Authors by program from Seville 2010
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After abortion: women’s emotions
Edna Astbury-Ward, United Kingdom
Methods: A qualitative interpretive study. Face to face in depth interviews were conducted with 17 women aged between 22-57 years, whose abortions took place between 4 weeks and 34 years previously.
Results: Whilst the study set out to explore women's perceptions of abortion care, it was apparent that care was not experienced in a vacuum and that women’s emotions were inextricably linked with the abortion experience. Women described a range of varied feelings after abortion. They included positive emotions such as the realisation the abortion was over and that it was the end of keeping secrets, women expressed how they were looking forward to life again and that they felt empowered, more in tune with themselves and looking forward to the future. They also experienced a range of negative emotions such as remembering with regret, feeling a sense of emptiness and loss, feeling isolated and concerned about the future. Some felt angry and ashamed at what they described as ‘as a loss of life’ some felt they had disappointed themselves and others. The overwhelming emotion was described as relief and this did not change over time although women re-evaluated their abortion experiences differently as a result of the passage of time and intervening life's experiences, some re-evaluated their abortion negatively and others re-evaluated their abortion positively.
Conclusion: Women's emotions varied in their response to abortion. The initial feeling of relief was re-evaluated over time; most felt it was the right thing to do at that moment and moved on with their lives. Time may have eroded the details, but not the fact of abortion.
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Improving the Provision of Contraception of the Day of Medical Abortion
Helen Nixon and Audrey Brown, NHS Greater Glasgow and Clyde, UK
Introduction:
Annually over 13000 women undergo therapeutic abortion in Scotland. Over 25% of these abortions are carried out in women who have previously undergone abortion. One strategy to reduce the number of abortions is to ensure the provision of reliable contraception on the day of abortion.
Objectives:
To describe national campaigns to increase uptake of long-acting reversible contraception, and to improve contraceptive provision at the time of medical abortion,
to describe a local training programme to achieve the national standards
to compare the provision of reliable contraception at the time of medical abortion before and after the introduction of the above
Methods: Case notes of women requesting medical abortion and accessing our abortion assessment clinic were reviewed for a 3 month period in 2007 (n=180) and 2010 (n= 157). Method of contraception chosen at the time of abortion assessment was recorded, as was method of contraception provided on the day of abortion.
Results:
% requesting method in 2007
% supplied with method in 2007
% requesting method in 2010
% supplied with method in 2010
COCP
33
39
31
38
POP
13
16
7
6
Implant
19
1
32
26
IUD/IUS
11
0
10
0
DMPA
14
18
11
11
Barrier
1
4
3
3
Nil/undecided
9
22
6
16
TOTAL
100
100
100
100
Discussion: Women who choose the oral or injectable contraception are usually provided with the method on the day of medical abortion in both 2007 and 2010. Although 19% of women chose a contraceptive implant in 2007, only 1% of women were fitted with an implant on the day of medical abortion. Several national campaigns, and local projects to enable medical abortion unit staff to fit contraceptive implants, took place during 2008 and 2009. Between 2007 and 2010, there was an increase in number of women choosing a contraceptive implant, from 19% to 32%. In addition, a contraceptive implant was fitted on the day of medical abortion in 26% of women, compared to 1% three years previously. Intra-uterine contraceptive methods are not fitted on the day of medical abortion in our unit. Despite around 1 in 10 women choosing this method, they cannot be provided with their chosen method at the time of abortion. Most women fail to return for interval IUD/IUS insertion, potentially leaving them at risk of further pregnancy. Consideration should now be given to improving timely provision of intra-uterine methods.
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Research on anxiety and depressed symptomatology in women that decided a termination (IVE)
Clinica Dator, Spain
Objectives: 1. To study depressive symptoms, anxiety and get and subjective evaluation of the stress that women who have decided a termination withstand.
2. To investigate, taking in account a pre and post IVE evaluation, if the termination itself might cause a trauma or a depressive psychological disorder dealing with anxiety.
3. To find out the differences that could exist in the sample, according to the previous goals, relative to age, nationalities, studies degree and other variables.
Methodology: The random sample is formed by 620 women that came to Clinica Dator (any day of the week) from December 2009 to April 2009. We got the evaluation by a questionnaire that was divided into several sections: personal data, information concerning the partner, their own stress valuation about the unwanted pregnancy and the termination (ranking from 0 to 5) and the consideration of the anxiety and depression Goldberg scale.( ). 163 Women came back for the check-up (26% of the whole sample).
Results: Age range: from 12 to 48 years. A 15% had psychiatric treatment precedents and main causes were depression (31%) and anxiety (28%).
The stress result of the unwanted pregnancy got a average grading of 3, 24 (DT: 1,45) and the stress due to the termination 2,81 (DT: 1,55), medium-high level in both cases.
Anxiety average is 5, 02: 57,6 % of the sample are over the cut-off point in probability of anxiety. Depression average: 3, 78 (DT = 2, 49), 65% of this women are over the cut-off point witch represents a likely depressive disorder.
To study the pre-post changes, women who came back for the check-up are compared to the ones of rest of the sample: there is not noteworthy differences in anxiety and depression level pre-post IVE regarding age, nationality, kind of job, study degree. There is an statistical significant difference in pre and post IVE anxiety. The anxiety average pre IVE is 5, 16 and decreases to 3, 15 after the termination. (Repeated measurements, F = 57, 37; p = 0.000; Eta2= 0.29). Depression average falls from 3, 82 before the IVE to 2, 18 after it (Repeated measurements, F = 54, 97; p = 0.000; Eta2 = 0, 27).
Both, depression and anxiety get better in 52, 5% of the sample, get worse in a 10, 7% and remain the same in a 2% of the cases. In the rest, 34, 8% of the sample, progress differently in relation to anxiety and depression. No epidemiologic variables were found to predict worsening. The analysis was carried out by logistics regression of the symptoms of both, depression (9 symptoms) and anxiety (9 symptoms), and the variables that turned out to be predictive were: feeling not much energetic, being unable to concentrate and feeling worse mood in the morning (Model: Chi 2 = 34, 07; p = 0.000; R2 Nagelnerke: 0,52). Those who had previous psychiatric treatment didn’t show any different symptoms with regard to the rest of the sample.
Conclusions: Stress produced by an unwanted pregnancy is medium-high short. More than 50% of women suffer, before the termination, an anxiety and depression level over the cut-off point in the mixed anxiety and depressed mood probability.
In most of the cases this level decreases after the termination, except a roughly 10% that feels worse, in this sense, after the IVE.
According to our information it is not truth that termination generates a trauma, or a psychiatric pathology. Most of women who do a termination feel better after it, except a low percentage with more significant anxiety and depression symptoms afterwards than before it.
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Final stage of early medical abortion at home : womens experiences and impact on a hospital abortion service
H.Dewart , S.T.Cameron, A.Glasier and A.Johnstone - Dean Terrace Centre, NHS Lothian, Royal Infirmary of Edinburgh, Department of Reproductive and Developmental Sciences, University of
Edinburgh, United Kingdom
Background and methodology: Research has shown that many women would prefer to be at home rather than in hospital, to pass the final stage of an early medical abortion. A pilot was therefore conducted over six months at a hospital abortion service in Edinburgh, Scotland, that allowed women up to 8 wks gestation to be discharged home soon after misoprostol administration. An anonymous questionnaire of womens’ experiences was conducted one to two weeks later. An audit of the numbers of abortions performed by each method, during the pilot and the same period the previous year, was also conducted.
