The fifth FIAPAC conference was held in Amsterdam on 24 and 25 May 2002. There were 350 participants from 24 countries who exchanged experiences and discussed new information.
Dr Ines Thonke reported. (This report appeared in the family planning circular in July 2002 from ProFamilia, Germany.)

The conference was aimed at professionals working in the field of abortion and contraception. The lectures included medical, counselling and legal aspects. The comparison between different countries in particular led to lively discussions. All lectures were simultaneously translated into German, English and French.

The conference had the following objectives:

• Support for women and men seeking suitable contraception methods and working for nation-wide freely available contraception
• Every woman has the right to decide whether she wishes to carry a pregnancy to full term or not
• In the case of deciding for abortion she should have the free choice and be treated according to the best medical standard
• Guaranteeing current medical standards in abortion.
• Offering psychological and social support on a voluntary basis to women with unwanted pregnancies.

Introduction

The FIAPAC has been organising international exchange on the above issues since 1997. Very quickly it became apparent from the contributions from the various countries, how important it still is to discuss the realities women and couples face, even in Europe. The first series of lectures concerned the following questions:

• How can women’s freedom of decision be improved?
• What is the reality for women inside and outside Europe, who need a safe and legal termination of pregnancy?
• What are the key problems and where do the challenges lie?
• What role do doctors play and what opportunities do they have to improve the situation for women during counselling and treatment?
  

The situation in Europe

Although in Europe 22 per cent of women end their pregnancies through abortion there has thus far been no normalisation of the issue. The differing legal situations in Europe, from liberal limits on the time within which abortion is permitted to complete ban on abortions, indicate the unacceptable situation facing women: so-called abortion tourism to countries with more liberal regulations continues. Thus, for example, even now 7,000 women a year travel from Ireland to England to have an abortion. However, within the respective countries, too, women have to travel great distances because their own region does not offer the medical service. Continued tabooing and discrimination facilitate an arbitrary price structure in the abortion services and high costs put claiming the right, let alone choosing between various methods, beyond the reach of women in poor financial circumstances. Thus, for example, in Poland it costs $630 to $1,250 for an (illegal) abortion. In France, a law that gives women the right to sufficient information and freedom to choose has not yet been implemented in practice. For this reason a publicity campaign on the right to terminate pregnancy is planned in the near future. Further obstacles arise in France from the regulation that terminations must be carried out in a hospital. The choice between full anaesthetic and local anaesthetic is also only available in a few centres. The eight days between counselling and termination stipulated in France, the obligation for parental agreement for minors and the lack of professional and financial recognition of the medical staff involved are aspects that urgently need changing in order to improve the situation for women. For other countries, too, various factors were identified that mean it is not possible to fulfil women’s needs adequately.
As a rule, unwanted pregnancy is an event that women are not prepared for. This means a stress situation, which cannot be handled openly. The needs in this situation are very different for each individual. Access to information is often difficult and it is often almost impossible to compare quality and costs. It is true that legal restrictions have no influence on the absolute number of pregnancy terminations, but they do have a negative effect on the quality of advice and medical treatment, however. As examples, the obligatory counselling, the legal order to separate the personnel doing the counselling and those carrying out the termination, or the different obligatory waiting times between counselling and termination are mentioned. Further restrictions concern the arbitrary regulations for medicinal termination, such as, for example, having to take medication in hospital and refunding payments for doctors, which do not fully cover the financial expense.
But there are further difficulties for those engaged in the counselling and those performing the procedure: various abortion techniques require different personnel qualifications and equipment, the various procedures are charged at different prices, pregnancy termination is not part of medical training in most countries, the professional exchange is hindered by moral/ethical reservations and fundamentalist resistance, the social status of “abortion” doctors is low, and information or effective publicity campaigns are not allowed.

What are the options for action?

The obstacles listed also point to the options for action: Doctors could and should have more influence. Their professional expertise and their political commitment is called for. In this connection, the importance of training medical specialists was emphasised. Termination of pregnancy should be a fixed part of the education and continuous training of all health professions – also for midwives and the caring professions. This calls for the development and continuous improvement of generally valid information, advisory and quality standards, because only information of the latest scientific knowledge guarantees women real choice. Legal limitations must be lifted, where they obstruct or limit the improvement of methods. They must also be called into question wherever thy obstruct access to basic information, including providers address or quality and costs of an abortion.

Medicinal termination of pregnancy – new developments

The method applied in France since 1989, with 600 mg mifepristone followed two days later by an oral or vaginal dose of 400 mg misoprostol, has in the meantime been used in almost all European countries in the same way. Many studies have the objective to simplify the procedure. Here, the emphasis is on the following aspects:

• taking the prostaglandin (misoprostol) at home
• extension of the period using mifepristone from seven to nine weeks (which is already legal in the UK and Sweden)
• varying the dosages of mifepristone and misoprostol
• routes of administration of the prostaglandin (misoprostol) oral-vaginal
• medical abortion with a prostaglandin only
  

Taking the prostaglandin at home

Previously, the prostaglandin (misoprostol/Cytotec®) has been given in a standardised way in the institution. Its prescription and taking at home is a possibility to spare women a visit to the abortion provider. In this connection, one study investigated the following questions:

• Do women wish to take the medication at home?
• Is it safe?
• Is it acceptable to women?

