Berlin, 24-26 Ottobre 2008: „Reproductive Health and Responsibilities“

  • 09:00-
    11:00
    Changing attitudes towards abortion: Endangering women’s health again
    Chair:
    • Christian Fiala, AT
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      Developing a strategic approach to the threat to women’s health

      Ann Furedi (Great Britain)

      Bpas, Great Britain

      This session discusses the current strengths and weaknesses of the anti choice movement. It looks at the way their arguments have changed over recent years and the most effective ways to present the case for choice.

      The media often exaggerate the strength of the opposition to abortion and suggest that we are in a weaker position than we really are. It is tempting for pro-choice activists to go along with this incorrect analysis because highlighting the threat to legal reminds society not to take abortion access for granted. However, this can result in us focusing only on defending what we have and failing to campaign for what we might gain.

      Sildes: Developing a strategic approach to the threat to women’s health
      PDF-Format (27.824193548387097kB)
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      Eastern Europe: Turning back the wheel?

      Rodica Comendant, Galina Maistruk, Irina Savelyeva (Moldavia)

      Reproductive Health Training Center, Moldavia

      Despite the widespread availability of abortion on legal grounds for more than 50 years, unsafe abortions account for 24% of maternal deaths in Eastern European (EE) region (WHO, 1998). Abortion rates remain high. Abortion is commonly used as a primary means to regulate fertility; the use of modern contraception methods remains low. Access to abortion services in EE has been challenged in recent years. Concerns about declining birth rates, pressure from religious groups have reduced support for family planning and abortion. The low quality of services is influenced by the lack of quality of care standards and quality control.

      In this context, the recent registration of Mifepristone  in many of EE countries, hasn’t much contributed to the improvement of the quality of abortion care.  Medical abortion is still inaccessible for general population and remains an “elite” method for most of the women. The analysis of the access to medical abortion in several EE countries  has showed the following common trends:

      • Cost  of the pills is prohibitive;
      • statistic is virtually inexistent;
      • low level of the awareness about the method in the population, low demand for comprehensive abortion care services, many existing myths;
      • lack of providers motivation to use a new method, the misuse, low efficacy;
      • unwillingness of the public health systems to take the necessary steps for the implementation of the medical abortion services, and unnecessary barriers imposed by their regulations.

      Recently launched by the leading abortion professionals and women advocates from 10 EE countries network „European Alliance for Reproductive Choice“ , supported by ICMA, among other objectives, has decided to focus on developing strategies, to make MA technology accessible in practice in EE countries. Experience-sharing, information, education, communication (IEC) activities, targeting potential users, to increase the demand for better and affordable services among women, advocacy for women rights to the access to the fruits of modern science, the improvement of providers knowledge among providers, transforming them in women advocates, advocacy events to register and utilize medical abortion are some of the listed strategies to consider.

      Sildes: Eastern Europe: Turning back the wheel?
      PDF-Format (1033.5475806451614kB)
  • 11:00-
    14:00
    Workshop 5 Medical abortion
    Chair:
    • Oskari Heikinheimo, FI
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      How to diagnose a complete medical abortion

      Christian Fiala (Austria)

      Gynmed Clinic, Vienna, Austria

      The most widely used definition of a successful medical abortion is the avoidance of a surgical intervention.

      Treatment will result in complete abortion in the vast majority of patients (³95%). However, a small percentage will experience incomplete abortion, missed abortion or continuing pregnancy.

      The following methods are used for evaluating the outcome of treatment at follow-up:

      • Visual verification of expulsion following intake of misoprostol,
      • history of clinical events (heavy or continuous bleeding and pain),
      • gynaecological examination,
      • hCG in serum measured quantitatively,
      • hCG in urine, using a rapid test with a high cut-off value,
      • ultrasound examination.

      The gestational age at the beginning of treatment must also be taken into consideration when considering the diagnostic method used at follow-up. This is because an intrauterine pregnancy becomes difficult or even impossible to diagnose prior to 5 weeks gestation.

      So far no standard has been described for the evaluation of successful treatment and various methods are used in clinical practice. Also, the time delay between mifepristone intake and the follow-up visit varies widely. There is no consensus about a recommended time delay and different providers offer various delays between a few days to 3 weeks.

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      Medical abortion at 7 - 9 weeks gestation: Considerations and challenges

      Kristina Gemzell (Sweden)

      Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden

      Medical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined with a prostaglandin has been available in Europe since 1988 for termination of pregnancy up to 49 days of amenorrhea. In the UK (1991), Sweden (1992) and later on Norway the method is approved up to 63 days of amenorrhea. Recently medical abortion up to 63 days has been approved also in the rest of Europe. With the recommended regimen the high efficacy and acceptability of the method can be maintained beyond 49days. Critical aspects to consider when medical abortion is used beyond 49days of pregnancy will be discussed in the workshop. These include the regimen of mifepristone and misoprostol, the interval between the drugs, pain medication and home-use of misoprostol. An increasing number of women in Europe opt for this choice instead of surgical abortion. A shift which is expected to continue in the next years world-wide. It is crucial that providers are familiar with the method and aware of the critical differences compared to medical abortion before 49 days of pregnancy.

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      Women’s choices: Why do they opt for medical abortion?

      Mette Løkeland, Line Bjørge (Norway)

      Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway

      Background. Norway has abortion on request, completely free of charge and easily accessible at every gynaecology ward up to 12 weeks of gestation. Up until April 1998 when medical abortion with mifepristone and misoprostol were implemented for pregnancies terminations performed at less than 9 weeks gestational length all first trimester abortions were performed surgically at Haukeland University Hospital. In 2003 medical abortion was made the method of choice for early first trimester abortions. Medical abortion for 9-12 weeks of gestation was implemented in 2005 and made method of choice in 2007. If there are personal or medical reasons the surgical method will be used instead.  In 2006 97.3% of all the abortions up to 9 weeks and 54.5% of those between 9-12 weeks were performed medically.

      Choice versus medical recommendations. A woman’s choice is dependent on different factors. Her personal experience, experiences of people she knows and relates to, what she believes is the best method and what health personnel advise her to. Most women do not have a strong opinion but will generally prefer what health personnel recommend them to do.

      The success rate of medical and surgical abortion methods are the same.The general medical view is that conservative treatment should always be preferred to surgical when the methods give equivalent treatment outcome. Surgical abortion in a safe and legal environment preformed by skilled personnel has few complications. In comparison medical abortion has a lowere complication rate ; especially the severe complications are few. Medical abortions should therefore be offered as the method of choice.

      To make an informed consent and be able to choose a method one need thorough information.Our experience is that women who opt for surgical abortion often do so because their family doctor or others who have no knowledge of medical abortion have told them that it would be the best method for them. They will normally change their opinion when informed about medical abortion. Less women opt for surgical abortion today than ten years ago.

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      Women’s experiences: Are they satisfied?

      Annie Bachelot (France)

      Unit INSERM-INED 822, Hôpital de Bicêtre, 82 rue du Général Leclerc,  94 276 Le Kremlin-Bicêtre Cedex, France

      This study aimed to document women’s experience of a home-use medical abortion and to compare it to women‘s experience of a hospital-use of misoprostol administration.

      A total of 43 women participated in in-depth interviews, 4-6 weeks following their abortion, after their follow-up visit. For 12 women this abortion was not the first one.

      Home-use of misoprostol affords women more privacy, comfort and control of their abortions, allowing someone familiar to provide support. The partners‘ participation seemed very important for women. But the home procedure can also create more anxiety than the hospital procedure, especially concerning the need for hospital admission in case of excessive bleeding, or the success of abortion. Women expressed their need for more explanations from clinicians. The different aspects of private status, “medical ability transfer” and social recognition of such abortions were explored.

      Both home and hospital procedures should be available to allow women to make their own choice.

    Workshop 6 Challenges in contraception
    Chair:
    • Anne Vérougstraete, BE
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      Attitudes of women, media and society towards contraception: Are we making progress?

      Mirella Parachini (Italy)

      San Filippo Neri Hospital, Via Cola di Rienzo 190, 00192, Rome, Italy

      Objective. A review of the main modifications about the attitudes towards contraception of women, media and society in the last years.

      Results. The diffusion of modern contraception has certainly contributed to the reduction in the number of unwanted pregnancies in developed countries. These new methods have been adopted by individuals and couples because of the major changes of attitude towards sexuality, the nature of marriage and other forms of union, the place of women in societies and, more specifically, the position of women in the work place. In developing countries surveys find that awareness of contraception is nearly universal among married women and that most people approve of family planning. In most countries the mass media, especially television and radio, are a key source of information about family planning. Despite great progress over the last several decades, more than 120 million women worldwide want to prevent pregnancy, but they and their partners are not using contraception. Millions more are using family planning to avoid pregnancy but fail, for a variety of reasons.

      Conclusions. The job of family planning will never be finished.

      Sildes: Attitudes of women, media and society towards contraception: Are we making progress?
      PDF-Format (99kB)
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      Contraception and sexuality: Effects on pleasure, spontaneity, and frequency

      Johannes Bitzer (Switzerland)

      Basel, Switzerland

      Introduction. Contraception aims at the separation of sexuality and reproduction. Thus each family consultation deals indirectly with sexuality. In usual practice the consultation is however focused on the technical aspects of contraception assuming that the sexual experience and sexual function of the patients are either their private matter or somehow normally functioning anyway or a minor problem. Statistics showing the high prevalence of sexual dysfunctions in women of the reproductive age group indicate that this assumption is wrong. It seems therefore necessary that the family planning professional takes a more active role in the care for the sexual health of their patients.