Results:A total of 250 women chose to go home after misoprostol. This corresponded to 34% of the total number of women having an early medical abortion. A 24% increase in the total numbers of women having a medical method (n=142) was observed compared to the same period the previous year. A total of 100 women completed questionnaires out of 145 distributed (69%). The commonest reasons given for choosing to go home were, to have treatment sooner (53%) and to be in the privacy of one’s own home (47%). Most women stated that bleeding (81%) and pain (55%) were as, or not as bad as expected. Most would recommend this method to a friend (84%).
Discussion and Conclusions: Discharge home for the final stage of a medical abortion was highly acceptable to women. Since availability is not limited by hospital bed space, more women can be treated by medical methods
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Efficacy and Acceptability of Home-Based Medical Abortion: A Systematic Review
Thoai D. Ngo, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Research and Metrics Team, Health System Department, Marie Stopes International,
London, UK
Background: Home-use of misoprostol can reduce the number of clinic visits required and improve access to medical abortion. We conducted a systematic review to assess the efficacy, safety, and acceptability of medical abortion administered at home versus at clinic.
Methods: The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Popline were searched for randomized and non-randomized prospective studies of medical abortion at home versus clinic. The main outcomes of interest were failure to achieve complete abortion, side effects, and acceptability. We calculated relative risks (95% CIs), and pooled estimates using a random-effects model.
Findings: Nine studies met the inclusion criteria (n=4,522 participants). All studies used a mifepristone-misoprostol combination for medical abortion. The proportion of women who had a complete abortion in home-based groups (n=3,478) ranged from 86% in India to 97% in Albania, with average success of 89.7%. Complete abortion in clinic-based groups (n=1,044) ranged from 80% in Turkey to 99% in France, with average success of 93.1%. Pooled analyses indicate that there is no difference in complete abortion between home-based (n=3,215) and clinic-based (n=593) intervention groups (OR=1.11; 95% CI: 0.65, 1.91). Serious complications of abortion were rare. Acceptability data indicate that women using self-administered medical abortion at home were more likely to be satisfied, to choose the method again, and to recommend medical abortion to a friend than women who opted for medical abortion at the clinic.
Interpretations: Evidence from prospective cohort studies suggests that the option of home-use of misoprostol for medical abortion is efficacious, safe, and acceptable to women living in both resource-limited and resource-rich settings. This option allows women greater flexibility and privacy in the abortion process, and could increase access to and acceptability of medical abortion.
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Teenage pregnancy in Sweden
Gabriella Falk, Sweden
Topic and problem: Teenage pregnancy rate in Sweden is low compared to other European countries. However abortion rates are high despite education in school about sexual and reproductive health (SRH) and access to youth clinics and subsidized contraceptives. To find reasons for this we conducted an interview-study with questions aimed at examine teenagers experiences with contraceptives and to explore the reasons behind their contraceptive choices. The participants attended an out-patient clinic.
Methods: Twelve teenagers who had applied for induced abortion were interviewed three to four weeks after abortion. The interviews comprised open questions about contraceptive experiences focusing on hindrance for contraceptive use. Six topic questions were used with further exploring questions posed when needed. Qualitative content analysis was resorted to.
Results: One theme was identified:Struggling with feelings of uncertainty and patterns of behaviour. Three categories emerged from the analysis. Uncertainty dealt with decisions and behaviours that varied with time and between the different individuals. Factors that influence contraceptive use dealt with the persons that the participants had discussed contraceptives with, how they acquired knowledge about contraceptive use and the nature of their behaviour. Anxiety dealt with the side effects of contraception
and feelings of fear related to contraceptive use.
Conclusion: The participants had feelings of uncertainty, anxiety and fear towards contraceptive use which led to non use and inconsistent use. They revealed insufficient knowledge about SRH at times. Guidance from health care providers and access to youth clinics varied and was sometimes unsatisfactory. Parents were supportive of contraceptive use but not active in the process of getting their child to initiate it. Friends and the Internet were the main sources for acquiring information that was not always correct
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Medical abortion between 9 and 12 weeks gestation: experiences from a nursing perspective
Linda Grung Ertzeid, RN, Ingrid Økland, RN, Line Bjørge, MD, Ragnhild Tveit Sekse, RN, Mette Løkeland, MD
Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
Background: Worldwide most late first trimester abortions are achieved surgically by vacuum aspiration. As the first hospital in Norway, medical abortion between 9 and 12 weeks of gestation was introduced at the Department of Obstetrics and Genecology, Haukeland University hospital, Bergen, Norway. in October 2005. Data from the implementation period has been analysed in detail, and shows that it is an effective and acceptable method for this gestational age (1). When the procedure was introduced women were given the choice between medical or surgical methods for termination of pregnancy. In June 2007 the medical abortion procedure became the method of choice for late first trimester abortions at the Department. The treatment and follow-up requires a close collaboration between different groups of health care providers. The nurses play a central role in treatment and follow-up of this patient group by administrating the medications, monitoring the patients clinically, confirming the terminations and
providing mental support as well as giving information about the procedure.
Method: A multi-competence team consisting of nurses and doctors with special interest was established. Its role was to develop treatment protocols and information materials and to enlighten and motivate the health care providergroups to use the new treatment alternative. At the first consultation at the outpatient clinic the doctor determined the gestational age and the choice of method were decided. The nurses informed the women about the treatment procedures, administrate mifepristone medication, governed misoprostol and pain killers, monitored bleeding, provided mental support and confirmed the termination by visual inspection. They were also responsible for contacting the women if further follow-up were needed. To build nursing competence structured training was made compulsory and given to all the nurses. They needed more knowledge about why conservative treatment should be preferred to surgical, and also be acquainted with the new procedures so they could be able to give a proper information and support to women.
Results: From October 2005 to April 2007 55% (254) of the women requesting abortion with gestational age 63 to 90 days chose medical termination. Initially many nurses found it hard to handle the new procedures, especially to verify the abortion by visual inspection to see that both fetus and placenta had been passed. To master this it was essential and important to give the nurses time for debriefing and for discussions, - like how to motivate each other and how to cope with different emotional reactions. Routines have also been made for new nurses. They were never left alone with this patient group until they felt secure with the procedures. This was important for a successful outcome of the implement of the new method.
Conclusion: Late first trimester medical abortion is an effective and acceptable method for termination of pregnancies. During the study period the numbers of procedures performed has increased and today more than 75% of all the abortions performed at this gestational age are performed medically. The key factors for the successful implementation were planning, delegation of treatment responsibility and motivation and follow-up of the nurses. Interdisciplinary cooperation on procedures and methods and increased knowledge has given the nurses professional confidence, competence and more responsibility for patient care provided for the women who choose abortion.
