Authors by program from Nantes 2018
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This presentation interrogates the idea of ‘need’ in abortion law and explores how we assess claims of necessity under international human rights law. Using examples from the Global Abortion Policies Database, the presentation highlights the arbitrariness, overbreadth and dysfunction that characterize much abortion law worldwide, including many liberal regimes. These laws do not achieve the ends they purport to serve, and often undermine ends of public health, safety, and morality. The presentation focuses on the harms of unnecessary abortion law including: public health impacts of dysfunctional laws, access inequalities of overbroad laws and abuses of arbitrary laws. Particular attention is given to the harms by which abortion law becomes normative or even prescriptive of our lives. How law comes to shape the very ways we understand, experience and practice abortion. For example, how law and its institutional controls were traditionally used to define abortion safety, and the impact today on how we regulate self-managed abortion. We have given law much imaginative power over our field. For too long, we built norms of abortion practice in the image of the law, rather than having law serve aims of health and human rights. Today still, we carry over many falsehoods of abortion law into research, practice and policy, such as when health regulations carry on the gatekeeping and punitive work of criminal law. The presentation thus concludes with the idea of ‘freedom from law,’ an open and imaginative outlook that steers us away from the classic terms, binaries, and frames of abortion law that have patterned our field (e.g. risk and harm, time boundaries, set indications, protections and limits). The presentation extends an invitation to think ourselves away from the routines of abortion law and to ask: What do we need or want from law?
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Today, a dream has come true: for the first time in human history we have the ability to effectively separate fertility from sexuality due to an unprecedented number of highly effective contraceptive methods and the availability of safe abortion. This has allowed us to effectively limit natural fertility to the individually desired number of children.
It began with the introduction of the birth control pill in 1960, which was hailed at the time as one of the biggest revolutions in human history. The development of effective and safe IUDs quickly followed. The ability to have sex without getting pregnant was very much welcomed by women and their partners and hormonal contraception became the standard within a few years. As a consequence, abortion rates began to decline.
While abortion continued to decline in some countries with good contraceptive access, rates have remained stable or even increased in other countries with reliable abortion statistics, such as the UK, France and Sweden. This is even more surprising as significant further improvements in hormonal contraception have been made since the introduction of the pill, namely with long acting reversible contraceptives (LARC).
This contraceptive paradox and the underlying reasons need to be analyzed if we want to use currently available contraceptive methods up to their full potential and effectively reduce unwanted pregnancies.
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The final session in Plenary 4 looks at how we can build a resilient cadre of abortion providers that is proud to offer women the means to control their fertility and will respond to some of the problems raised throughout the conference.
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Today many women are reluctant to use any of the existing contraceptive methods due to side effects or fear of experiencing such effects. Unsafe abortion is a major contributor to maternal mortality. Therefore effective methods for contraception and safe and acceptable methods for termination of unwanted pregnancies are prerequisites for reproductive health, for gender equality and for the empowerment of women. New methods for contraception are also needed including improved methods for emergency contraception and new mechanisms of action as well as mode of delivery. Additional health benefits of contraceptive methods such as protection against various cancers, and a wide range of other benefits need to be better recognized. Based on their mechanisms of action Progesterone receptor modulators (PRMs) can be used for emergency contraception as well as regular contraception by various modes of delivery. Progesterone receptor modulators have been shown to be effective when used on demand post coital, as daily pills, once-weekly or once-a-month and is a well establish method for medical first and second trimester abortion. The use of progesterone receptor modulators for contraception and positive health benefits such as the possible protection against breast cancer as well as prevention of uterine leiomyomas and endometriosis deserves to be further explored. Progesterone receptor modulators have also been studied for “late emergency contraception” and for menstrual induction. Very early medical abortion (VEMA) before an intrauterine pregnancy can be visualized by ultrasound has been shown to be acceptable, safe and effective. Medical abortion is also highly effective later in the first trimester and can be self administered by women. Thus PRMs such as mifepristone if offered in a suitable dosage provides a model for a woman centred contraceptive continuum with added health benefits and increased autonomy for women.