      Methods. Literature research about the relationship between contraceptive methods and Female Sexual Dysfunction. Regular case discussions and supervision by two trained sexologist in our family planning consultation unit elaborating a basic management program for clients with sexual problems.

      Results. Results concerning the prevalence of FSD in women using different contraceptive methods are contradictory and variable due to methodological problems and lack of well designed studies. COCs seem to have a negative impact on desire and pleasure and even on pain in a small group of “vulnerable” women.

      To respond to sexual complaints of patients the professional for contraception needs some special knowledge, understanding, communicative skills and technical competences.

      1. Knowledge about the types of sexual dysfunctions women may experience during different phases of their reproductive life;
      2. Understanding of the complex interplay between biological, psychological, relationship and sociocultural factors contributing to sexual problems including the possible impact of various contraceptive methods on different levels of the sexual response;
      3. Communicative skills to address sexual issues with patients in an open, non-judgemental, structured way being able to respond to and handle emotions.
      4. Technical competences to establish a biopsychosocial diagnosis of the sexual problem(s), provide basic counselling and treatment and refer to other specialists if necessary.

      The training program will be presented.

      Sildes: Contraception and sexuality: Effects on pleasure, spontaneity, and frequency
      PDF-Format (358.56774193548387kB)
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      Economic discrepancies for contraception in Europe

      Ines Thonke (Germany)

      Pro Familia Bundesverband, Germany

      Implementation. A survey was carried out among IPPF Europe (International Planned Parenthood Federation) member organisations. It was carried out 17 sovereign nations of Europe with the emphasis on the situation in the European Union concerning costs and access of contraception. The evaluation of contraceptive costs undertaken here focuses also on the situation in Germany.

      Results. This comparison of contraceptive costs and access in Europe demonstrates the great divergence in absolute price. Prices tend to be aligned with the economic situation in the respective countries; however they highlight the arbitrariness in price-setting, particularly as a number of the richest countries even supply contraceptives free of charge.

      Germany always takes second place and for hormonal IUDs is the most expensive of the countries in the survey, while the country in first place is different every time.

      In terms of relative prices, shown here as a percentage of income per head, no universal tendencies whatsoever can be identified

      Free access to contraceptives for all or for specific groups is offered almost exclusively by countries with high income per head rates and most comprehensively in France and the UK, for example, but all – even the poorest countries in the survey – provide all their citizens free access to medical consultation – which only in Germany is no longer the case.

      The fact that Germany is expensive is primarily due to the recently introduction of medical consultancy fees. It is in this respect a new finding, as this last reform catapulted Germany out of the middle ground. The special provision for under-18s and under-20s should also be noted At the same time however it must be pointed out that cancelling free provision of contraceptives to those on social welfare benefits has reduced their access to contraceptives significantly in Germany compared to price levels in the rest of Europe.

      Conclusion. It has been shown that it is useful to compile a comparison of contraceptive costs in Europe. Only by making specific comparisons does the particular situation in individual countries (here, the German situation is outlined in greater detail) become comprehensible. It has been substantiated that in the case of Germany the price for contraceptives is in the upper range in terms of an absolute as well as a relative comparison and that the introduction of the Gesundheitsmodernisierungsgesetz (GMG or Healthcare Modernisation Act) in 2003 has created a huge financial burden for clients when compared to the rest of Europe.

      The survey should be made available to all European member organisations in the form of a useful and up-to-date factual report on the situation.

      Proposals for subsequent work will be worked out.

      Sildes: Economic discrepancies for contraception in Europe
      PDF-Format (130.6508064516129kB)
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      Long cycle combined hormonal contraception

      Gabriele Merki (Switzerland)

      Family planning clinic, University hospital, Zürich, Switzerland

      Prolonged use of combined pill preparations (COC) has been widely performed to suppress menstruation in women with clinical conditions like premenstrual symptoms, endometriosis, or cyclic headache. At present there is in several European countries a trend to use the long-cycle to suppress normal menstruations for convenience, particularly for women who are already taking COC. Some authors medicalize and pathologize the natural event of menstruation and declare normal cycles as unnecessary annoyance and as possibly health risk. We intend to discuss open questions concerning the safety of the long-cycle and long-term health risks specially on the breast and the endometrium. Furthermore we speculate about the consequences of cycle suppression in healthy adolescents for their later attitude towards menstruation.

      Sildes: Long cycle combined hormonal contraception
      PDF-Format (198.94838709677418kB)
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      When contraception fails: Adolescent contraception practices and teenage pregnancy

      Silja Matthiesen (Germany)

      Universitätsklinikum Hamburg-Eppendorf, Germany

      When young people become pregnant it is usually due to a failed attempt at contraception.  The primary question examined here is why these attempts fail.  The author conducted a quantitative analysis of a questionnaire distributed to underage pregnant females (n=2278) and a qualitative analysis of interviews with underage females who terminated their pregnancies (n=62).  The quantitative data show that approximately two-thirds of the unwanted pregnancies were the result of improperly using birth control pills and condoms.  Three particularly vulnerable groups were identified:  social disadvantaged teenagers; those involved in relationships in which an egalitarian relationship with the male partner is not present; and those who experience an emotional distance to their partners.  On the basis of the interviews information could be gained concerning the problems encountered in using contraceptives in the context of the sexual biography of the participants.  Results show that using contraceptives is a learning process on the part of both partners.  The failures in contraception use are not primarily due to a lack of information about sexuality, but rather to a lack of competency in managing the relationship dynamics as well as to a lack of knowledge about the proper use of contraceptives.

    Workshop 7 Value clarification - an interactive workshop
    Chair:
    • Christina Wegs, US
    Workshop 8 Free Communications
    Chair:
    • Carolyn Phillips, GB
    • Sam Rowlands, GB
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      Challenges and barriers to accessing safe abortion services in Nepal

      Mahesh Puri (Nepal)

      Center for Research on Environment Health and Population Activities (CREHPA), Kusunti, Lalitpur, P.O. Box 9626, Kathmandu, Nepal

      Abortion was broadly legalized in Nepal in 2002, and the policy implemented in 2004. Before legalization, abortion was treated as a criminal offence resulting in the imprisonment of women. Law and provision of services are necessary but not sufficient to guarantee access. The legal reform has certainly created a new paradigm requiring the framing of right-based polices and programmes by the government to be implemented in collaboration with non-governmental organisations and donors. Universal access to information and safe abortion services has the potential to significantly reduce the country's maternal mortality and morbidity. This paper examines the post legalisation challenges and barriers to accessing safe abortion services in Nepal. There are many obstacles those must be overcome before Nepalese women will be able to exercise their rights. Some of the major barriers and challenges are lack of knowledge about the law especially among rural women, inadequate access to safe and legal services, low economic status and high abortion fee, poor supportive environment including societal, cultural and religious attitudes, including stigma and not supportive attitude of rural men for women’s absolute rights to abortion and sex selective abortion. Due to all of these reasons, unsafe abortion continues to prevail in the country despite the four years of safe abortion service expansion. The prevention of unsafe abortion practices in the country and creating enabling environment for women and couples to access legal and safe abortion services as outlined in the safe abortion service procedure are daunting task and requires strategic interventions.

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      Implementing first-trimester public-sector legal abortion services in Mexico’s Federal District

      Christopher Bross, Raffaela Schiavon, Rubén Ramirez, Patricio Sanhueza (IPAS, Mexico)

      Christopher Bross, Ipas, 300 Market Street, Suite 200, Chapel Hill, NC 27516, USA

      The passage of the law legalizing first trimester abortion in Mexico’s Federal District marked an important milestone in the campaign to reduce unsafe abortion, both in Mexico and within the Latin America region. Within three days of passage of the law, women began receiving legal abortion services in designated hospitals of the Federal District’s Ministry of Health (MOH). Ipas has been providing training and technical assistance to the MOH in support of its efforts to provide high-quality abortion services. This presentation will look at the experience in launching and sustaining public sector services during the first year, training and equipping needs identified and implemented by the MOH, technical assistance provided by Ipas and selected partners, and observable trends from the official data. In particular, the presentation will provide a brief context about the law, key aspects of the official guidelines that were emitted by the MOH within 2 weeks following the law’s passage, the evolution of service provision within the health system, trends in abortion technologies utilized in public services and number and characteristics of women receiving legal abortion services in the public sector. By the end of first year, more than 8,000 women had received a legal abortion in public hospitals. The mean age of women was 25 years and 55% of abortion clients were single. Seventy-nine percent resided in Mexico City, 85% identified themselves as Catholics, 84% received their first abortion, and 57% were experiencing their first pregnancy. The mean gestational age at request was 8 weeks and in 95% of the cases, the women requested the abortion for personal reasons. Only 5% reported they were seeking an abortion because of rape, risk to health or congenital malformations. Overall, 34% of procedures were performed using sharp curettage, 29% with MVA and 37% with misoprostol alone. However, the trends in type of procedure indicate a dramatic shift away from previously common practice of sharp curettage towards misoprostol alone or misoprostol in combination with MVA.

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      In Iraq “illegal termination of pregnancy” still happens!

      Inas Alhamdani, Taghreed Alhaidari (Iraq)

      Al Elwyia Maternity Teaching Hospital and College of Medicine, Baghdad University, Baghdad, Iraq

      Background. 55.000 unsafe abortions take place all over the world, with 95% in developing countries and with more than 200 maternal deaths per day. In the Arab World 5% of all maternal deaths are due to unintended abortion related complications. The 2003, the UNFPA reports showed that Iraq has an increase in spontaneous and unsafe abortions but with no data on the exact number of illegal terminations.

