowledge on different types of contraception revealed better knowledge among gymnasium students. Self-assessment of knowledge on STIs revealed poorer knowledge among vocational-school students. Vocational-school students were more likely to get information on sexuality from their parents and less likely from the internet than others; books and magazines were more often used by gymnasium students. Gymnasium students would more often use books and magazines, friend's advice or internet to get more information on sexuality. Sexuality education was most frequently performed in gymnasium (77.0 %) and least frequently in vocational school (64.7 %) but in the latter students were more satisfied with it. Conclusions: There were significant differences among secondary-school students in sexual behaviour and knowledge on contraception and STIs, regarding type of the school. Systematic sexuality education is needed to minimize the differences.

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    Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a checklist in Rajasthan, India: study protocol and intervention adaptation of a randomized controlled trial

    Mandira Paul2, Kirti Iyengar1 ,4, Sharad Iyengar4, Kristina Gemzell-Danielsson1, Birgitta Essén2, Marie Klingberg-Allvin3 ,1 1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden, 4Action Research, Training for Health (ARTH) Society, Udaipur, India - mandira.paul@kbh.uu.se

    Background: The WHO suggests that simplification of the medical abortion regimen will contribute to an increased acceptability among women and providers. It is expected that home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic. This study protocol describes an RCT that aims to evaluate the efficacy of home-based self-assessment after a medical abortion and the acceptability and feasibility of the intervention in a low-resource setting. Method/Design: The study is a randomised, controlled, non-superiority trial that will evaluate the effectiveness and acceptability of self-assessment using a low-sensitivity pregnancy test and a checklist two weeks after medical abortion. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. Eligible women randomised to the self-assessment group will use the low-sensitivity pregnancy test and the checklist at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. To ensure feasibility of the self-assessment intervention an adaptation phase took place at the selected study sites before study initiation. This was to optimize and tailor-make the intervention and the study procedures and resulted in the development of a pictorial instruction sheet on how to use the low-sensitivity pregnancy test and the checklist of danger signs after a medical abortion. Discussion: In this paper, we will describe the study protocol for a randomized controlled trial investigating the efficacy of simplified follow-up in terms of home-based self-assessment, two weeks after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor.

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    Social counselling in the field of the rights to family planning and to termination of pregnancy

    Zlata Licer, Lili Dreu University Medical Centre Ljubljana, Division of Gynaecology, Ljubljana, Slovenia - zlata.licer@kclj.si

    The right to family planning and to artificial termination of pregnancy is a basic human right. Social counselling on an individual basis should enable people to choose freely to have children and to have access to social rights during periods of distress. Expert assistance in decision-making is necessary in different stages of life, especially among vulnerable groups of women, which consist mainly of a) adolescents, b) women with a pregnancy over 10 weeks and c) women over 35 years of age. Counsellors must treat their sexual and reproductive health as their basic human right and take into account all their needs. For example, adolescents must have a right to comprehensive sex education, education for equal gender relations and youth-friendly and accessible reproductive healthcare. Women with a pregnancy over 10 weeks are usually in a difficult social situation while older women tend to feel more emotionally vulnerable. In the field of artificial termination of pregnancy counsellors need to be especially attentive to provide their clients with all the relevant information which enables the clients to make autonomous decisions in relation to their reproductive health.

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    Sociological aspects of violating the natural gender balance of newborns in Georgia

    Gulnara Shelia1, Nino Tsuleiskiri2 1NGO"Association HERA-XXI", Tbilisi, Georgia, 2Tsereteli State University, Kutaisi, Georgia - dodoshelia@yandex.ru