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Women are seeking abortion at increasingly earlier gestations, with 41% of first trimester patients in the U.S. receiving an abortion at <6 weeks gestation. The efficacy of medical abortion at <6 weeks gestation is not significantly different than at 6-7 weeks, however, seeking abortion very early in gestation increases the likelihood that providers will have difficulty visualizing the pregnancy on ultrasound, the current standard of care in many clinics.
The most serious risk of treating women with an undesired pregnancy with mifepristone and misoprostol without first confirming a diagnosis of intrauterine pregnancy is a missed diagnosis of ectopic pregnancy. Studies suggest an incidence of ectopic pregnancy of 0.2-0.3% among women presenting for medical abortion. Data support the practice of providing mifepristone and misoprostol medical abortion in the setting of undesired pregnancy of unknown location (PUL) using serial serum hcg testing to simultaneously exclude ectopic pregnancy and determine the efficacy of the medical abortion. Guidelines that enable provision of medical abortion in the setting of PUL, when the patient is asymptomatic, low-risk for ectopic and when combined with close follow up to exclude ectopic pregnancy exist to support this service development.
This presentation will review the evidence for providing medical abortion at <6 weeks gestation including in the setting of PUL.
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All restrictions to access abortion services, legal logistic financial, creates social inequality. Women with access to financial means and information will always be able to access safe abortion services and women without the financial resources are most affected by these obstacles. abortion laws. Women on Waves and Women on Web use new technology (drones, robots, internet, apps) and research, to break the taboo around abortions and change policies and laws and in the same time make sure women have access to contraceptives and safe medical abortions. This presentation will highlight some of the work, achievements and challenges in the past years.
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When planning post-abortal contraception it is important to note that women seeking trimester termination of pregnancy (TOP) have demonstrated their high fertility and are at risk of subsequent induced abortion. The importance of the efficacy of the post-abortal contraceptive method has been increasingly recognized during the last decade. A safe and highly effective method with minimal dependency on the user compliance, i.e. long-acting reversible method of contraception (LARC) is clearly of value. When compared to use of LARCs and especially intrauterine contraception (IUD), use of oral contraceptives or postponing initiation of contraception is associated with a significantly increased risk of subsequent TOP.
Placement of an IUD immediately at the time of first trimester surgical abortion is the standard of care and it is also recommended in international guidelines. In comparison to delayed insertion, the expulsion rate is somewhat higher (5 vs. 3 %). following immediate insertion. However, the number of IUD users during the follow-up is increased when compared to delayed insertion (92 vs. 77 %).
Increasing use of the medical TOP and home administration of misoprostol pose challenges to provision of post-abortal contraception. However, progestin implants can be safely inserted on the day of mifepristone administration. A recent RCT comparing fast-track insertion (≤3 days vs. 2-4 weeks after misoprostol administration) of the levonorgestrel-releasing intrauterine system (LNG-IUS) after first trimester TOP has shown that also rapid initiation of intrauterine contraception is feasible. Fast-track insertion is associated an increased risk of partial expulsion (12.5 vs. 2.3%).However, fast tract insertion was safe with similar rate of adverse events, and identical bleeding profile as that associated with later insertion. At one year of follow-up the user rate was higher and number of new pregnancies lower if the LNG-IUS had been inserted immediately.
Thus, an effective, quickly-started long acting contraception should be the goal of treatment regardless of the method of TOP as long as a new pregnancy is not planned. To reach this contraceptive initiation should be an integral part of comprehensive patient friendly abortion care with low threshold and easy access. This will also reduce the need of additional visits, subsequent TOP, and allows initiation of an effective contraception, with all its added health benefits.
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WHO strives for a world where all women’s and men’s rights to enjoy sexual and reproductive health are promoted and protected, and all women and men, including adolescents and those who are underserved or marginalized, have access to sexual and reproductive health information and services. Access expressed through laws, policies, and guidelines is a key component of the enabling environment for safe abortion. However, abortion laws and policies can be punitive or protective; specific or non-specific; confusing and even contradictory at times, all of which may exacerbate a chilling effect on those who seek, provide or advocate for access to services.