      Aim. To assess how wide the problem is, throughout a survey performed in 2007 at one of the big maternity centers in Baghdad; that is Al Elwyia Maternity Teaching Hospital.

      Methodology. The current work presents an observational longitudinal study, including 322 women who present cases of illegal termination of pregnancy from a total of 3100 women who terminated their pregnancy before 24 weeks of gestation for any indication during the year 2007. All those women had a direct interview with special questionnaire, clinical examination was conducted thereafter.

      Results. Out of the total 3100 women admitted for termination of pregnancy, 322 were confirmed to have illegal termination. That represents 10. 4% of the total. Most of the patients (62%) were between 20-30 years old, with 69.9 % already having children. The most common mode of termination was the combined medical and surgical method, which has been performed by medical or paramedical staff (86,9 %). In 93.7 % of cases, pregnancy was confirmed by ultrasound. Failed contraception due to improper pills intake represents 53% of the cases. Decision for termination was taken by the wife herself in 64% of cases; mainly due to financial reasons. The most common presentation was septic abortion (86%), with 89.4% requiring 1 to 3 units of blood transfusion.

      Conclusion and Recommendations. Illegal termination of pregnancy is still an ethical, religious and medical problem all over the world, including our country. The main determining factor for termination of pregnancy amongst those women seemed to be the fact that it was unwanted and/or unplanned; either due of inappropriate timing, problems in the relationship itself, or due to social and economic implications, which are important issues in Iraq. The main problems encountered were improper contraceptive use in spite of very good awareness and/or the desire to use, as well as the abuse of misoprostol (which is not yet  approved in our country) by pregnant women and paramedical staff . There is a real need for thorough attention to update our national family planning and access to contraception policy, in order to meet the emerging social demands.There is also an urgent need to integrate abortion care related services into the overall reproductive health care, as part of a broader and safer motherhood plans.

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      Promoting misoprostol for multiple ob-gyn indications: A strategy for increasing access to safe abortion in Latin America

      Rodolfo Gómez Ponce de León, Virginia Chambers, Traci Baird, Leila Adesse and Pearl Friedberg (IPAS, United States)

      IPAS, United States

      Latin America has some of the world's most restrictive abortion laws and yet abortion is prevalent and the proportion of maternal deaths due to abortion is high. In the past two decades, misoprostol, which is widely accessible as an ulcer treatment drug, has been increasingly well known and used by women to self-induce abortion. In a few countries, health authorities have reacted to women’s own use of misoprostol by restricting access to the drug by making it available only by prescription or limiting its use to hospitals. Given the adverse political environment around abortion and the threat that misoprostol could become severely restricted, Ipas developed a regional strategy in 2004 to promote misoprostol for multiple ob-gyn indications, working closely with the Latin American Federation of Societies of Obstetrics and Gynecology (FLASOG), the Latin-American Consortium against Unsafe Abortion (CLACAI), and other partners.

      This multiple-indication approach serves to: open the door to talk with providers or policymakers about “safe” subjects, such as misoprostol for prevention of maternal deaths; increase provider knowledge, acceptance and correct use of misoprostol; reduce the stigma associated with the use of misoprostol; and reach a broad audience with information on misoprostol, even in countries where abortion is restricted. Ipas and our partners are also advocating for inclusion of misoprostol in health system guidelines and formularies for all obstetric uses.

      In 2005 FLASOG published and disseminated evidence based guidelines about the use of misoprostol for all ob-gyn indications, which serves as a key tool in educating healthcare providers on misoprostol. In 2007 this publication was updated, and 26,000 copies of the guideline, including the book, CD, and pocket-card, were disseminated to participants at national ob-gyn conferences in each country in the region. Before the formal introduction we distributed a questionnaire to a convenience sample of attendees evaluating their knowledge, use and training needs for misoprostol.

      We have had some concrete successes result from the multiple-indications strategy. For example, following the publication of the first edition of the FLASOG manual on misoprostol for ob-gyn uses in 2005, Ipas Brazil and the State Secretary of Health for Rio de Janeiro convened a working group of state hospital administrators and misoprostol experts to develop a consensus statement on ob-gyn uses of misoprostol. The consensus statement was disseminated throughout the state health system.

      In this presentation we will outline the major steps taken to promote misoprostol for a full range of ob-gyn indications, present data from surveys of ob-gyns in the region about misoprostol knowledge and use, and discuss the successes that have resulted from this strategy. We will also explore implications and recommendations for other regions.

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      Sexual risk taking for self and partner as perceived by young men in Sweden

      Maria Ekstrand, T. Tydén, M. Larsson (Sweden)

      Uppsala University, Uppsala, Sweden

      Purpose. We conducted a qualitative interview study guided by the main concepts of the Health Belief Model (HBM) in order to explore young men’s perceptions of (i) risk for themselves and their partners in connection with unprotected intercourse and (ii) the main barriers to practicing safe sex.

      Methods.In-depth interviews with 22 Swedish males aged 16-20 were analyzed using qualitative content analysis.

      Results.Risks connected to unprotected sex with a new partner (such as sexually transmitted infections and/or unintended pregnancy), were generally perceived as low. The young men calculated risks and considered preventative strategies based on perceived susceptibility, severity and whether or not risks were considered as immediate or distant. For example, HIV/Aids was by most perceived as highly severe, but few worried about personally getting infected. Chlamydia-infection was associated with high susceptibility, but most viewed Chlamydia as an infection which would not do much harm. The young men worried more about the personal consequences regarding sexual risk taking; eventual consequences for a temporary partner were of minor concern. No one wanted to become a teenage father, but most were confident that any resulting pregnancy would not be carried to term; this led to decreased motivation for sharing pregnancy-preventing practices with their partner.

      The main barriers to condom use were interference with spontaneity, pleasure reduction, fear of loosing erection, and embarrassment or distrust. Other obstacles were the girl’s use of hormonal contraception, and difficulties in communicating about safe sex.

      Conclusion.Male disengagement and uneven gender distribution in issues regarding sexual and reproductive health are matters of concern. Helping young men gain confidence in their abilities to share contraceptive responsibility with their partners, and challenging the contemporary picture of western masculinity, may constitute important public health strategies for protecting young people’s sexual and reproductive health.

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      Women’s perceptions of viewing ultrasounds before and products of conception after an abortion

      Ellen Wiebe (Canada)

      Willow Women’s Clinic, 1013-750 West Broadway, Vancouver, BC V5Z 1H9, Canada

      Introduction. Anti-choice organizations often use pictures of ultrasounds and products of conception in their campaigns. In the past, it was common for staff at abortion clinics to prevent women from seeing the ultrasound pictures (US) before the procedure or the products of conception (POC) because they thought it would upset them unnecessarily. In recent years, it has been more common to offer the choice. There have been no reports published on women’s perceptions of seeing POC at the time of their abortions. There is only one report about US showing that many women want to see US and concluding that women should be offered a choice. The purpose of this study was to offer women the choice to view US and POC and discover what the experience was like for them.

      Data-Collection Methods. This was a questionnaire study of women presenting for abortion. Before the ultrasound and procedure, women answered questions about whether they wanted to see the US and POC and what they expected to see and feel. Those women who chose to view the US and/or POC were asked about their perceptions afterwards.

      Summary of Results. There were 311 women who answered the first questionnaire about ultrasound and 214 (68.8%) chose to view. Women were more likely to choose to view if they were younger (p=.04), had no children (p=.001) or were East Asian (p=.03). Of the women who chose not to view the US, 43% expected that it would make it harder on them emotionally compared to 10.2 % of the women who chose to view. After viewing the US, 209 women answered the second questionnaire and 34 (16.2%) said they found it harder emotionally.  Of 452 women who answered the first questionnaire about POC, 123 (27.2%) wanted to view. There were 117 women who answered the follow-up questionnaire about viewing POC and 18 (15.4%) said it was harder emotionally. Comments included “it made it easier”, “I thought I would see more”.

      Conclusion. Offering women the choice to view the ultrasound and the products of conception after first trimester termination allows women opportunities to explore personal preferences. For most women who choose to view, it is a positive experience and may improve the quality of services for abortion care.

  • 14:00-
    16:00
    Workshop 09 Local anaesthesia in surgical abortion
    Chair:
    • Giovanna Scasselatti, IT
    • André Seidenberg, CH
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      Anatomy and clinical aspects

      André Seidenberg (Switzerland)

      Zürich, Switzerland

      Local anesthesia is the method of choice for an induced abortion by the surgical suction method. This is the evidence based recommendation of the WHO (2003) and the official British (RCOG 2004) and French guidelines (ANAES 2001). A general anesthesia is not recommended as method of choice for an induced abortion by the surgical suction method.

      These recommendations are mainly based on an old CDC-study comparing the mortality following abortion with local anesthesia versus general anesthesia (Peterson 1981, Lawson 1994). Deaths caused by induced abortion at less than 12 weeks gestation are rare in developed countries offering a good access to contraception and abortion treatment: In the USA 8.5 deaths among 1 million legal induced abortion cases were found. According to the CDC-study almost four times more woman died by general anesthesia than by local anesthesia for an induced abortion by the surgical suction method. These correlations were also visible analyzing only deaths not directly caused by the method of the anesthesia: 3½ times more woman died after general anesthesia than after local anesthesia. The same correlations revealed when biases as sterilization, preexisting diseases, or duration of the gestation were considered for the calculations: general anesthesia remained minimally 2.5 times riskier than local anesthesia. Younger studies with morbidity end points revealed the same technical advantages of the local anesthesia compared to general anesthesia for an induced abortion by the surgical suction method (Pons 2004, Thonneau 1998, Osborn 1990). With general anesthesia (without Halothane®) more uterine perforations, cervical lesions, and severe bleedings were recorded (Soulat 2006, Osborn 1990).