    Objective: Explore the sociological aspects of disturbing the natural gender balance and reasons behind “skewed sex ratios”at birth (111 boys for 100 girls) in Georgia. Method: 1600 women have been interviewed. The target groups of investigation were women of childbearing age and their families, also medical staff of 4 cities . Quantitative and qualitative data analysis was conducted using the computer program SPSS. Results: Analysis of the data shows, that sex selection in Georgia really exists. As a consequence there is significant evidence of prenatal sex identification practice. Additionally to the existing stereotype, technological innovations and disseminated information about modern family planning methods resulted in determination of the number of children and identification of the sex of the fetus by women.This behaviour is not inhibited by service providers.The existing economic and social conditions and level of education are contributing factors to having an abortion. Religion is the only deterrent to abortion.To the question “how important to you is the sex of the future child ?“, 52-72% answered that ”has no relevance“, but correlative analysis shows inconsistency of this response with other answers. 63% of the investigated women had undergone their first abortion; for 24% it was the second. Conclusion: Abortion is still the main method of birth control in Georgia. Termination of pregnancy, by interviewed women , is socially conditioned.There is the practice of prenatal sex selection with the termination of unwanted pregnancy in Georgia. Directly and spontaneously or under pressure Georgian women decide not to give birth to daughters, who are considered a burden to their family and unable to perpetuate the family lineage. This situation (the prenatal sex selection and related selective abortion) requires more adequate attention from authorities and development of specific measures for prevention.

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    State report on pregnancy termination among raped adolescent girls in Korean metropolitan city, Busan

    Myoungseok Han1 ,2, Chul Kwon Kim1 ,2, Byung Moo Choi1 1Dong-A University Hospital, Busan, Republic of Korea, 2Centre for Sexually Assaulted Women, Busan, Republic of Korea - hmsobgy@dau.ac.kr

    Objective: To investigate real state of pregnancy termination among raped adolescent girls from 2010 to 2013 in a Korean metropolitan city. Method: We reviewed the annual reports published by the institution, that had been built to provide medical and social support for the raped women. From 2010 to 2013, adolescent girls registered or consulted at the institution were recruited for analysis. Results: The institution was responsible for the metropolitan city, Busan, whose population is 3,590,101. 1762 adolescent victims had visited or inquired to the institution during the period, complaining of being raped. Among them, 26 pregnancies had been terminated after obstetric evaluation. 9 cases (34.6%) were first trimester and 17 cases (65.4%) were second trimester. Of the second trimester cases, 6 were over 20 weeks of gestation. All of them had been reimbursed the medical cost of termination by the government. Conclusion: The cases of second trimester termination were much more than that of first trimester. It could be concluded that the possibility of pregnancy among raped girls might be ignored by their parents.

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    Statistical analysis of abortions in Georgia between 2000 and 2013

    Alexander Chavchidze, Gulnara Shelia Tsereteli State University, Kutaisi, Georgia - dodoshelia@yahoo.com

    Objective : To show the number and the structure of women who had decided to interrupt the unwanted pregnancy in Georgia during the period 2000 to 2013. Method : Results are based on statistical analysis of National Centre for Diseases Control and Public Health (NCDC) . Results : Despite decreases in the rate of abortions at the present time, Georgia continues to have one of the highest recorded rates of induced abortion in the region ( 3.7 abortions per woman In 2000 , 3.1- in 2005 and 1.6 - in 2012). Most abortions (86 – 87.1 %) were performed in the legally sanctioned gestation range of up to 10 weeks. The average age of women was 30 years (range 14 – 45 years). Induced abortion was most commonly performed in women ranging from 25 – 34 years old 52.3 % (2000) and 56.4 % (2012). Closely followed by women ranging from age 35 – 39 (25.3 % and 26.5 % accordingly - in 2000 and 2012). Women under 20 were represented with 4.1 % (2000) and 4.2% (2012). 62.7% (2000) and 41.4 % (2012) of the women had undergone their first abortion, for 26.7 % (2000) and 33.5% (2012) it was the second. The abortions were performed : in hospital (55.8%) , in a clinic (42.2 %) and outside of a health care institution (1.9 %). Conclusions: The falling number of abortions in Georgia (in spite of the still large number) reflects the more adequate family planning and usage of contemporary contraceptive methods. In Georgia family planning has not achieved its goal yet and induced abortion is still the most common method of fertility regulation. This underlines the need for fully implementing the organizational measures aimed at improving these indices.