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Early medical abortion as the first choice method at the University Department of Obstetrics and Gynaelacogy in Ljubljana, Slovenia
Andreja Štolfa Gruntar and Bojana Pinter, Department of Obstetrics and Gynecology, University Medical
Centre Ljubljana, Slovenia
Medical abortion was introduced as a method of first trimester induced abortion 20 years ago, when as one of WHO collaborating centres in the area of reproductive health our Department of obstetrics and gynecology was offered the possibility to carry out the studies investigating the efficacy and safety of abortion inducing drugs, although the drugs had not been registered in Slovenia.
Until 7 years ago medical abortion was performed only in women enrolled in various WHO studies. However, when the direct import of the needed drugs (mifepristone and misoprostol) became possible, we started to perform early medical abortions on a regular basis in women who decided on this method for early abortion of an unwanted pregnancy. Knowing the method well we wanted it to become the predominant method of early abortion. But since there was no agreement among gynecologists that it should be the method of choice for an early abortion, women still choose the method they prefer. Dilatation and curettage under general anesthesia is still the most frequently used method, although some women decide on endometrial aspiration without anesthesia, too.
The reasons why women decide on a surgical abortion under general anesthesia are: not being aware of what is being done, fear of pain, gynecologist's advice. Many gynecologists still advise their patients the abortion done under general anesthesia, because it has been done successfully for years, and as they are still sceptical about medical methods due to the lack of knowledge and personal experience.
Our intention is to increase the percentage of medical abortions among the eligible women wanting to end an unwanted pregnancy. Due to the aforementioned reasons our aim has not been achieved yet. There are around 1500 early abortions to end an unwanted pregnancy at the Department per year (e.g. 1546 in 2006, 1334 in 2008). Of these there are 13,5% endometrial aspirations without anesthesia, 55,6% surgical abortions under general anesthesia, and only 30,9% medical abortions. Obtaining good results with medical abortion and spreading the knowledge among patients and gynecologists, and with efficient motivation for medical instead of surgical procedure, the rates of early medical abortion to end an unwanted pregnancy have been slightly increasing, but the rates could be further improved. So in March 2010 we organized a seminar to promote medical abortion as the first choice method and to exchange experience with other abortion-care practitioners in the rest of Slovenia.
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A pilot study on women’s experiences with misoprostol at home or in the hospital in medical abortion up to 63 days of pregnancy.
Monica Johansson, Eneli Salomonsson and Helena Ekberg, Dept of Woman and Child Health,
Division of Obstetrics and Gynecology, Karolinska Institutet / Karolinska University Hospital, Sweden
Background: Home-use of misoprostol in medical abortion up to 63 days of pregnancy was approved in Sweden in 2004. It is now an increasingly popular option for women undergoing first trimester induced abortion. The experiences with misoprostol at home or in the hospital were explored among abortion seeking women.
Methods: Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 800 g and advised to take them vaginally 36–48 hours later either at home or in the hospital. A follow-up visit was performed a few weeks after the misoprostol treatment.
The main outcome measures were:
1) acceptability assesses as satisfaction with the choosen method.
2) feasibility, assessed through successful completion of abortion at home without the need for hospital admission.
In addition contraceptive choice and uptake was investigated.
Results: A total of 53 women participated in this pilot study. Of these, 29 women aborted at home and 24 in the hospital. The majority of women were satisfied with their choice of method and place of treatment. Two women per group reported not being satisfied. No surgical interventions were reported but two women per group had unscheduled visits to the clinic before the Follow-up (FU).
Follow-up was performed after a mean of 24 or 20 days among women who administered misoprostol at home or in the clinic, respectively. At that time all women except two per group reported that they considered it highly important to avoid another pregnancy at the moment. Six or 7 women per group had had sex before the FU. Among them 6 and 4 women, respectively, had not started any contraceptive method. In the first group (home-use of misoprostol) 6 women had started contraception before the FU and 12 started at the FU while in the second group 9 women started before the FU and 7 at FU.
Conclusions: This study supports that women should be free to choose their preferred location of the induced medical abortion. The reason why so many women postpone post abortion contraception despite stressing the importance to avoid a pregnancy needs to be further explored.
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Medical abortion at 9+1 to 12+0 weeks of gestation - a pilot studyon efficacy, bleeding and women´s experiences
Monica Johansson, Department of Women´s and Children´s Health, Division of Obstetrics
and Gynecology, Karolinska Institutet/Karolinska University Hospital, Sweden
Background:Medical abortion up to 9+0 weeks gestation was approved in Sweden in 1992. Today a majority of induced abortions are medically induced and performed before the eight’s week of gestation. The standard method for termination of pregnancy in the late first trimester is still surgical using vacuum aspiration. However, more recently medical abortion has become increasingly used also beyond 63 days of gestation.
Objectives: The objectives of this pilot study were to evaluate women´s experiences with late first trimester abortion and to collect data on efficacy, bleeding and side effects.
Methods: All women received mifepristone 200 mg orally under nursing supervision, followed by 800 micrograms misoprostol self administered vaginally 48 hours later. Misoprostol was repeated every 3 hours orally, to a maximum of five doses if needed. A clinical examination including ultrasonography if needed was performed prior to discharge If expulsion had not occurred women were kept in hospital over night and vacuumaspiration performed the following day. Follow-up was performed 3 weeks after treatment. Bleeding and side effects were reported two times from the intake of mifepristone until follow-up.
Results: A total of 14 pregnant women with gestational age 9+1 to 12+0 weeks were included. The successful termination rate was 85,7 %. Surgical evacuation was carried out in 2 (14,2 %) women and only 3 (21,4 %) estimated bleeding more than a regular period. Most women 13 (92,8 %) found the method of treatment highly acceptable.
Conclusion: Medical abortion is a highly acceptable method for termination of pregnancy also in late first trimester and could safely be offered to more women.
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How to make the right decision? Women’s experience of the decision process related to completing or terminating a pregnancy during the first trimester
Marianne Kjelsvik, Norway
According to the law Norwegian women have the right to decide on abortion within a limit of twelve weeks of pregnancy. Out of totally 75 000 pregnancies in Norway each year, 15 000 are terminated. Both in the group of women who decide to keep the foetus and in the group who choose to remove it, many have qualms about the decision. The aim of this phenomenological study was to seek in-depth information on women’s experience when they consider terminating a pregnancy in the first trimester.
Qualitative interviews with four first time pregnant women between 25 and 32 years were conducted. None of them had decided whether to complete or terminate the pregnancy. Each woman was interviewed twice during a period of two weeks to grasp their experiences related to their uncertainty. Data were analysed by using Giorgi’s five step model of analysis.
One main finding was that the women struggled to make “the right decision”. Several experienced disappointment and despair at the lack of understanding of their thoughts, feelings and vulnerability when they involved others in the decision making process. At the same time as they wanted autonomy they needed understanding and acknowledgment both from significant others and from health care providers.
Consequently, more awareness of these matters among professionals as well as in society is necessary in order to assure that pregnant women get properly support to make their own decision.