      Experience and good surgical technique (Hern 1990) are crucial. A French thesis (Ambassa 2007) of last year gives an overall view on local anesthesia for an induced abortion by the surgical suction method. Priming (with 2 tabs Misoprostol intra vaginally) is recommended 3 hours before the operation. Only the cervix is anesthetized, which alleviates dilation. The pain caused by the uterine contraction during and after the suction procedure is not influenced by the local anesthesia. The sensible nerve fibers deriving from the inferior hypo gastric plexus enter at the isthmus of the uterus. Be aware of the close neighborhood of these blood vessels and be careful with avoiding intra vascular injection. The maximum of 3 mg / kg Lidocain (≈ 20 ml of a 1% solution) should not be exceeded. All deaths caused directly through local anesthesia were due to overdose (Peterson 1981).

             

      Para Cervical Infiltration / Para Cervical Block

      Intra Cervical Infiltration

      Trans Canalicular Infiltration

      Sub Epithelial Infiltration Modified acc. Ambassa 2007

      There are principally 2 techniques for the infiltration of the local anesthetic (Ambassa 2007): the para cervical block and the intra cervical Infiltration. Many variants are used in practice. For the para cervical block the anesthetic depot is injected at 4 and 8 a clock in 2-5 mm depth.  For intra cervical infiltration often a 2% solution of Lidocain is used. Addition of Adrenalin is not recommended because diffusion is suppressed and a longer effect of the anesthetic is not needed for cervical the dilation. Adrenalin additionally accentuates side effects as there are oppression and palpitations.

       

      Comparing pains the local anesthesia for induced surgical abortion causes an acceptable level of analgesia (Ambassa 2007). E.g. pains during the cervical dilation are comparable  to menstrual pains.

      Regardless of the lower costs many woman prefer the local anesthesia to general anesthesia for induced abortion by the surgical suction method (Bachelot 1992).

      Sildes: Anatomy and clinical aspects
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      Comparison between local and general anaesthesia

      Philippe Lefèbvre, Marie Duriez (France)

      Service d’Orthogénie (Hospital Family Planning Service), Roubaix, France

      Aim. To identify potential risk factors of inefficiency for elective medical termination of pregnancy based on records of failures of this technique in a hospital environment.

      Patients and methods. A retrospective study was conducted on elective medical pregnancy terminations performed up to 49 days post amenorrhoea in the Family Planning Service of Roubaix hospital between January 1st 2001 and December 31st 2005.

      The service's termination protocol consists in an oral dose of 600mg mifepristone, followed by an oral dose of 400mg misoprostol 48 hours later. A 2nd oral dose of misoprostol (400mg) is given 3 hours later if there has been no expulsion. Every patient is required to return 15 days later to check their bHCG levels.

      Failure is defined as ongoing pregnancies, total or partial retentions, and cases requiring emergency surgery. Success is defined as complete abortion requiring no additional surgical or medical treatment.

      Five items were analysed: patient age, patient parity, duration of pregnancy, bHCG levels on the day mifepristone (D1) was given, and the dose of misoprostol received.

      Results. 1,975 medical terminations were performed during this period. 125 (6.33%) of these patients did not return to be checked and have been excluded from the study. The analysis was thus performed on 1,850 patients.

      The method was a success in 97.08% of cases (1,796/1,850). 54 failures (2.92%) were recorded, including 7 ongoing pregnancies (0.38%). Patients for whom the method resulted in a success compared to patients who had failures have a significantly lower age. The duration of pregnancy was not different for the two groups. Nulliparous (873/1,850) patients had significantly fewer failures (12/873: 1.37%) than multiparous patients (42/977: 4.30%). Age is significantly higher for failures amongst the nulliparous patients. Conversely, for patients who have had at least one child, age is not a determining factor.

      28 patients did not receive any misoprostol because they expulsed prior to the 48th hour (1.51%). Amongst the 673 patients who received only a single dose of misoprostol, 11 (1.63%) required additional actions including one emergency admission for haemorrhage. Amongst those who received two doses of misoprostol, 43 failed (3.74%), including 2 re-admitted the same day for haemorrhages and 1 for pelvic pains.

      Discussion and conclusion. The overall efficiency results for the method are excellent despite an exhaustive and detailed analysis of the failures. The various studied factors have demonstrated that there is an increase in failure rates for the method with parity and, to a lesser extent, with the patient's age. High plasma beta HCG levels are also seem to be more often associated with failures of the method. The addition of a second dose of misoprostol is likely to increase the chances of an expulsion during the hospital stay but, this non-comparative retrospective study can not conclude on the beneficial effect of a second dose of misoprostol on overall efficiency.

      Finally, it should be noted that none of the criteria evaluated in this study can be used as a diagnosis factor to predict the outcome of an elective termination as none of them has the sensitivity / specificity that is required to identify 'at risk' patients from amongst other patients.

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      How frequently is it done? Possible reasons for the huge regional differences

      Anne Verougstraete (Belgium)

      Sjerp-Dilemma-VUB: Family Planning and Abortion Centre: Vrije Universiteit Brussel; Hôpital Erasme: Université Libre de Bruxelles (Obstetrics), Belgium

      Surgical abortion is a very safe procedure and with local anaesthesia it is safer than with general anaesthesia. This has been repeated by WHO (2003), the RCOG (2004) and ANAES (2001).

      In Europe, there are huge regional differences in the anaesthesia used for surgical abortion, and in a given region, some hospitals perform the procedure only under local anaesthesia and others only under general anaesthesia. It seems very unlikely that these differences reflect the choice of women!

      Possible reasons for the regional differences:

      • Routine habits in hospitals;
      • the hospital earns more money if the procedure is done under general anaesthesia;
      • poor management of local anaesthesia, so that the procedure is too painful;
      • no proper accompaniment available in surgery wards of hospitals;
      • a growing number of women choose “not to be there” at the moment of the abortion;
      • general anaesthesia is no option in outpatient abortion centres.

      Conclusion. Local anaesthesia is, medically speaking, safer than general anaesthesia. With a proper technique (priming of the cervix, local anaesthesia and oral painkillers) and a good accompaniment, it is accepted by most women. Ideally, women should have the right to choose which anaesthesia they want for their abortion. In the workshop we will discuss how it is in your region, and the reasons why.

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      Presenting a recent review

      Nathalie Ambassa, K. Bourzoufi, Francis Collier (France)

      Orthogenics and medicine of the couple department, Hôpital Jeanne de Flandre, CHRU Lille, France

      Objective. Two different local anaesthesia techniques are commonly used for pain relief during first-trimester surgical abortion: paracervical block (PCB) or intracervical injection (ICI). The superiority of one technique versus the other has not been clearly established. In practice, the choice between these two techniques is made empirically, according to specific habits of each centre or each practitioner. This prospective observational study compared the effectiveness and acceptability of these two techniques to reduce pain during first-trimester surgical abortion following cervical priming with misoprostol.

      Patients and methods. Two-hundred and forty-nine women undergoing suction evacuation up to 12 weeks gestation were randomized into two groups: (ICI) 5 mL of 2% lidocaine injected at the 4 and 8 o’clock positions of the cervix; (PCB) 10 mL of 1% lidocaine injected at the 4 and 8 o’clock positions of the vaginal vault. Using a 0-10 scale, women rated pain associated with local anaesthetic administration, cervical dilatation and during and after suction evacuation. Pain scores, post-operative analgesic demand and satisfaction levels were compared among the two groups.

      Results. Pain levels during local anaesthetic administration were significantly lower (p<0.0001) in the paracervical group (2.1±2.1) than in the intracervical group (3.9±2.4). There were no statistically significant differences in the pain scores during cervical dilatation and suction evacuation. Post-operative demand for analgesics was significantly (p=0.0286) higher in the intracervical group. There was no difference between the groups concerning the global satisfaction of the patients (p=0.2489).

      Conclusion. The paracervical block is less painful and at least as effective against the pains related to the cervical dilatation as the intracervical injection. Therefore, the paracervical block seems to be the technique of choice in first-trimester surgical abortion under local anaesthesia. This study should lead to a modification of our practice in Lille with a broader use of the paracervical block for our patients. 

      Sildes: Presenting a recent review
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    Workshop 10 The role of counselling in abortion care
    Chair:
    • Marijke Alblas, ZA
    • Maria Francès- Kircz, NL
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      Challenges in contraceptive counselling in abortion care

      Olga Loeber (The Netherlands)

      Mildredhuis, Centre for Contraception, Sexuality and Abortion, Arnhem, The Netherlands

      Use of contraception prior to abortion
       

      One would assume there is no problem: all forms of contraception are possible after an uncomplicated first trimester abortion. Moreover in the clinics in the Netherlands there is always attention to contraceptive counselling after abortion. So, why is the repeat abortion so high?

      In the eighties this percentage was around 25%, now it is more than 36%. The abortion rate is also higher: in 1992 this was 5,5 per 1000 women in the fertile age, in 1999the rate was 7,4  and in 2006 the rate was 8,6.