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    Sublingual versus vaginal misoprostol for cervical dilatation, 1 or 3 hours prior to surgical abortion, a placebo-controlled, double-blind study

    Ingrid Sääv1 ,2, Helena Kopp Kallner1, Majken Ullmark2, Madelaine Dahlin2, Eva Broberg1, Kristina Gemzell-Danielsson1 ,2 1Dept of Women & Child Health, Karolinska Institutet, Stockholm, Sweden, 2Div of Obstetrics & Gynaecology, Karolinska University Hospital, Stockholm, Sweden - ingrid.saav@karolinska.se

    Background: Woman undergoing surgical abortion are treated routinely with misoprostol, administered 3 hours before surgical termination of pregnancy. Many women complain of side-effects, and some have bleeding and expulsion before the abortion. Shorter priming time would make it possible to treat women in clinic. Misoprostol reduces the risk of surgical damage, heavy bleeding and incomplete abortion. Vaginal administration has been shown to induce less side-effects. Objective: We wanted to study if a reduction of priming time from 3 to 1 hour could give equal priming effect. We also compared vaginal to sublingual administration. Material and methods: 186 nulliparous women undergoing surgical abortion during the first trimester were recruited. They were randomized to 4 groups, in which they received misoprostol vaginal or sublingual, 1 or 3 hours prior to the abortion. The study was performed in a double-blind fashion. The resistance of the cervical os was measured objectively using a tonometer during the dilatation. The amount of bleeding was noted, and the patients were asked if they had experienced any side-effects, and which administration route they preferred. Results: There was no difference in priming effect between 1 and 3 hours when given sublingually (p=0.62). However, when given vaginally, there was a significant difference with higher force needed in the group with 1 hour priming time (p=0.028). Fewer women started bleeding when the priming time was reduced to one hour. Most women preferred vaginal treatment, in most cases due to bad taste in the mouth for a long time when taken sublingually. Conclusion: It is safe to reduce the priming time to one hour with misoprostol prior to surgical termination of pregnancy. When the priming time is reduced to one hour, sublingual treatment should be used. Shorter priming time induces less side-effects, and fewer women experience bleeding and expulsion prior to the abortion.

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    The feasibility of offering medical abortions by telemedicine: two years’ experience

    Ellen Wiebe1 ,2, Cheryl Couldwell2 1University of BC, Vancouver, Canada, 2Willow Women's Clinic, Vancouver, Canada - ellenwiebe@gmail.com

    Objective: To describe the results of our programme of providing medical abortions by telemedicine. Methods: We did a retrospective chart review May 2012 - May 2014. Women saw a physician and counsellor by Skype videoconferencing for screening, information and consent. They went to a local laboratory for hCG tests for initial screening, the day of the medication and one week later. The medications were couriered or a prescription was faxed to a local pharmacy. At the follow-up visit by Skype we discussed her experience and her blood test results. If the hCGs had fallen by 80% in one week, we told her the abortion is completed and she needed no further follow-up. If she needed more medication, surgery or further blood tests, we arranged these. See www.willowclinic.ca. Results: In 24 months we saw 23 women for medical abortions by telemedicine and 65 were seen in clinic for the first visit and booked for telemedicine follow-up. Of the 88 women, three women were lost to follow-up (3.4%), four had surgery (4.5%) and 14 (15.9%) needed another follow up (more misoprostol or just another hCG). During that time, we saw 3757 women for the usual in-clinic medical abortions. Conclusions: This method of providing telemedicine abortions is feasible in our setting and may improve access to abortions. The main innovation in this programme is that the patients were in their own homes using their own technology (a computer or smart phone) and yet we provided the same physician and counseling services as we did in our clinic. Most women prefer to come to the clinic.