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More medical abortion but high secondary intervention rates in an alternative abortion setting in the Netherland
Gunilla Kleiverda, MD, PhD, gynaecologist and Elles Garcia, MD, Flevoziekenhuis, Almere, Netherlands
Abortion clinics provide the vast majority (94%) of abortions in the Netherlands. Of the 11807 first-trimester abortions performed in 2008, 10% were medical abortions, the remaining 90% instrumental procedures.
In Almere, a vast-growing city close to Amsterdam, no traditional abortion clinic is present. The local Flevoziekenhuis started therefore an out-patient abortion clinic as a satellite in 2008. The clinic, not located in the hospital, offers possibilities of medical and instrumental abortion, and anonymous and non-anonymous care. Non-anonymous instrumental abortion up to 12-14 weeks is performed in the Flevoziekenhuis. For anonymous abortion and abortion after 12-14 weeks gestation, women are referred to abortion clinics in Amsterdam.
Women were referred either by their general practitioner or by self-referral. In the first year, 616 patients were seen. 127 did not have a termination of pregnancy, because a decision to keep the pregnancy, because of not being pregnant or a non-viable pregnancy. 56 women were referred to abortion clinics because of the wish to have an anonymous treatment or advanced gestational period.
Of the remaining 435 women, 239 (55 %) had a medical abortion, 196 (45%) had an instrumental first trimester abortion. The percentages of women who requested a medical abortion was high compared to national figures. However, rates of secondary aspiration were high as well, 35 (14.6%) in the medical abortion group, 5 (2.6%) in the primary aspiration group. Patient and health-care characteristics related to this high curettage risk will be presented and discussed.
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Emergency contraceptive pills: Knowledge, experience and dominions of undergraduate students in a University in Southern Thailand
Jitsai Lawantrakul and Pranee Pongpaiboon, Assistant Professors Faculty of Nursing Prince of Songkla University, Jitti Lawantrakul, Obstetrician & Gynecologist Hatyai Hospital, Sopen Chunuan, Associate
Professor Faculty of Nursing Prince of Songkla University, Thailand.
Adolescents’ sexual behavior leads to the problem of unwanted pregnancies and unsafe abortions, which contributes significantly to maternal morbidity and mortality The purposes of this descriptive study were to explore the levels of knowledge, experiences, and opinions of Emergency contraceptive pills (ECPs) of undergraduate students in a University in Southern Thailand.
The subjects were undergraduate students from the Prince of Songkla University, Thailand. The sample size was determined using Yamane’s equation and there were 200 participants. The questionnaire was developed by researchers with KR-20 (0.78). The subjects completed a questionnaire dealing their demographic characteristics, knowledge about ECPs, experiences of using ECPs, and their opinions of ECPs.
The results revealed that the subjects’ knowledge level was moderate (55%). Most of the subjects (84.5 %) had heard about ECPs. Only 7 % had ever used them and nearly half of the users (42.86 %) had experienced side effects of ECPs. The sources of subjects’ knowledge were schools, friends, internet, journals or magazines. As to preferred sources, the subjects would like to get information from friends and health personnel. Regarding who should give information about ECPs, they favored health personnel especially pharmacists, physicians, and nurses. As to opinions about ECPs, they agreed that adolescents should have knowledge about ECPs and know how to use them. They disagreed that male adolescents should be the ones to decide to use ECPs for their partners.
This study provided the information that the level of adolescents’ knowledge was moderate and they need more information and accurate knowledge from health personnel. Thus, health personnel, especially nurses, should take a proactive role in educating, advocating, and supporting adolescents and the general population by providing information about ECPs.
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Combined oral contraception and weight changes
Medard Lech, Fertility and Sterility Research Center Warsaw and L.Ostrowska, Medical University of
Białystok, Poland
Obesity is associated with a host of medical conditions, including diabetes mellitus, osteoarthritis, cardiovascular diseases, sleep apnea, breast, colon and uterine cancer, pregnancy and reproductive disorders. Last but not least, overweight [and obesity] is of great concern to most women in today’s world.
There are many, complex, inter-related reasons for overweight and obesity in women, a phenomenon which is related to genetic, endocrine, social and other factors. The most common reason for obesity is high food intake and low levels of physical activity. Some pharmaceutical products may also affect the energy balance in women and thus lead to overweight and obesity. The list of such pharmaceuticals is not fully defined, but steroids (and most commonly, hormonal contraceptives) are often included here.
As combined oral contraception [COC] is the most popular method of hormonal contraception, there is a large number of publications discussing the unwanted side-effects of COC. Generally the discussion focuses on cardiovascular problems, whereas the most common concerns of patients concentrate on weight gain and cancer risk, especially the risk of breast cancer. This discrepancy between scientific concerns and the problems arising in clinical settings is even greater due to the long list of possible unwanted side-effects mentioned in COC pack inserts.
Clinical practice during the 60’s and 70’s showed that COC use was linked to estrogen related nausea, vomiting, headache and breast tenderness. Since that time, the estrogen dose in COC has been markedly diminished, largely to reduce the rate of unwanted, cardiovascular effects, but also as the method of lowering the number of side effects related to quality of life [headache, breast tenderness, nausea and vomiting]. Most controlled clinical trials found neither a correlation between COC use and body weight nor any possible mechanisms affecting body weight in COC users.
Although there is no - scientifically-proved - relationship between COC use and weight gain, many women have discontinued their use of hormonal contraceptives due to “weight gain”. More than half of US women believe that COC causes weight gain. Gynecologists from all over the world report that their patients frequently consider COC one of the causes of their “weight gain”, but neither early [with COC containing more than 35 mg ethinyloestradiol] nor recent [with COC containing 20 – 35 mg ethinyloestradiol] placebo-controlled trials confirm this.
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Analysis of medical abortion in first trimester in a small regional hospital in Slovenia
Eva Macun, General Hospital Jesenice, Slovenia
Introduction: Medical abortions have been performed in General Hospital Jesenice since 2005. The first attempts were made during our participation in the WHO supported study which was coordinated by Gynecological Department of the University Medical Center in Ljubljana. Both drugs that are used regularly for medical abortions (mifepriston and misoprostol) are not register at the Agency for Medicinal Products and Medical Devices of Slovenia. Therefore a special approval is needed for their import. Our doctors needed time to accept the method but since 2009 two thirds of all abortions have been performed using this method. One step forward has been made and a clinical pathway for medical abortion is being prepared. Our final goal is to make the method widely available, to educate all the involved professionals and to make it possible for home use.
Methods: In the current presentation an analysis of all performed medical abortions from 2005 to 2009 is shown. All data were collected by hand. A WHO protocol was used for medical abortions under 9th week of pregnancy. Women were given 200mg of mifepriston orally and after 36-48 hours 800µg of misoprostol vaginally. For women, who were pregnant 9 to 12 weeks, the protocol was adjusted for every single pregnancy.
Criteria for successful abortion that we used after 14 days were: no gestational sac, endometrial lining thinner than 15 mm, if there were hiper- and hipoechogenic areals in the endometrial lining from 15 to 20 mm, we prescribed uterotonic and antibiotic therapy and ultrasound control after menstrual period. In case of prolonged bleeding we did a curettage.