      Apparently for some women effective use of contraception is a growing problem. Ineffective use of contraception is directly related to use of less effective methods but also to personal factors. Personal ideas that can cause ineffective use are opinions like: all those hormones cannot be good for you, he should use something; using contraception means you have a stable relationship or want to have sex.

      A survey in Sweden of the characteristics of the women with a repeat abortion showed a psychological vulnerability: they had many problems and a feeling of insecurity towards partners and contraceptive use. The cause of the contraceptive failure was not the lack of knowledge or information, but the lack of the ability to integrate this in actual behaviour.

      Other research in the Netherlands showed that these women do not seem to learn from former experiences.

      A last factor seems to be related to country of origin. In the Netherlands many women who have a (repeat) abortion come originally from other countries. About 57% of our abortion clients is born in another country, a huge overrepresentation compared to the general population. This group uses more often no contraception at all and makes more mistakes in using the pill, condoms are unpopular. Among the countries of origin differences are apparent because of differences in background, per region and in culture.

      Compared to the Netherlands the contraceptive use in other countries can be very different from that of the Netherlands due to

      • different man/woman relations,
      • religious conceptions,
      • availability of contraception,
      • fear of some forms of contraception,
      • fertility wishes,
      • discussion of sexual matters can be taboo.

      These differences are important in counselling women about contraception after abortion, so as to find the best contraceptive choice for this one individual patient in front of you.

      Conclusions and recommendations.

      • Thorough knowledge of contraceptive problems and solutions
      • Attention to factors responsible for failure of contraception
      • Knowledge of cultural factors
      • Counselling with these factors in mind
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      Counselling in 2nd trimester: What do women need?

      Mariet Lecoultre (The Netherlands)

      Beahuis & Bloemenhove Kliniek, The Netherlands

      From 7 weeks LMP onwards, the Dutch Pregnancy Termination Act (1984) provides for a mandatory five-day consideration period. The actual abortion can take place in at least 5 days after a first consultation with a doctor. During this initial doctor’s appointment the GP/MD must inform the woman of the alternatives available to her. The woman herself decides whether she continues her pregnancy or not.

      In 2006 32,992 abortions were performed in the Netherlands. 13.7 percent of these interventions concern women who are non residents of the Netherlands. Due to the restrictive law in their respective countries, these women have to travel to another country for the intervention. As in the previous year, 15.2 percent involved second-trimester abortions from 14 weeks LMP onwards. 70% of these second trimester abortions concerned non Dutch residents. The great majority (94.3 percent) of the interventions in Holland takes place in one of the 16 specialized abortion clinics and is done by general practitioners.

      The Centre where I work is specialized in second trimester abortions. We perform interventions till 22 weeks am. Many of the women we see have gone through various and sometimes difficult stages in their demand for a termination due to the fact that they have passed the legal delay for an abortion in their home country or have consulted a doctor who has ethical difficulties in dealing with second trimester abortion and refuses to refer her to a clinic where she could have the intervention.

      Although there is not much difference in second and first trimester counseling it is our  experience that all women have to be offered the possibility to discuss their demand. The true conviction of our entire staff is that it is only the woman who can decide and consequently counseling should be superfluous unless the woman indicates that she needs a consultation about her decision with a professional. However, as we are bound to a law which is not so liberal – contrary to what many may believe from the Netherlands – I will focus my presentation on the typical Dutch model we have developed to work within the framework of this law and at the same time leave the responsibility of the decision to the woman.

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      Obligatory counselling: Germany's example

      Ulla Ellerstorfer (Germany)

       

      Today, 2008, far away from the sixties and seventies, sexuality and moralities have changed. With one exception. When a woman and a man are making love, having sex with each other, the possibility to become pregnant has not changed for a woman, who can be fertile for more than thirty years. Getting pregnant is no more unusual than forty years ago. Self-determined sexuality does still include fertility.

      In case of being pregnant unexpectedly, it seems, everything today runs smoothly and easy for her. Rare complications in case of abortion, no more long-lasting diseases and no more deaths. There are cost-free counselling services offered by different service-providers which a woman can choose from. The out-patient medical treatment, mostly in day-clinics, is of good quality and includes different methods of abortion.

      Don’t you agree, there is nothing to complain about in Germany?

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      No compulsory counselling: The advantages for women

      Margot Schaschl (Austria)

      Gynmed Clinic, Vienna, Austria

      Austrian law only requires counselling by the medical doctor. This is usually no more than a standard medical conversation about informed consent. There are no other regulations, and no requirement for further counselling, nor does the law provide for any compensation for such counselling.

      Our experience has shown that more than 90% of the women who come to us for an abortion have already made their decision. In most cases, the decision is made quickly, within a few days, usually with advice and support from a partner, family, or friends. Many women also search the Internet for information. But most women do not need professional counselling to make a decision.

      The advantages of the Austrian system for women are:

      • The woman does not have to visit a counselling centre, which usually incurs extra effort and financial costs (i.e. taking time off work or school, travel expenses, childcare, etc.)
      • For advanced pregnancies, each day counts and the extra time needed for compulsory counselling can put a woman past the legal deadline.
      • A rapid appointment is possible. This offers a better possibility to choose between medical and surgical abortion.
      • The woman need not justify her decision in front of a stranger, thus respecting her privacy and reducing the psychological pressure.
      • Less emotional stress means less problems, pain and fear when the abortion is done.
      • Unnecessary concerns are not raised or fuelled.
      • The decision remains self-determined by the woman. This helps her “own” it, so she can accept the responsibility and live with her decision more easily.

      The basis for the counselling is accepting and respecting the woman’s decision. To challenge her decision is neither fair nor professional. On the contrary, being too investigative can lead to paternalism.

      Another key element of the counselling is that each woman knows best about her present life circumstances. Therefore, only she can decide if she needs assistance in her situation.

      Professional counselling is good and necessary. Nevertheless it should be voluntary, patient-directed, and individually adapted for each woman.

      There are few things that could do more harm than biased counselling that tries to lead the woman to a particular decision. That can lead to indoctrination.

      Sildes: No compulsory counselling: The advantages for women
      PDF-Format (74.06209677419355kB)
    Workshop 11 → ESC session (European Society of Contraception)
    Chair:
    • Teresa Bombas, PT
    • Medard Lech, PL
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      Challenges in post-abortion contraception

      Oskari Heikinheimo (Finland)

      Department of Obstetrics and Gynecology, Helsinki University Central Hospital, POBox 140, 00029-HUS, Helsinki, Finland

      The influence of contraceptive use and counseling on the risk of repeated abortion is unclear. In a recent prospective study, specialist counseling and provision of contraceptives did not have an effect on the rate of repeated abortion (Schunmann and Glasier, Human Reproduction, 2006). However, in randomized clinical trials the use of intrauterine contraception, initiated at the time of surgical abortion, has been effective in reducing further unintended pregnancies (Pakarinen et al., Contraception, 2003).

      We analyzed recently risk factors for repeat abortion among a cohort of 1269 women undergoing medical abortion between August 2000 and December 2002 (Heikinheimo et al., Contraception, 2008). Contraceptive use was assessed at the time of follow-up performed at 2-3 weeks following the abortion; intrauterine contraception was initiated at the clinic at the time of follow-up, or within 2 months. The subjects were followed prospectively via the Finnish Registry of Induced Abortions until December 2005, the follow-up time (mean ± SD) being 49.2 ± 8.0 months.

      In comparison with combined oral contraceptives, use of intrauterine contraception was most efficacious in reducing the risk of another pregnancy termination. In multivariate analyses the hazard ratios (95% Cl) of repeat abortion were 0.33 (0.16 to 0.70) among Cu-IUD users and 0.39 (0.18 to 0.83) among LNG-IUS users when compared to users of combined oral contraceptives. The incidence of repeat abortion was highest among women the postponing initiation of contraceptive use.

      Contraceptive choices made at the time of abortion have an important effect on the rate of re-abortion. Use of intrauterine contraceptives for post-abortal contraception is most efficacious in decreasing the risk of repeat abortion.

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      Future contraceptive methods: What to look forward to?

      Regine Sitruk-Ware (United States)

      Rockefeller University and Population Council, New York, United States

      Contraceptive research will build upon advances in biomedical research, which have created new opportunities for studying the basic biology of reproduction. Basic research could, in turn, lead to the discovery of novel targets for contraception. The novel technologies of genomics, proteomics, lipidomics, and glycomics, has great potential in the identification of protein targets and their regulatory genes specific to the reproductive system. Developing small molecules that will inhibit these targets to stop the reproductive processes would allow more specific approach to contraception. In addition the progress made in the drug delivery area may also facilitate the development of advanced contraceptive systems in the future.

      New methods currently under development are designed to meet the challenges of expanding contraceptive choices for both women and men and, of answering an unmet need for contraceptives that would satisfy new categories of users. Long-acting systems would be preferred to improve compliance and easiness of use. Both IUDs and implants are now widely available; transdermal gels and sprays are in early stages of research and a one-year contraceptive vaginal ring is in the last stages of development. All these delivery systems are based on the use of steroidal hormones delivered continuously at very low doses, which suppresses ovulation in cycling women.