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    Training: ultrasound for midwives involved in abortion care

    Monica Johansson, Eneli Salomonsson Karolinska Universitetssjukhuset Sesam gyn dagvård, Stockholm, Solna, Sweden - monica.el.johansson@karolinska.se

    Background: The aim of the course was to teach both theoretical and practical aspects of ultrasound diagnostics to those who are active in the field of abortion care. Material and Methods: The target audience was midwives and OBGYN residents active in the field of abortion care who had completed a 3-day theoretical course on induced abortion. The curriculum included two half days of lectures and two afternoon sessions with practical training involving simulators or patients at the abortion care unit at Karolinska University Hospital. The theoretical parts included lectures on ultrasound technique, ultrasound devices, ethics, the legal situation, communicating with patients, ultrasound findings in normal and pathological early pregnancies (until week 9+0) and an update on medical abortion care. After having completed the course and a written exam, participants continued practical training under supervision of a local mentor. A minimum of 50 supervised and 50 independent examinations should be documented and approved by the course leaders. 18 midwives and 1 doctor took part in the ultrasound course in 2013. Of the midwives 14 are now certified and work independently. Results: Introduction of midwifery- led abortion clinics has resulted in: shortened waiting times, time saved for patients and staff, better continuity and reduced costs for the clinic. Significance: Training midwives in medical abortion care will help to shorten waiting times, reduce costs and help to better allocate healthcare resources.

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    Unwanted pregnancy and contraceptive practice in Latvia

    Arta Spridzane1, Areta Tula1, Lasma Lidaka2, Ilze Viberga2 1Riga Stradins University, Riga, Latvia, 2University of Latvia, Riga, Latvia - tula.areta@gmail.com

    Objectives. To understand determinants of unwanted pregnancy and investigate factors influencing the decision to terminate pregnancy in Latvia. Materials and methods. Cross-sectional descriptive study based on semi-structured anonymous questionnaires consisting of 47 questions on determinant factors of unwanted pregnancy - given to patients undergoing elective abortion in 40 medical institutions all over Latvia (October 2012 - April 2013). Data analysis: MS Excel 2007, CIA, SPSS 19. Approved by the Central Medical Ethics committee of Latvia. Results. A total of 731 eligible questionnaires were analyzed. The average age of women undergoing elective abortion was 29.2 years. For 47.5% of women this procedure was the first abortion in their life and in 14.6% of cases this was the termination of their first pregnancy. 15% of women were on maternity leave. 84% of respondents had a steady sexual relationship with one partner. 77% of partners supported the decision to terminate the pregnancy. 21% of women had not used any contraceptive method during the intercourse that resulted in the unwanted pregnancy: 28.3% had used withdrawal, 7% - spermicide, and 7% - calendar method. Condoms had been used in 31.6% and COC in 6.4% of cases. 74.3% of women were informed about the emergency contraception pill and 62.4% of study participants knew that it can be acquired over-the-counter, however, only 2% of respondents who were aware of emergency contraception, had used it. 28.2% of women considered emergency contraception harmful to their health. 55% of women stated that they had not made a decision regarding future contraception method following the procedure. Conclusions. Women undergoing elective abortion in Latvia do not use highly effective contraceptives and avoid the use of emergency contraception. Moreover, they have not decided what method of contraception they will use after the procedure thus being at increased risk for repeated unwanted pregnancy and another abortion.

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    Unwanted pregnancy: who are the ambivalent women?

    Lauriane Pichonnaz, Fabienne Coquillat, Saira-Christine Renteria Centre for Sexual Health and Planned Parenthood, Unit for Psychosocial Gynaecology and Obstetrics, ObGyn Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland - lauriane.pichonnaz@chuv.ch

    Introduction: Certain studies show that the women who are the most at risk for postabortion problems are those who were ambivalent at the beginning of the pregnancy (Adler, N.E., and al., 1990). Other studies show that influences/pressures from other people (Romans-Clarkson, S.E., 1989), a lack of a support from the partner, a psychiatric history or belonging to a cultural group that is anti-abortion (RCOG, 2000) also increase the risk of postabortion distress. These studies clearly demonstrate the importance of studying ambivalence towards pregnancy. Aim: The purpose of the study is to have a better understanding of women ambivalent towards their pregnancy. The study will do so by exploring the reasons for becoming pregnant, the possible existence of conflict between couples, external pressure and violence, as well as the link to their final decision to go on with the pregnancy or not. Material and methods: From May 2012 to May 2013, the six sexual health counsellors of the Centre for Sexual Health of the CHUV gathered data about every ambivalent woman consulting for counselling. The data of a total of 88 subjects was collected. Statistical analyses were made, completed by qualitative data. Results: 64.8% of the women had been using a contraceptive method. We can thus suppose that they intended not to get pregnant. Nevertheless more than a quarter of them used a contraceptive method in an inconsistent way. Conflicts between couples were high (47.7%). Concerning external pressure, half of the women were under pressure (53.4%), predominantly from the spouse (44.3%). Actual violence was present in 10.2% of the situations and mostly exercised by the male partner (6.8%). Conclusions: Half of the women decided to give birth and half to have an abortion. This demonstrates the importance of the health professionals' support during the decision-making process.