In other cases we took this as unsuccessful abortion and completed it with a curettage.
Results:We performed 124 medical abortions in this time. Till 49 days of amenorrhea we performed 75 abortions: 3 patients needed curettage, because there remnants of trophoblast in the endometrial lining after 14 days. Success rate of the method in our department was 96%.
Between 7th and 9th week we performed 39 abortions. Two needed additional curettage (5%).
We also performed 10 abortions between 9th and 12th weeks. All were successful.
All together the success rate was 93.4%. for abortions performed in women who were pregnant less than 12 weeks. We found no complications (heavy bleeding, infection).
Conclusions:In our department the method is very successful. We see a lot of potentials in promoting medical abortion in Slovenia, because we have really good experience with it, our patients prefer medical over surgical abortion, we need less professionals, we will make a clinical pathway for hospital use. But our goal is to perform medical abortion at home, because the method is safe. In this project good cooperation would be achieved with local gynecologists who will follow the patients at home.
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Immediate adverse events after second trimester medical termination of pregnancy - results of a nationwide registry study
Maarit J. Mentula, M.D., Maarit Niinimäki, M.D., Ph.D., Satu Suhonen, M.D., Ph.D., Elina Hemmiki, M.D., DrPH., Mika Gissler, M.Soc.Sc., Dr. Phil., Oskari Heikiheimo, M.D., Ph.D.
From the Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Helsinki, Finland (M.M., O.H.), the Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland (M.N.), the City of Helsinki Health Care Centre Unit for Maternity and Child Health Care and Health Promotion (S.S.), The National Institute for Health and Welfare, Helsinki, Finland (M.G., E.H.),
The Nordic School of Public Health, Gothenburg, Sweden (M.G.).
Objective: To assess the rate of adverse events following medical second trimester termination of pregnancy (TOP) and to compare it to those in the first trimester medical TOP.
Methods: This register based cohort study included 26,053 women, who underwent medical TOP in Finland between 1st January 2000 and 31st December 2006. Women were identified from the Abortion Registry. Adverse events related to medical TOP within 6 weeks were searched from the Hospital Discharge Registry. The rate and risk factors for adverse events were estimated during 2003 to 2006.
Results: The rate of surgical evacuation of second trimester medical TOP decreased during the first three years of the study period and thereafter stabilized at 39.5%.Second trimester TOP increased the risk of surgical evacuation (OR 9.3; 95% CI 8.1 to 10.7), especially immediately after fetal expulsion (OR 41.0; 95% CI 32.9 to 51.0). Also the risk of infection was elevated (OR 2.1; 95% CI 1.5 to 2.9). Increased length of gestation did not influence the risk of surgical evacuation or infection in the second trimester medical TOP.
Conclusions: The medical TOP during second trimester is generally safe. Surgical evacuation because of residual tissue is avoided in more than half of the cases, though it is much more common than in first trimester medical TOP. More wide use of medical TOP decreased the use of surgical evacuation. The risk of surgical evacuation and infection does not increase by gestational weeks in the second trimester TOP.
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Pilot project: potential for midwives to manage medical abortions independently
Anneli Pehrsson and Pia Karlsson, Licensed Midwives; Karolinska University Hospital, Sweden
Background: According to rules issued by Sweden’s National Board of Health and Welfare, Advice on Abortions 2004: Section 4; Chapter 2, when a woman has made the decision to have an abortion it should be carried out at the earliest possible time.
Our previous routines could not adequately address the waiting times for the required ultrasound examination by physicians. Not every woman who had contacted the clinic <9 weeks gestation could be offered medical abortion. Hence, a project was initiated to train two midwives in transvaginal ultrasonography.
In 2007, the National Board of Health and Welfare decided to make the regulatory changes necessary to broaden the authority of midwives in this context.
Aims: - To train and certify midwives to independently manage medical abortions, perform dating scans by transvaginal ultrasonography, and prescribe mifepristone and misoprostol.
- To provide women with rapid and effective care.
- To be able to offer a medical abortion to any healthy woman <9 weeks gestation.
- To ensure continuity, i.e. the woman meets one and the same person during the entire abortion process.
Methods: - Auscultation/training in transvaginal ultrasonography, at IVF clinic.
- Individual training and supervision in ultrasonography, Center for Fetal Medicine.
- Individual training and supervision in transvaginal ultrasonography, by Prof. Seth Granberg.
- Transvaginal ultrasonography with the department’s gynecologists. Images were reviewed, commented on, and approved by Prof. Seth Granberg. Accompanied by theoretical studies.
- Ten cases of abortion counseling with ultrasound examinations, supervised by C. Rasmussen (Section Chief at the time).
Results: - For the past 2 years we have performed transvaginal ultrasonography in healthy women early in pregnancy. We have been delegated authority to prescribe mifepristone and misoprostol, to prescribe contraceptives, and to deliver patient care encompassing the abortion itself and follow-up visits.
- We have shortened the waiting times at the clinic; freed time for physician appointments; increased the number of medical abortions; and reduced the demand on surgical time and recovery unit beds.
- We can offer medical abortion to all healthy women who request it, and most can begin the abortion with the first visit.
Conclusions: - Midwives with adequate education have the capability to independently manage healthy women requesting an abortion early in pregnancy. Usually the problems are more of a psychosocial than medical nature. The abortion is not the problem, but often the solution to the woman’s problem.
- In the past 2 years we have become proficient in performing and assessing ultrasonography and detecting anomalies, whereupon we contact the attending physician.
It is important for midwives and physicians to collaborate in the care of these women. It must not become a matter of prestige.
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Differences in circumstances regarding the decision on abortion or ongoing pregnancy among women in the Ljubljana region, Slovenia
Bojana Pinter, S.Baznik and T.Vovko, Department of Obstetrics and Gynecology,
University Medical Centre Ljubljana, Slovenia
Objectives: The aim of this study was to obtain a broader insight into social-economic, religious, and other characteristics of pregnant women having an induced abortion (IA), and into the reasons for induced abortion, use of contraception before and after IA, and to analyze women's attitude towards professional counselling before IA in the Ljubljana's region.
Design & methods: The study was based on two comparable questionnaires that were given to two groups of pregnant women: a study group of women that were having a first trimester IA at the Department of Obstetrics and Gynecology, University Medical Centre Ljubljana (323 subjects) and a control group of women in the first trimester of pregnancy that intended to give birth (60 subjects) and were attending out-patient clinics in the Ljubljana region. Participation in the study was voluntary and anonymous. The differences between the groups were analyzed using a chi-square test, and the correlations between individual characteristics were calculated using Pearson correlation coefficient. P values below 0.05 were regarded as significant.