      In other cases, the provision of an additional health benefit may increase compliance with contraceptive use. Current contraceptive methods do have many benefits: some improve menstrual bleeding patterns, alleviate dysmenorrhea and acne, and sometimes pre-menstrual syndrome. Others can produce amenorrhea and help prevent anemia.  Should new contraceptive methods provide additional protection against breast cancer they would also have wide appeal.  In addition, dual-protection methods which join contraceptives to antiretroviral agents to protect women against both unwanted pregnancy and transmission of human immunodeficiency virus (HIV), would meet a major need. Men now tend to accept the concept of taking responsibility for the control of the couple’s fertility, leading to a growth in requests for male contraceptives, an emerging and challenging area of research.

      Above all, new contraceptives, which are designed to be used by healthy men and women, should be very safe and easy to use, reversible, as well as affordable.

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      Hopes for new male contraception: Are they realistic?

      Eberhard Nieschlag (Germany)

      Centre of Reproductive Medicine and Andrology, University Hospitals, 48149 Münster, Germany

      The world population continues to grow rapidly while resources for sustainable living dwindle and manmade ecological problems increase proportionally to the overpopulation. Family planning is required to reduce population growth in developing countries and to stabilize populations in developed countries. Contraception makes abortion superfluous and provides the key to family planning. Women increasingly demand that men share the burden and risks of contraception and – as opinion polls show – men would be willing to use contraceptives if they were available. Research has established the principle of hormonal male contraception based on suppression of gonadotropins and spermatogenesis. All hormonal male contraceptives use testosterone, but only in East Asian men can testosterone alone suppress spermatogenesis to a level compatible with contraceptive protection. In Caucasians additional agents are required of which progestins are favoured. Clinical trials concentrate on testosterone combined with norethisterone, desogestrel, etonogestrel or DMPA. The first randomized, placebo-controlled clinical trial performed by the pharmaceutical industry demonstrated the effectiveness of a combination of testosterone undecanoate and etonogestrel in suppressing spermatogenesis in volunteers. However, the two companies involved left the field of male contraception when they were taken over by other firms. Hopes now rest on organisations such as WHO and the Population Council that they may develop modalities for male contraception attractive enough to be marketed by industry.

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      Is there a place for observing fertile periods?

      Ellen Wiebe (Canada)

      Willow Women’s Clinic, 1013-750 West Broadway, Vancouver, BC V5Z 1H9, Canada

      In abortion clinics we see many women who conceived while taking hormonal contraception, usually the “pill”. It is important to understand why these women have failed contraception in order to help with them with their choices for the future.

      Often women blame themselves or are blamed by others for the failure because they missed a pill or were not “compliant”. A study using computerized pill packages showed that over 60% of women who did not get pregnant missed at least one pill each month. Therefore, missing one or two pills in a cycle does not explain the failure.  The most important risk factor for oral contraceptive failure is a previous failure according to a study of 769 women who presented for an abortion saying that they had taken all their pills. Anecdotally, it was observed that many women presenting for abortion had conceived early in their cycles. Our hypothesis was that there is a subset of women having contraceptive failure because they ovulate early and therefore their method of contraception is ineffective.

      We did a retrospective chart survey of data we normally collect in our abortion clinics, i.e., the LMP dates, whether the cycle is regular and the last period normal, the gestational age of the pregnancy and what form of contraception was used during the month of conception. We reviwed 913 charts reviewed of women presenting for an abortion with an intrauterine pregnancy of less than 63 days gestation as determined by endovaginal ultrasound and who said they were “sure” of the date of their last normal menstrual period. Their mean age was 28.4 years with a range of 14 to 47 years. The mean gestational age was 42.3 days with a range of 32 to 63 days. About half were white Caucasians and most of the rest of Asian descent. The mean cycle day of conception was 14.6 with a range of 1 to 40 and the mode was 15. There were 26/99 (26.3%) of women using cyclic hormonal contraception who conceived before Day 10 of their cycle compared to 100/679 (14.7%) using all other forms of contraception. (p=.004). There were no other differences in day of ovulation with respect to age, ethnicity.

      Conclusion. There is an important subset of women who ovulate early and therefore the usual pattern of hormonal contraception may have a higher failure rate for these women.

    Workshop 12 Free communications
    Chair:
    • Sam Rowlands, GB
    • Kevin Sunde Oppegaard, NO
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      Choosing induced abortion: an existential event?

      Maria Liljas Stålhandske (Sweden)

      Centre for the Study of Religion and Society, Faculty of Theology, Box 511, 751 20 Uppsala, Sweden

      How do Swedish women cope with early induced abortion as a life event? This paper raises the issue of women’s existential needs in relation to abortion. Material from an ongoing empirical study, including interviews with women who have had an early abortion and personnel working in abortion care, will be presented. The study works out of a feministic perspective and aims at bringing a partly tabooed question connected to female reproductivity into the scholarly discussion. The aim is not to question the liberal abortion legislation in Sweden, which the author endorses.

      To make an induced abortion is to make a crucial decision. Current Swedish abortion research shows that the decision often comprises strong and conflicting emotions. For many women it means to go through a period where feelings of pride, desperation, relief, grief and emptiness succeed each other. At the same time abortion is not included among those life events that people normally share and manifest through religious and/or social rituals and traditions. The consequences of this for women’s existential wellbeing have not yet been studied in international research.

      The preliminary results of the study indicate that the need of existential and/or ritual processing is dependent upon the degree to which the woman experienced the abortion decision as difficult or ambivalent. When ritualizations of the event occur, they also seem to take different forms depending on how the woman relates to the aborted fetus.

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      Effectiveness of intracardiac potassium chloride for feticide prior to termination of pregnancy between 20 and 24 weeks

      Emeka Oloto (Great Britain)

       

      Background.There is a rising trend in the number of abortions carried out for England and Wales residents and the total was 193737 in 20061. Only 1.5% (2948) of these was carried out at 20 weeks and over of which 34% (1002) were reported as involving feticide. In United Kingdom, termination of pregnancy (TOP) can only be carried out in a National Health Service (NHS) hospital or in a place approved for the purpose by the Secretary of State for Health (non-NHS setting). In 2006, 75328 (39%) of all abortions were performed in the NHS hospitals of which 679 (<1%) were at gestations of 20 weeks and above. The distribution of the feticide procedures between the two settings was not obvious from the published data1.

      Objective. This study was conducted to assess the effectiveness and safety of intracardiac Potassium Chloride administration in inducing fetal demise prior to second trimester pregnancy termination in a non-NHS setting.

      Patients and Methods.Data regarding the age, parity, gestation, dose of KCl required to achieve asystole, presence or absence of cardiac activity at delivery or immediately before surgery, duration of procedure (from entering to leaving the theatre) and complications were prospectively collected in an excel spreadsheet from February 2007 till date. The feticide was carried out in theatre under general anaesthesia, aseptic conditions and continuous ultrasound guidance. A 16 cm 17-G Chiba needle (Cook Ob/Gyn, Spencer, Indiana, USA) was inserted into the fetal heart and a concentrated KCl (15% , 20mM/10ml ; B-Braun Melsungen AG, Germany) was injected 1 ml at a time until fetal asystole was achieved. A minimum of 5 mls of KCl was given in each case but the dose required to achieve asystole was recorded. Fetal cardiac activity was then observed for about 1-2 minutes to confirm that asystole persisted, but scan was not repeated thereafter. Anti-D immunoglobulin (500 iu) prophylaxis was given to all RhD-negative women. Following feticide, labour was induced for those undergoing medical TOP and surgery the following day for the rest.

      Results.Till date241 feticide procedures have been carried out for women between 20 and 24 weeks gestation (mean gestational age of 22 weeks) of which 2 (0.8%) failed to achieve fetal demise. Fifty women (21%) had medical TOP while the rest had surgery. The average age of the patients was 22 years (range 13 – 42 years) and the average parity was 1 (range 0 – 5). 48% of the women were teenagers. The average duration of procedure was 12 minutes (range 5 – 40 minutes) and the average dose of KCl required to achieve asystole was 3 mls (range 1 – 15 mls). No live birth occurred and no maternal complication. The two cases where feticide failed were for planned surgery which was carried out successfully.

      Discussion.The Royal College of Obstetrician and Gynaecologists (RCOG) recommended that the method chosen for all terminations at gestational age of more than 21 weeks and 6 days should ensure that the fetus is burn dead. Feticide prior to TOP at late gestation is necessary to avoid resuscitation dilemma for patients, nurses and doctors2; to avoid medico-legal and economic consequences of live birth that survives3; to shorten the mean ‘initiation-expulsion interval4; to reduce the prostaglandin requirement for mid-trimester medical abortion5; and to soften fetal cortical bones which aids surgery and minimises risk to the patients4. Of the available methods for feticide6, intracardiac injection of potassium Chloride (KCl) appears to be the most effective. The average dose of KCl required in this study (3mls) is similar to that reported recently7, but much less than the amount reported by Bhide et al.8

      Conclusion.This is, to my knowledge, the first report of the experience of using intracardiac KCl for feticide prior to mid-trimester abortion in non-NHS setting in United Kingdom. It is an effective and safe procedure in non-NHS settings with appropriately trained team and should not be limited to tertiary fetal medicine unit as suggested by Pasquini et al.7

      References.

      1.      Department of Health Abortion Statistics, England and Wales: 2006, Statistical Bulletin 2007/xx. London: Department of Health 2007.

      2.      Royal College of Obstetricians and Gynaecologists. Further Issues Relating to Late Abortion, Fetal Viability and Registration of Births and Deaths. RCOG Statement London; RCOG Press; 2001.

      3.      Clark et al. An Infant who survived Abortion and Neonatal Intensive Care. Blumenthal PD et al. Abortion by Labour Induction. A Clinician’s guide to Medical and Surgical Abortion.