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    Use of contraception and attitudes towards contraceptive use in Swedish women: a nationwide survey

    Helena Kopp Kallner1, Louise Thunell4, Jan Brynhildsen3, Mia Lindeberg2, Kristina Gemzell-Danielsson1 1Karolinska Institutet, Stockholm, Sweden, 2MSD, Stockholm, Sweden, 3Linköping University, Linköping, Sweden, 4Lund University, Lund, Sweden - helena.kopp-kallner@ki.se

    Objective: To describe contraceptive use and attitudes towards contraceptive use in Sweden. Secondary objectives were to investigate knowledge of contraceptive methods and how women handle unplanned and unwanted pregnancies. Method: We performed a national telephone survey of women aged 16-49 years. The survey contained 22 questions with answers being of both spontaneous and multi-choice character on demographics, contraceptive use, knowledge of and attitudes towards contraception, the importance of monthly bleeding and experience of unintended pregnancy. Main outcome measures were distribution of use of contraceptive methods and non-use of contraception among Swedish women and prevalence and outcome of unintended pregnancies. Results: A total of 1001 women participated in the survey. Of all women, 721/1001 (72.1%) women currently used contraception, 268/1001 (26.8%) women did not use contraception and 12/1001 (1.2%) had stopped using contraception sometime in the last 12 months. A total of 781 (78%) women had never experienced an unintended pregnancy whereas 220 (22%) women had had at least one unintended pregnancy. Users and non-users alike stated that one of the most important characteristics of a contraceptive method is its effectiveness. Conclusions: A large proportion of Swedish women do not use contraception. Furthermore, a large proportion of women have experienced at least one unintended pregnancy. Increasing awareness of contraceptive effectiveness and promoting use of all contraceptive methods and especially long-acting reversible contraception is a possible way forward in the effort to reduce the rates of unintended pregnancy, unwanted pregnancy and termination of pregnancy.

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    What are the contraceptive issues for women conceiving too soon after a live birth, miscarriage or abortion?

    Nicola Mullin, Suzanne Kirkwood, Andrea Brockmeyer Countess of Chester Hospital NHS Foundation Trust, Chester, Cheshire, UK - nicola.mullin@btinternet.com

    Background: Timely access to contraceptive advice and supplies is important for couples following a live birth (LB), miscarriage (M) or abortion (A) to prevent another pregancy too soon. There is national guidance on postnatal care. Method: Women who had an unplanned and unwanted pregnancy within 12 months of their last pregnancy received standard abortion care but were asked 5 questions about the quality/timing of contraceptive advice given previously and any problems accessing or using their chosen method of contraception. Results: Of 40 women identified, 28 previously had a live birth, 6 a miscarriage, 6 had an abortion. Overall, all women who had had an abortion and all but one women who gave birth remembered receiving contraception advice, but only 50% (3/6) women who had had a miscarriage received advice. LB group: 16 women conceived within 6 months and 12 conceived 6-12 months later. Thematic analysis revealed only 50% recalled advice being helpful. Issues: health professionals assuming parous women knew about contraception or were going back to a previously used method or the advice given was too early to be useful. Several women had difficulty obtaining pills or getting an appointment to have an implant or IUD/IUS fitted. Miscarriage group: 3 women conceived within 3 months and one commented ‘that she didn't know it was possible to conceive so quickly'. Two women found the miscarriage particularly traumatic and stated that both they and the staff found it difficult to talk about contraception. Women having a repeat abortion conceived later than the other groups (after 8-12 months). They reported difficulties using contraception and several stopped the long-acting reversible (LARC) method provided at the earlier abortion. Conclusion: The quality of postnatal contraception provision needs to be improved for women who give birth or have a miscarriage. There is a high uptake of LARC in our abortion service but women need more support managing side effects to improve continuation rates.