Results: The average age was 28.8 ± 3.4 years in the study group, and 28.6 ± 7.0 years in the control group, the difference was not statistically significant (p=0.737). In the study group there were significantly more women that had finished primary school only than in the control group (17.9 %: 0.0 %; p<0.05), and fewer had achieved graduate (18.8 %; 6.7 %; p<0.05) or post-graduate education (2.2 %; 11.7 %; p<0.05). In the study group fewer women were employed (56.9 %; 80.4 %: p<0.05), and more of them unemployed (18.2 %; 5.4 %; p<0.05), and fewer lived with their spouses or family (55.5 %; 76.7 %; p<0.05). Women in the study group considered their socio-economic status significantly lower and fewer declared themselves as Roman-Catholics (66.3 %; 92.6 %; p<0.05). There was a significantly higher rate of barrier contraception use in the study group before the pregnancy. The main reasons for IA were current lack of wish for a child (48.7 %), financial and social reasons (35.3 %) and school or career (29.7 %). The majority (84.0 %) of women in the study group had professional counselling and 42.1 % of women in the study group would want such counselling.
Conclusions: Pregnant women who decided on an IA had poorer socio-economic status, fewer of them were Roman-Catholics, and they used less efficient contraception.
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Abortion practice in Swiss hospitals – results of an inquiry by APAC-Suisse in 2009
Anne-Marie Rey, secretary of APAC-Switzerland
Despite a liberal legislation since 2002 (abortion on request in the first 12 weeks of pregnancy and without time limit if it is necessary to turn away from the pregnant woman the „risk of a serious emotional distress“), we suspected certain gaps in service provision in Switzerland.
In summer 2009, we made an inquiry among private and public hospitals, including some day care clinics we were aware of. Out of 157 clinics contacted, we received 113 answers that could be evaluated (72%). Among these, 93 clinics (82%) practice abortions.
In the first trimester, two thirds of them offer the surgical as well as (in the first 7 or 9 weeks) the medical method with mifepristone plus misoprostol. Only 12 clinics (13%) offer local anesthesia for surgical abortions.
As for abortions after 12 weeks, an earlier inquiry among family planning centers had revealed that almost half encountered difficulties in their region in this respect. In fact, after 12 weeks gestation, only 49% of the clinics accept psychosocial indications as defined by law and most limit abortions for these reasons to 14 or 16 weeks.
Access to abortion in the second trimester or later remains very restricted in Switzerland. The range of discretion allowed by the law is not sufficiently used. Moreover, the surgical method is very rarely offered in the 2nd trimester
These are the reasons why a certain „abortion tourism“ still exists, estimated at 50 women who every year have to seek second trimester abortions in clinics in other countries.
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Contraception before and after abortion at home
Pascale Roblin, Claire Ricciardi, Aubert Agostino and Raha Shojai, France
Objective: In France, despite a wide range of highly effective, easily accessible and reimbursed contraceptive methods, the rate of abortions remains high and one third are repeat procedures. We analyzed womens’ contraceptive path surrounding a medical abortion.
Methods: A retrospective study of 450 women who had medical abortion at home before 7 weeks was realized in a community care office in Marseille between 2006 and 2010. All women were seen at the post abortion visit and had received contraceptive counselling before and after the procedure with emphasis on long acting reversible contraceptives (LARC). The last declared failed contraceptive method leading to the unwanted pregnancy and the method finally adopted by the patient at the immediate follow-up visit were noted.
Results: Before abortion, 43 (9,5%) used no contraception, 92 (20,5%) used natural methods and 244 (54,2%) used condoms. Women declared using COC in 71 cases (15,8%) and the vaginal ring in one case. None had an IUD or an implant. After abortion, 37 (8,2%) requested no prescription of contraception, 259 (58%) had COC, 15 (3,3%) used a vaginal ring and 12 (2,7%) opted for a transdermal patch. Following abortion, 31% of patients switched to LARC (121 IUD and 18 implants) and 37% to highly effective forgettable methods. Among the 244 pre-abortion condom users, 163 (73%) switched to COC. Among the 71 pre abortion COC users, 45% still maintained COC as their preferred method and 34% switched to IUD.
Conclusion: Most unwanted pregnancies occurred with the use of male condoms. Immediately after abortion, the majority of women opted for combined oral contraceptives. On the short term, peri-abortion contraception counseling may however encourage women to switch to more effective and forgettable methods (IUD or implant).
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Does a previous abortion modify womens’ contraceptive choice?
Pascale Roblin, Lisa Tichane, Sylvie Camil, Aubert Agostini and Raha Shojai, France
Objective: Care givers often expect that women with a previous abortion are more likely to use highly effective contraceptive devices to prevent further unwanted pregnancies. We assessed the failed contraceptive method used before an abortion between women with and without a previous abortion.
Methods:In a series of 450 women requesting a medical abortion at home before 7 weeks in a community care center in Marseille, France, there were 157 (35%) patients who had a history of at least one previous abortion. We realized a case –control study to compare the failed contraceptive method leading to an unwanted pregnancy between 157 women with a previous abortion and 293 women without a previous abortion. Chi-2 test was performed and considered significant for p<0.05.
Results: The rate of women using no contraception, natural methods or condoms were similar in both groups. The rate of COC users was 16% in the group of patients with a previous abortion vs 14,7% in the control group (p=0,8). None of the patients used IUD or implants in both groups.
Conclusion:The contraceptive profile of women with an unwanted pregnancy is similar between women with and without a previous abortion. In our population, a history of abortion did not modify womens’ contraceptive choice towards more effective methods.
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Early post abortion insertion of Mirena IUS
Ingrid Sääv, MD and Kristina Gemzell Danielsson, Professor, MD, PhD, Dept of Woman & Child Health,
Div of Obstetrics & Gynaecology, Karolinska University. Hospital / Karolinska Institutet, Sweden
Background: Today a majority of early abortions are conducted medically, in accordance to the woman’s choice. When opting for an IUS/IUD as contraception method, the insertion routinely takes place at the check up visit 3-4 weeks after the abortion. This means an obvious risk of a new pregnancy.
Objectives: We wanted to study if early post abortion insertion of Mirena IUS could be conducted in a safe way and without increased risk of expulsion or infection. Furthermore, we wished to investigate however early insertion would have an impact on the bleeding patterns during the first 4 weeks, and if Mirena use during the first year is comparable between the two groups.
Material and methods: 65 women undergoing elective early medical abortion up to 9 weeks gestation and opting for a Mirena IUS were included. They were randomized to either early insertion on day 5-9 (34 women), or routine insertion at 3-4 weeks (day 21-31) (31 women). The medical termination was performed according to clinical routine. Antibiotic prophylaxis was not administered routinely, but a screening test for Chlamydia infection and bacterial vaginosis was performed. An ultrasound examination was performed before Mirena insertion. Hb and S-hcg was determined on day 1 and at the day of insertion. The patients were scheduled for control visit 4 weeks after Mirena insertion and complications such as infection and expulsion was recorded, and a diary of the bleeding pattern was collected from the patient. Hb was determined, and a urine pregnancy test was performed.
Results: 34 women were randomized to early insertion (day 5-9). 4 women were excluded, of these one was diagnosed with missed abortion and scheduled for vacuum aspiration, one was booked to late by mistake, one did not show up and one woman had regrets and requested a cupper IUD instead. 31 women were randomized to routine insertion (day 21-31). 3 women were excluded, one was diagnosed with a viable pregnancy and was scheduled for a vacuum aspiration and two did not show up for insertion. There were no infections in either group. There were 5 expulsions (17%) in the early group, compared to 3 (11%) in the late group. The bleeding pattern post IUS insertion did not differ between the groups; neither did the acceptability of the patient regarding insertion of the IUS or further use.