      5.      Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstet Gynecol 1999;94:139-41.

      6.      National Abortion Federation – Clinical Practice Bulletin: Digoxin Administration. May 2, 2007.

      7.      Pasquini L, Pontello V, Kumar S. Intracardiac injection of potassium chloride as Method for feticide: experience from a single UK tertiary centre. BJOG 2008;115(4):528-531.

      8.     Bhide A, Sairam S, Hollis B et al. Comparison of feticide carried out by cordocentesis versus cardiac puncture. Ulrasound Obstet Gyncol 2002;20:230-2.

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      Ibuprofen and paracetamol for pain relief during medical abortion

      D.S. Seidman, A. Livshitz, R. Machtinger, G. Yerushalmi, Y. Ben David, M. Spira, A. Moshe-Zahav, L. Lerner Geva, E. Schiff (Israel)

      Department of Ob. & Gyn., Women and children's research unit and Gertner Institute for Epidemiology, Sheba Medical Center, both affiliated to Sackler School of Med., Tel-Aviv University, Tel-Aviv, Israel

      Background. Non-steroidal anti-inflammatory drugs (NSAIDs) have long been avoided in pain relief protocols for medical abortion because of concern over their potential inhibition of prostaglandin induced uterine contractions. 

      Objective. To determine whether the use of the ibuprofen for pain relief is effective and whether it can adversely affect the outcome of medical termination. 

      Methods. In a prospective double-blind controlled study 120 women undergoing medical abortion with 600 mg oral mifepristone and 400 mcg oral misoprostol were randomized to receive ibuprofen or paracetamol when pain relief was necessary.

      Results. Ibuprofen was found significantly more effective (p<0.0001) for pain relief after medical abortion compared with paracetamol. Other parameters that significantly influenced the pain score after administration of the analgesics included the pain score before the analgesia and abortion in the past. There was no difference in the failure rate of medical abortion, and the frequency of surgical intervention was slightly higher in the group that received paracetamol (16.3% versus 8.5%).

      Conclusions. Ibuprofen was found highly efficient for pain reduction during medical abortion and more effective than paracetamol.  We also found that a past history of a surgical or medical abortion was predictive for high pain scores.  Importantly we found that despite its anti prostaglandin effects ibuprofen did not interfere with the action of misoprostol and was not associated with an increase in surgical interventions.

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      IUD after medical abortion: Should it remain underused?

      Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)

      University Hospital of Marseille, France

      Objective. Immediate post-abortum IUD insertion remains an underused option in daily practice. We evaluated the safety and acceptability of IUD insertion shortly after medical abortion at the office.

      Patients and Methods. In a prospective series of 300 women who underwent medical abortion in a private office before 49 days, we observed the incidents that occurred among the 104 patients (34,6%) that opted for an insertion of IUD shortly after abortion. Uterine vacuity had been controlled by ultrasound between the 8th and 12th days post abortum. IUD were inserted between the 8th an 30th day following abortion. None of the patients had received prophylactic antibiotics. 62 (60%) patients had hormonal IUD and 42 (40%) had Copper IUD.

      Results. Women’s mean age was 31 years, 26% were nulliparous and 37% had already had previous abortions. None of the patients had long term reversible contraceptions before requesting an abortion and only 5 (1,6%) had used emergency hormonal contraception. 72% of IUD were inserted at the control visit on the 8th day. When uterine vacuity seemed incomplete, IUD insertion was postponed but for 90% of our patients insertion was possible before day 30. No mechanical (expulsion or perforation) and no infectious complications were registered. At insertion, the mean pain score on an analogical visual scale was 2/10. Mean duration of bleeding following IUD insertion was 6.5 days. With a follow up of 24 months in our database, 8 patients (7,7%) requested IUD removal : in 2 cases because of pelvic pain but no evidence of pelvic inflammatory disease, in 2 cases for excessive bleeding and in 4 cases for desire of pregnancy.

      Conclusion. Our preliminary findings suggest that IUD may be offered shortly after an induced medical abortion before 49 days. When such method is chosen by the patients, safety and continuation rates seem high. Proposing an IUD immediately after a first trimester abortion at the office may help reduce repeat abortions.

      Sildes: IUD after medical abortion: Should it remain underused?
      PDF-Format (50.04677419354839kB)
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      Outpatient use of mifepristone and misoprostol before and after 8 weeks gestation

      Marisa Moreira, Renato Martins, Teresa Bombas, Teresa Sousa Fernandes, Manuel Pitorra, Maria Céu Almeida, Paulo Moura (Portugal)

      Genetics, Reproductions and Fetal Maternal Medicine Department, Coimbra University Hospitals, and Bissaya Barreto Maternity, Coimbra Hospital Center, Portugal

      Introduction. Since 16th of July of 2007, abortion is legal by women request before 10 weeks. The use of medical abortion is associated with lower complications. According to OMS protocols, the use of Mifeprostone and Misoprostol for abortion in out patient therapy can be used, for early pregnancies.

      Objectives. We analyzed the use of medical therapy in abortions under 10 weeks gestational age comparing two groups – under 8 weeks (Group 1) and between 8 and 10 weeks (Group 2).

      Material and Methods. We analyzed the clinical reports of women that came for abortion, during one year of experience, since 16th of July of 2007, in both medical facilities of Coimbra.

      Results. We included 600 women. The average age was 28.2 ± 7.6 years. Most women are Portuguese (about 90%) and lived in Coimbra. More than half of these women are married and live with their partner. The authors split these women into 2 different groups: Group 1 (before 8 weeks gestacional age) with 450 women, and Group 2 (between 8 and 10 weeks) - 150. Both groups showed no statistical difference in all demographic aspects analysed. In terms of abortion method, correlation between the 2 groups revealed no statistical difference. Both groups revealed 5% complications, mainly due to failure of medical therapy. Between the two groups no statistical difference was found in terms of complications.

      Conclusions.The use of medical abortion in out patient regimen can be safely used. The authors showed in this study that results between two different groups had no statistical significance. Moreover, when questioned, patients showed a high level of satisfaction with this protocol.

      Sildes: Outpatient use of mifepristone and misoprostol before and after 8 weeks gestation
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      Perception of pain during misoprostol-induced medical abortion

      Marja Tikka, Satu Suhonen, Timo Kauppila, Seppo Kivinen (Finland)

      Helsinki University Central Hospital, Finland

      Counselling, information about the process of medical abortion as well as sufficient pain relief are important factors when a woman chooses medical abortion. Menstrual pain, parity and woman’s age may influence pain perception and satisfaction with the chosen method of abortion. Medical abortion can be performed with misoprostol administered in home. How painful the abortion experience is, and can this pain be predicted would be useful to know when medical abortion is chosen and especially when home-use of misoprostol is planned.

      Fifty-six women who had chosen medical abortion were allocated in this study. Their mean age was 26.2 years (SD 6.2, range 15-43). On the day the medical abortion was started, the median length of pregnancy evaluated by transvaginal ultrasound was 47 days (range 32-63). This was the first pregnancy for 4 women. Altogether 29 women (51.7 %) were nulliparous.

      The women were asked to describe their menstrual pain by describing how intense (sensory discriminative component of pain) and unpleasant (affective-motivational component) the pain was. Visual analogue scale (VAS) and a pain drawing of the body area where the pain was felt were applied. When the participants were at the ward after receiving misoprostol, they were asked to describe similarly the pain they felt during the abortion. Afterwards, the type of pain at home, its duration and need for painkillers were recorded, too. At the control visit after medical abortion, their willingness to have gone through the abortion at home was also asked.

      The intensity of menstrual pain correlated significantly with the intensity of pain perceived during medical abortion. Both intensity and unpleasantness of menstrual pain correlated with the affective-motivational component of pain perception during medical abortion, too. Older and parous women reported less pain. In these women the area where pain was felt was also smaller. At the time of control visit, 55 % women were willing to choose home administration of misoprostol as a method of choice for abortion. Their VAS scores for pain during abortion were lower than in women who would not prefer home administration of misoprostol (12 vs 68 mm, median). Most of the women who were willing for home-administration were parous. However, neither the length of pregnancy at the time of abortion nor the age of the woman had an influence on her view.

      In nulliparous women, dysmenorrhea predicts the pain perceived during medical misoprostol-induced abortion. Sufficient pain relief is important to all women, but especially if home-administration of misoprostol is planned during medical abortion.

      Sildes: Perception of pain during misoprostol-induced medical abortion
      PDF-Format (237.77983870967742kB)
  • 16:00-
    17:30
    First trimester abortion
    Chair:
    • Kristina Gemzell-Danielsson, SE
    • Michel Tournaire, FR
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      Abortion care over the Internet: New options for women

      Rebecca Gomperts (The Netherlands)

       

      Unsafe abortion causes the death of 70 000 women every year. 1 in 300 women undergoing an unsafe abortion dies. These death are totally preventable. Medical abortion with Mifepriston and Misoprostol has a mortality risk of less than 1 per 500.000.

      Women on Web is a service which uses telemedicine to help women access mifepristone and misoprostol in countries with no safe care for termination of pregnancy (TOP). After an online consultation, women with an unwanted pregnancy of up to nine weeks are referred to a doctor. If there are no contraindications, a medical TOP is conducted by mail. The presentation will discuss the impact of the online abortion help service by looking at women’s acceptability, efficacy and curettage vacuum aspiration rate after the medical abortion.