Launched in June 2017, the Global Abortion Policies Database (GAPD) contains abortion laws, policies, standards and guidelines for UN and WHO Member States designed to strengthen global efforts to eliminate unsafe abortion by facilitating comparative analyses of countries’ abortion laws and policies. The abortion laws, policies, and guidelines within the GAPD are juxtaposed to information and recommendations from WHO safe abortion guidance, national sexual and reproductive health indicators, and UN human rights bodies’ guidance to countries on abortion.
This presentation provides a brief overview of the GAPD, an analysis of selected countries, and demonstrates the vagueness and complexities that exist in laws and policies.
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There is wide variability in contraceptive choices and preferences among different populations. None of the commonly available contraceptive methods is perfect, and each method has its own merits and limitations. Important factors that commonly determine women’s contraceptive choice include effectiveness, safety and side effects, affordability and accessibility, user friendliness as well as non-contraceptive benefits. The relative importance of these attributes varies between different users and is influenced by one’s own fertility planning as well as her physical, social and cultural circumstances. While effectiveness is emphasised by most providers, the acceptance and satisfaction is greatly determined by the perceived or actual safety and side effect profile. Menstrual bleeding changes may positively or negatively affect method satisfaction and continuation.
Concerns about weight gain, effects on sex life and other side effects are also important reasons for method discontinuation, and these may be exaggerated by myths and misconceptions. Affordability and accessibility do vary with specific populations. Improved user-friendliness can be conferred by promoting the use of long-acting reversible contraceptives which are generally easy to use, more “forgettable” and less user-dependent. Non-contraceptive benefits such as improvement of menstruation-related symptoms and acne by hormonal methods and prevention of sexually transmitted infections by condoms are additional merits to some users. Healthcare providers generally have great influence on the contraceptive choice of most women. The tiered-effectiveness approach combined with shared decision making can be a useful way of contraceptive counselling. Within the effectiveness framework, the most effective methods are discussed first, while addressing the user’s own concerns, preferences and reproductive goals. This aims at achieving the optimal balance between effectiveness and other attributes based on the user’s personal circumstances.
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Medical and surgical methods of abortion are highly effective, safe, and acceptable to women. Women value being offered a choice of methods and receiving a preferred method is a strong predictor of satisfaction with care. For women who do not have a strong preference for a particular method, clinical trial evidence suggests that randomisation to a surgical abortion results in higher satisfaction rates than randomisation to a medical abortion.
While providers may wish to optimise women’s abortion experience by offering a choice of methods, this can be challenging with the increasing shift toward medical methods and the very early gestational ages at which women now present for abortion care. Surgical abortion under general anaesthesia may be cost-prohibitive and the predominance of medical abortion in some settings can reduce opportunities for obtaining surgical skills. Providers may be uncertain of whether or how to offer surgical abortion in the earliest weeks of pregnancy.
This talk will address the evidence supporting the offer of a choice of abortion methods and will discuss less resource intensive models of outpatient surgical abortion care as well as a protocol for providing surgical abortion before a gestational sac is visible on ultrasound.
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Abortion remains a contentious and stigmatised medical procedure, despite being a commonly performed gynaecological procedure.
It is often framed as a moral, religious or legal issue rather than a medical one and is reinforced at structural, policy, community, and individual levels. Abortion stigma is a multifaceted phenomenon, impacting on the experiences of women who undergo abortion and the health care professionals involved in abortion care. Public discourses focussed on particular types of abortion that are viewed as problematic – ‘repeat, ‘late’ – are further stigmatising and potentially discriminating. Even the language itself is inherently judgemental. This presentation will review contemporary evidence of the experience of abortion stigma among women and providers, the implications of this for health and wellbeing and inequalities, and how abortion stigma can be countered and challenged.