Conclusion: There was no difference in safety between the groups. There was no case of endometritis or pelvic infection. Acceptability and bleeding patterns did not differ between the groups. The expulsion rate was substantially elevated in both groups, compared to routine insertion in a non-pregnant woman. We conclude that all women undergoing post-abortion insertion should be scheduled for a control visit
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Day case surgical abortion in late second trimester
John A D Spencer, Senior Clinical Consultant, Marie Stopes International, London, United Kingdom
A review of the management of all surgical abortions with a gestation between 19 and 23 weeks was undertaken during 2009 by prospective collection of data. All were day-cases, admitted subsequent to clinical assessment, blood tests, and consent. Cases not suitable for general anaesthesia in our centres were referred for hospital management. Cervical preparation was by intracervical Dilapan rods (a hygroscopic dilator) and vaginal Misoprostol. Dilatation and Evacuation was performed after waiting at least four hours.
Of a total of 770 cases in two London centres data were collected on 726 (94%). Three of the four doctors performed 94% (37%, 37% and 20%) of cases respectively. The number of cases each month varied between 50 and 84 and there were no significant differences between the two centres. Cervical preparation began before 1100 hours in 95% of cases.
The age range of clients was 14 to 46 years (96% were between 15 and 39). 38% were multiparous (parity 1-4) of which 17% had a history of one or more caesarean sections. 95 % experienced noticeable abdominal cramps during the cervical preparation interval but only a small minority requested analgesia. The incidence of diorrhoea was 5% and vomiting 3%. One client began bleeding sufficient to require transfer to hospital before surgery.
Analysis of the treatment patterns showed that the dose of Misoprostol administered was influenced by age (more if younger), gestation (more if 22 or 23 weeks) and parity (less if multiparous). Most clients had 3 Dilapan rods inserted through the internal cervical os and difficulty were noted in only a few nulliparae. The preparation interval was significantly longer if the gestation was 22 or 23 weeks, and if a higher dose of misoprostol was given. Multipara had a shorter preparation interval.
The cervical dilatation found prior to commencing Dilatation and Evacuation was significantly greater after the higher dose of misoprostol, with higher gestations, in multiparae. The procedure duration was longer with higher gestations, and was shorter if the cervical dilatation was greater and in multiparae. Metal (Pratts) double-ended cervical dilators were rarely (less than 5%) required. Recovery was uneventful in all cases not already transferred to hospital, and all clients were discharged within 2 hours.
There were only four serious complications which required transfer to the local hospital. The case of haemorrhage from a low-lying placenta had a placenta accreta related to a previous caesarean scar and required subtotal hysterectomy. Three cases had a laceration of the internal cervix or lower uterus,
directly related to surgery, and were successfully managed with an intrauterine balloon and suturing.
Table to summarise treatment and outcomes by gestation
19 wks
20 wks
21 wks
22 wks
23 wks
n (%) of study group
120 (17)
193 (26)
161 (22)
139 (19)
113(16)
Mean age for each gestation
23
24
25
25
24
Intracervical Dilapan x 3 (%)
99
99
96
96
75
Intracervical Dilapan x 4 (%)
0
0
2
3
24
Misoprostol 600 mcg PV (%)
97
97
91
53
55
Misoprostol 800 mcg PV (%)
2
1
7
46
44
Cervical preparation for 4-6 hrs (%)
93
91
91
78
91
Cervix pre-op Cx dilat >18mm (%)
67
79
81
86
88
Procedure duration <20 min (%)
99
97
87
81
71
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Development of care model for women after an abortion
Wattana Sripotchanart, Sopen Chunuan, Jitsai Lawantrakul, Pranee Pongpaiboon, Jitti Lawantrakul,
Sureeporn kritcharoen, Sirirat Kosulwat,. et al., Thailand
Unsafe Abortion is a major public health problem and society .Each year, Thailand has a woman problem of unsafe abortion around 300,000 people. Complications resulting from unsafe abortion are an important cause of maternal deaths.Hospitals are tertiary places. But with the health care system that is limited. Task of making more women after an abortion care were not taken care coverage.This participatory action research have the following purposes:
1) to study and develop models of care women after abortion.
2) to study the satisfaction of women receiving post-abortion care model developed later.
3) to study the obstacles in developing models of care women after abortion.Participant consisted of 12 nurses who work in units of one hospital and 60 women after abortion.
Before and after the development of models of care of 60 people the tools used to collect information line is open-end questions. And satisfaction survey of women after abortion. Value equal to 0.97 poise storage to a depth interviews. Group discussions and questionnaires.
General data analysis using descriptive statistics. Qualitative data analysis with content analysis. Comparative satisfaction of women after abortion in the quality of hospital care before and after the development of quality care using statistics Independent-Sample t-test at the end of the research. Model of care women after abortion care is holistic, including building relationships that impressed. Having a positive attitude. Advising and counseling. And to maintain continuous compliance with the needs of women after abortion. The satisfaction of women after abortion before and after the development patterns of care differ statistically significant (p =. 05) obstacles in the development patterns found that the burden of care is more leisurely.
Summary of development patterns of care by women after abortion, research that focuses on practical involvement of nurses. Allow nurses are aware of more holistic care. Have better attitudes to women after abortion. The brochures created financial advice and counseling. To women after abortion has led to comply.
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Women experiences with legal abortion services in private clinics in Mexico City
Erika Troncoso (Ipas Mexico), Olivia Ortiz (Ipas Mexico), Raffaela Schiavon (Ipas Mexico)
Background: Decriminalization of induced abortion during the first trimester of pregnancy in Mexico City has broadened reproductive choices for women since April 2007. The objective of this study was identify the barriers and conditions that impact access to legal abortion (LA) in private clinics.
Methods: Seventeen semi-structured interviews were conducted with women who received a legal abortion in two clinics in Mexico City.
Results: The majority of the women interviewed were young, single with higher levels of education. Three women travelled to Mexico City to obtain a LA. The majority of women sought medical advice prior to arriving at the center and changed their decisions due to unfriendly care and lack of trust. Also, the majority of women obtained information on conditions and facilities offering services through the internet, as well were already aware of the legal changes pertaining to abortion. This allowed them to speak more openly on the subject with those most trusted, and even with healthcare providers when seeking consultation. Other factors that facilitated the experience included: being attended by trained medical personnel in legal and sanitary conditions, receiving comprehensive information about the procedure, and experiencing friendly and non- judgmental treatment by health personnel. Finally, establishing a personnel bond with one of the healthcare providers helped the process to be more comfortable. In respect to the barriers, the interviewed group identified what close relatives and friends perceived of them, informed by religious beliefs and moral judgments, as important. Other aspects were difficulties finding specific information on the way different methods work, the effects, and lack of economic resources to be treated immediately. Some women stated fear of feeling rejected by health personnel when requesting care. Women stated having distorted information produced and disseminated by the opposition concerning abortion. In addition, they found that some providers passed judgment or they felt hostility from health personnel in other areas, including prolonged waiting periods. However, these factors did not push them to change their decisions. The women stated their need for emotional support, something that was not considered in LA provision of services.