      Sildes: Abortion care over the Internet: New options for women
      PDF-Format (1156.2354838709678kB)
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      Cervical priming prior to surgical abortion

      Helena von Hertzen (WHO)

      WHO, Geneva

      Cervical priming before surgical abortion is especially beneficial for young women and for those in the advanced stages of pregnancy, with cervical anomalies, as they have a higher risk of cervical injury or uterine perforation. When the use of laminaria was the main method to prepare the cervix, the WHO Scientific Group on Medical Methods for the Termination of Pregnancy recommended routine priming for durations of pregnancy of over 9 completed weeks for nulliparous women, for women younger than 18 years of age and for all women with durations of pregnancy of over 12 completed weeks.

      This recommendation may need to be review, as recent research suggests that all women may benefit from routine priming of the cervix with misoprostol: a WHO study involving 4791 women demonstrated that routine priming of the cervix with two misoprostol tablets of 200 µg administered vaginally 3 hours prior to vacuum aspiration in pregnancies of up to 12 weeks, decreased the need for further dilatation of the cervix, shortened the time to complete the procedure and significantly decreased the rate of incomplete evacuations. The use of laminaria now seems outdated, as comparative studies report more complications after laminaria than after prostaglandins.

      The optimal dose of misoprostol is 400 µg: lower doses are less effective and higher doses only produce more side effects. The appropriate interval between vaginal misoprostol and vacuum aspiration is 3 hours; shorter intervals are not sufficient for full priming effect, even if the dose is increased. The interval may be shortened to 2 hours when misoprostol is administered sublingually. Only the use of mifepristone can compete with misoprostol in efficacy and low rate of side effects, but its high price and the long interval required between the treatment and procedure render it less attractive.

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      New developments in medical abortion care at 9-13 weeks

      Alan Templeton (Scotland)

      University of Aberdeen, Scotland

      After considerable experience of a mifepristone-misoprostol regimen for induced abortion in the early first trimester, pilot studies indicated the feasibility of using a similar regimen in the late first trimester. A randomised study was then carried out which demonstrated efficacy and acceptability compared with surgical abortion, and indicated that medical regimen was an effective alternative, acceptable to the majority of women. Subsequent review of experience indicated that approximately half of women will opt for medical abortion at 9-13 weeks gestation, if offered the choice. However acceptability is less than surgery, and decreases with gestation. Similarly the ongoing pregnancy rate is higher at higher gestations. Further randomised study has indicated the efficacy and acceptability of sublingually administered misoprostol at all first trimester gestations, even though the frequency of prostaglandin related side affects is higher. Further developments using the regimen will be reported at the meeting.

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      Where should medical abortions take place?

      Elisabeth Aubény (France)

      10, rue du Docteur Lancereaux, 75008, Paris, France

      Medical abortion takes places in 2 stages: the administration of mifepristone which inter00:rupts the pregnancy then,  48h later, the administration of a prostaglandin which results in expulsion of the uterine content. Where should these two medicines be provided and taken? Mifepristone is currently bought by the doctor and taken by the woman in his presence. Why should the woman not buy mifepristone herself at the pharmacy with a medical prescription and then take it, like any other medicine, at home? Fear of a black market? Prostaglandins. The regimen for Misoprostol administration varies from one country to another. In many countries administration of misoprostol takes place in a hospital centre, followed by a 3h monitoring period due to fear of serious adverse events including and haemorrhage at the time of expulsion. Experience shows that, for pregnancy of less than 49 DA, this precaution is not medically necessary with a regimen of mifepristone 600 mg + oral misoprostol 400µg. For this reason in Sweden and France the administration of misoprostol “at home”is now authorised. Studies have demonstrated that this approach is also possible up to 63 DA but with a different regime: mifepristone 200 mg + misoprostol 800µg by vaginal or buccal route. This technique is authorised in Sweden and practiced in the USA (900,000 cases) without related problems. This “at home” administration of misoprostol allows avoidance of one consultation and thus simplifies the method. It is very well accepted by the women who chose it: greater intimacy and confidentiality. However, certain women prefer to be in a medical environment at the time of administration of misoprostol and during the hours that follow. It is important that women are able to choose between the two options. From 63 DA until the end of the first trimester medical abortion is not legally authorised anywhere. However, it is sometimes used. In this case, it is essential that the women take misoprostol in hospital and that they are monitored until expulsion has taken place as bleeding may be heavy and pain must be actively managed. Also at these later gestations products of conception are more visible and must be disposed of appropriately. When using gemeprost, this requires to be stored in a freezer, and the administration must take place in a hospital centre.

  • 17:30-
    Chair:
    • Ana Campos, PT
    • Christiane Tennhardt, DE
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      Closing remarks: How to move forward

      Christian Fiala (Austria)

      Gynmed Clinic, Vienna, Austria

      When applying evidence-based medicine, it becomes obvious that there is no sensible alternative to unrestricted access to effective contraception and safe, legal abortion paid for by social security. In fact, these provisions are inseparably connected with respect for women and their needs. But respecting women implies giving them the power to decide over every aspect of their fertility. History provides us with an abundance of examples and social experiments where societies have patronised women to various degrees. Even forced routine gynaecological examinations have been tried in an attempt to compel women to carry their unwanted pregnancies to term.

      All these initiatives have led to a complete failure in fulfilling the intended goal: To bring a country to glory by increasing its population and military power. However, all these attempts had negative or even catastrophic consequences for the health and survival of women, as well as for societies as a whole.

      Respecting women therefore implies that we truly give women and couples full power to decide over their reproductive choices. It also implies that we must eliminate all remaining obstacles and patronizing restrictions.

      Since women get pregnant by men’s actions, men have a special obligation to provide the legal setting and financial support so that women can decide and act freely on a pregnancy.

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      Why do we need new contraceptives?

      Regine Sitruk-Ware (United States)

      Rockefeller University and Population Council, New York, United States

      The total world population is predicted to reach the 6 billion mark in 2015. Although a steady increase in contraceptive use has been observed both in developed and less-developed countries, the contraceptive needs of a significant percent of couples have not yet been met, with an increase in unplanned pregnancies of which 60% lead to abortion.

      Although several methods of contraception are available, access may be limited due to poor quality of services or to costs of methods not endorsed by health systems and insurances. In addition, a high discontinuation rate is observed during the first year of use of currently available methods due to inconvenience or poor tolerability. Safer methods are still needed in order to minimize the side-effects and increase compliance.

      In addition different needs appear according to the stage of reproductive life. Adolescent girls would need easy to use and remember methods that would improve compliance. Also, on-demand methods for occasional sexual relationship may be favored. During their reproductive life, men and women would need methods that may help to space out pregnancies and both partners may alternate the endorsement of a contraceptive method. Finally women who would have completed their family may rather need long-acting methods that would also treat possible gynecological diseases of the later years of fertile age.

      In other cases, the provision of an additional health benefit may increase compliance with contraceptive use.  Current contraceptive methods do have many benefits: some improve menstrual bleeding patterns, alleviate dysmenorrhea and acne, and sometimes pre-menstrual syndrome. Others can produce amenorrhea and help prevent anemia. Should new contraceptive methods provide additional protection against breast cancer they would also favor wider use and compliance. 

      New methods under development are designed to meet the challenges of expanding contraceptive choices for both women and men and, of answering unmet needs for contraceptives such as pre and post-coital methods, user-controlled long-acting delivery systems, long-acting methods for men, methods with dual protection and additional medical benefits.

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      Why safe abortion and contraception is a necessity for society

      Marcel Vekemans (IPPF)

      IPPF, London, United Kingdom

      In traditional medicine, doctors know best. In the field of contraception and abortion, we health care providers indeed can easily prove that safe abortion is better than unsafe abortion, that contraception is better than unwanted pregnancy, that high contraceptive use decreases abortion rates, that access to safe legal abortion decreases maternal mortality and morbidity, and that huge cost savings for health systems can be made by eliminating unsafe abortion. Have we been able to convince all societies?

      Societies are a heterogeneous mix of formal and informal groups, of diverse “communities”, and of individuals with divergent opinions. Forces are exerted in various directions. Concerning abortion and contraception, opposition to liberal attitudes comes from different sides, as influenced by traditions, social and economic pressures, convictions, religions, patriarchy, conservatism, fundamentalism, etc… As a result attitudes, behaviours and legislations vary hugely between countries, and over time. The claim that safe abortion is unacceptable in a society as a whole is a myth, as shown by the fact that abortions occur everywhere. But countries with restrictive abortion laws and/or limited access to contraception are evidence that significant parts of a society can refuse to accept or endorse our simple truth that “access to contraception and safe legal abortion is best”.

      Demographic concerns also intervene: governments favour population expansion (to be strong, politically and economically; to have a powerful army; to avoid ageing of the population) or limitation (to avoid famine, impoverishment, exhausted resources, pollution), or remain unconcerned.

      Pro-choice activists need to harness two opportunities: the diversity of societies and the ability to influence the development of laws and policies.

      Access to safe legal abortion and to contraception is a basic human right, but very often essential prerequisites to exert these rights are lacking. Most importantly, almost everywhere education about reproductive health and sexuality remains problematic, despite efforts started a century ago. We still need to ensure, especially in the developing world, easy access to a well-developed health care system, equal status of women and men (a fundamental prerequisite for exerting women’s rights), and the elimination of gender exploitation and violence (zero tolerance). 

      We still need to convince many societies of the importance of contraception and safe abortion, and/or of taking action to make the services accessible.