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    What is the best way to provide women with postnatal contraception?

    Nicola Mullin, Rebekah Hughes Countess of Chester Hospital NHS Foundation Trust, Chester, Cheshire, UK - nicola.mullin@btinternet.com

    Background: Many women attending our National Health Service abortion service reported difficulties with using contraception, particularly the women who had had an unplanned pregnancy within 12 months of giving birth. Aims: To discover if women know how soon they should resume contraception postnatally. To understand when and how women prefer to receive information about contraception and contraceptive supplies. Method: A prospective questionnaire was offered to pregnant women accessing an English hospital-based antenatal clinic. The questionnaire was also completed by postnatal women and included a contraceptive ‘pack' of information and condoms. Results: There were 106 completed questionnaires in the antenatal (AN) group (1 refusal). In the postnatal (PN) group 50 women completed questionnaires (no refusals). Most women were aged 21-30 and over 50% in both groups had other children. Very few women could recall having received any kind of information about postnatal contraception: 16% (17/106) AN and 18% (9/50) PN. The majority of women thought contraception should be started as soon as sex was resumed after delivery; however, the knowledge of the effects of breast feeding and when there was a risk of conception if not breast feeding was low. Many women had already decided on their preferred contraception, 38% (40/106) AN and 52% (26/50) PN, including 3 women who wished to be sterilised (2 were currently pregnant). Most women chose contraceptive pills or condoms, few were interested in long-acting reversible contraception. The AN group preferred to receive contraception from their midwives at the one week postnatal home visit or at the routine postnatal check up at 6-8 weeks. In contrast, most postnatal women wanted to leave hospital with their contraception supplies. Conclusions: This work has informed the maternity department of our patients’ wishes regarding receiving information about contraception and how and when they would like to be given supplies of contraception.

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    Whether contraception is effective enough

    Galina Dikke1, Liubov Erofeeva2 1Russian Peoples Friendship University,, Moscow, Russia, 2All-Russian Association for Population and Development, Moscow, Russia - erofeevfamily@mail.ru

    Relevance. Despite the wide choice of contraception in Russia the number of unwanted pregnancies is 41%, most of them are terminated artificially totalling about 1 million per year. Objectives: To study the frequency of the contraception methods used, their effectiveness in the population of the Russian women. Material and methods. In-depth and structured interviews conducted with 1027 women aged 18-45 years in 7 Federal Russian districts in 34 localities. Anonymous survey of 161 patients who applied for abortion on request. Results. Contraception was used by 85%, 15% did not use it. Modern methods (LNG IUSs) used - 46%, condoms - 45%, natural/traditional - 32%. Two methods simultaneously used by 38%. Condoms the most popular - 45%, COC - 30%, coitus interruptus - 23%. LARC: copper IUDs - 11%, releasing systems used by 4.5%. 3 months before this pregnancy 52% used contraception: natural methods - 9%, traditional amounted to 14%, modern - 87% (IUD - 16%, COC - 60%, condoms - 25%). In the structure of hormonal methods, proved ineffective were: COC - 37%, transdermal patch - 27%, vaginal ring - 16%, injection - 6%. 56% of women were looking for, but could not get a doctor's consultation for family planning. Discussion. Half of women who became unwillingly pregnant were using modern contraceptive methods. Nearly 60% of the "failure" is among COCs users, which is 2.5 times higher than among condom users, which does not coincide with the theoretical data on these methods effectiveness (the Pearl Index for condoms is higher than for COCs). Conclusion. The reason for the lack of effectiveness of hormonal methods is its inappropriate use by the consumers because of the limited accessibility to medical care and advice on this matter. Another possible reason is the prevalence of traditional methods and the lack of LARCs among promoted ones.