Discussion: Before arriving at the medical facility, the majority of the women was confronted by many complex and diverse situations and had made decisions as a method of self-defense and survival. Deciding to have a legal abortion served as an opportunity to change or avoid greater repercussions in the woman’s life. Legal abortion services must be aware of these situations because they will have an influence on the experience of the services. The analysis shows how women requesting legal abortion used various criteria to determine how much they trusted the service: both the legality and the expectation of care were used in order to determine who would be their health provider. Finally, this study shows the need to do further research on women’s emotional experiences, aiming to identify the factors that put them at risk in the immediate future with an unwanted or unplanned pregnancy.
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Implementing Resident Training in Abortion: Summary of Ryan Programs in Ob-Gyn Residency Programs in the US and Canada
Jema Turk, F.Preskill, G.Patel, U.Landy and J.Steinauer, USA/Canada
Objectives: The Kenneth J. Ryan Residency Training Program in Abortion and Family Planning (Ryan Program) provides technical and financial support to help US and Canadian obstetrics and gynecology (ob-gyn) residency programs comply with the Accreditation Council for Graduate Medical Education mandate to integrate abortion into training. Since 1999, 54 Ryan Programs have been established in 28 states and in two Canadian provinces. A total of approximately 1600 residents have been trained through the Ryan Program since its inception. Our objective was to describe the clinical and departmental impacts in the Ryan Programs.
Methods: All 54 Ryan training programs are systematically reviewed through pre- and post-rotation surveys completed by residents, and through annual reports, site reviews, and yearly on-line surveys completed by Ryan Program directors, department chairs, and residency program directors. Programs and residents undergo extensive evaluation during the first two years of active funding. Thus, the data discussed here represent evaluation pursued in the first two years of program existence.
Results: A total of 746 residents have completed pre- and post- rotation surveys to date, giving a total response rate of 70%. On average, residents spend 15 days in clinics providing abortion and/or contraception care. The location of training varies between in-hospital clinics (45%), out-of-hospital clinics (40%), and a combination (15%). During the Ryan Program rotation, residents provide pregnancy options counseling, routine and complex contraceptive services, cervical preparation, and perform first-trimester manual uterine aspirations and electric uterine aspirations, medication abortions, and second-trimester dilation and evacuation procedures. Comparing pre- with post-rotation surveys, residents’ self-assessed competence in first and second-trimester uterine aspiration increases significantly, as well as the intention to provide all techniques of abortion after residency. In addition, residents, Ryan Program directors, department chairs and residency program directors describe a variety of benefits beyond residents’ skills in abortion care. These include residents’ skills in counseling, contraception, ultrasound, and outpatient surgery; improved continuity of care for patients; and improved appeal of the residency programs to medical student applicants.
Conclusions: The Ryan Program has been successful in integrating abortion and family planning into 54 (21% of all) US and Canadian ob-gyn residency programs. These rotations have led to approximately 1300 ob-gyns graduating with proficiency in abortion care, and over 75 percent plan to include these skills in their subsequent practice. In addition, the Ryan Program’s successes have contributed to reinforcing the importance of training in family planning as a central part of obstetrics and gynecology.
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The impact of US Fellowship in family planning
Jema Turk, H.Steele, M.Fulton, U.Landy and J.Steinauer, USA/Canada
Objectives: To describe the US-based fellowship in family planning.
Background: In 1991, the Fellowship in Family Planning was established at the University of California, San Francisco to promote advanced training in contraception and abortion. The Fellowship in Family Planning provides two years of post-residency training in clinical care, research and policy training. The fellowship also requires an international placement in a low-resource setting and completion of a masters degree in clinical research or public health and is available to graduates of either obstetrics-gynecology or family medicine residency training.
Methods: The fellowship is assessed yearly through annual reports completed by faculty and fellows, bi-yearly site visits, and regular audits of fellowship publications.
Results: The Fellowship in Family Planning has grown to include 21 medical schools throughout the United States. To date there are 118 graduated fellows and 38 fellows currently in training. Fellows develop expertise in abortion care and complete a median of 168 first-trimester uterine aspiration and 102 second-trimester D&E procedures over two years, in addition to developing skills in contraception and maintaining non-family planning skills. Fellowship directors and graduated fellows have generated a wealth of research addressing some of the most critical questions in family planning, with over 120 peer-reviewed publications in 2009. Fellows have participated in international placements in 39 countries in four continents. Twenty-four (20%) graduated fellows have gone on to direct abortion training programs in residency programs.
Conclusions: The development of a fellowship in family planning in the US has led to a cadre of subspecialists and consultants in abortion and family planning clinical care and research who have become the leaders in training and research in the US.
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Sexual and Mood Side Effects of Hormonal Contraception
Ellen Wiebe MD, Lori Brotto PhD, University of British Columbia Vancouver, Canada
Objectives: To determine the rate and characteristics of women who reported mood and/or sexual side effects with previous hormonal contraceptives. Three cohorts were compared: women presenting for abortions, for IUDs or for primary care.
Method: Women presenting for abortions or IUDs at an urban women’s clinic were given a questionnaire in the waiting room asking if they have ever used hormonal contraception in the past and, if yes, whether they ever had problems with sexual or mood/irritability side effects from hormonal contraception. Women age 15-50 presenting for primary care at family doctors offices were given the same questionnaires. Descriptive statistics were prepared to discover the rate of these side effects and compare the women who had or did not have these side effects. The three cohorts were compared.
Results: There were 1243 women who completed questionnaires; 77% (954) had previously used hormonal contraception and 169 of these were from primary care, 560 were abortion patients and 221 were IUD patients. Of the ones who had previously used hormones, 51% (482) said they had at least one mood side effect on at least one brand and 38% (358) said they had at least one sexual side effect on at least one brand. Self reported ethnicity in these women was: White/Caucasian 66% (663), East Asian 17% (161), South Asian 8% (71), other 9% (88). The three groups of women who had used hormonal contraception were similar except that the primary care group were older (p<.001) and had a higher proportion of Caucasians (p=.009). The 289 women who had never used hormonal contraception were less likely to be Caucasian (p=<001), more likely to have children (p=.003) and had less education (p=.001).
Women presenting for abortion and primary care had similar rates for all side effects but women presenting for IUDs had higher rates of mood side effects (p=.002). Women who complained of sexual side effects were more likely to also complain of mood and physical side effects (p=<.001). Women who complained of mood side effects were more likely to be younger (p=.03), unmarried (p=<.001), nulliparous (p=<.001) and presenting for an IUD rather than primary care or abortion (p=.002). Women complaining of sexual side effects were more likely to have more education (p=.03), be unmarried (p=.02) and nulliparous (p=.004). Caucasian and South Asian women complained about more hormonal side effects than East Asian women (p=.001).
Conclusion: Women have a high reported rate of sexual and mood side effects from previous hormonal contraception. These rates are similar to two studies which found sexual and mood side effects the most important reasons women discontinued hormonal contraception.