The research was carried out in Tunisia, Turkey and Vietnam. Between 80 and 88 per cent of women preferred taking the medication at home. The reasons given for this were: better confidentiality, lower costs for the women, time saving, higher security and that it is more pleasant. The women who decided to take it under medical supervision in the institution gave similar reasons: they too felt their choice was more pleasant and confidential. The results show comparable rates of success for home and clinic use. Side-effects and pains were just as easy to control for women at home as they were in the clinic, and the acceptance was high for both groups. To sum up, it was established that women find themselves in different life circumstances and therefore have varying expectations of the treatment. Many women wished to be able to take the prostaglandin at home. This has shown to be equally effective as use in a clinic. Home use is simple for the women to carry out and thus represents a safe alternative to use in a clinic.

Extension of the period of use – changes in dose

According to French guidelines, the use of mifepristone is approved up to the 49th day LMP (first day of the last menstruation). Most countries have approved mifepristone based on this regimen, with a dosage of 600 mg mifepristone and 400 µg misoprostol. Exceptions are England, Sweden and China. There, the medicinal termination of pregnancy with mifepristone is approved up to the 63rd day LMP.
Two studies evaluated a reduced dosage of 200 mg mifepristone and 800 µg misoprostol vaginally from the 10th to 13th weeks of pregnancy. A complete abortion was achieved in 95 per cent of cases using this procedure.
The comparison between medical and surgical abortion has shown more side-effects in the group using medical termination. But the high level of acceptance and the 94-95 per cent effectiveness let to the conclusion of medicinal termination as being an alternative for women between 10th and 13th weeks of pregnancy, if they wish to avoid surgical intervention and general anaesthesia.

Abortion with Misoprostol (Cytotec®) alone

Carrying out medical pregnancy termination using only vaginally administered misoprostol (prostaglandin) in the early stage of pregnancy gave an abortion rate of about 85 per cent in the studies. Because of this failure rate, misoprostol alone is not an alternative to the combined method, wherever mifepristone is available.

Different forms of administering Misoprostol (Cytotec®)

Giving misoprostol orally, the highest blood plasma level was found after 30 minutes. Administering it vaginally, the highest lebel was measured after one to two hours. The bio-availability, which is proportional to the contractility of the uterus, was observed later on vaginal administration, but three times the level of oral administration. The highest bio-availability was observed after sublingual administration (through the mucous membrane of the mouth).
After the 49th day, as a rule, vaginal administration of the prostoglandin is recommended.

Abortion and contraception in a multicultural society

One lecture described developments in the Netherlands – over many years the country with the lowest rate of abortions in the world. The abortion rate in 1996 was still as low as 6.5 per 1,000 women between 15 and 45 years of age, whereas in the year 2000 it had risen slightly to 8 per 1,000 women. 60 per cent of the terminations carried out are for women of non-Netherlands origin. The number of unwanted pregnancies in minors is rising, and immigrants represent a risk group both for unwanted pregnancies and for sexually transmitted diseases. Service providers have to take into account the cultural differences. Thus there are fundamental differences in the understanding of motherhood, perception of the body, sexual health and ethnophysiology (ideas about the functioning of the body). Examples were cited of the differing understandings of norms and values, fertility regulation and modern contraception. Whereas in the Netherlands the control over the body plays a major role, in Japan it is the relationship that is controllable. In South Africa the pill represents a magical object and in Nigeria it is not contraception but (fear of) sterility that plays a major role in connection with fertility. In some countries the effect of the pill is explained through the warming and dehydration of the body, and for this reason it is rejected. In Jamaica there is the conviction that the energy flow is stopped by the pill. Because of this belief it is only taken immediately before intercourse. These ideas, which may be present in various ethnic groups, can only be corrected by adequate health education.
The effectiveness of contraception programmes can also be hindered or obstructed when insufficient account is taken of the violent relationship between the sexes. Women’s social situation is often characterised by isolation, low status, the dominance of men and the tolerance of male violence.
The conclusion of the lecture: living in a multicultural world means a never-ending learning process in which mutual respect of cultural values must be promoted with the objective of implementing human rights.

Working group on standards of medical training

A working group on the subject of medical training standards was only able briefly to sketch out the differences between individual countries. Scotland is exemplary: there are established training modules on the subject of fertility and contraception both for degree courses as well as in the medical further training phase – here there are even differences for general practitioners with basic modules and specialists in leading positions with specific training curricula. For the US, too, there is a curriculum on the subject area of pregnancy termination.
In many countries, however, the subject is not, or insufficiently standardised. On this basis the development of obligatory degree and training guidelines and individual training terminology was discussed. In this context it was repeatedly emphasised that involvement in the subject should not be influenced by the individual’s attitude. Abortion activity often means a low professional status and it is necessary to discuss ethical-moral fundamentals anew, as young doctors who only experience abortion issues in a negative context have no experience of the often fatal consequences of illegal abortions.

Over-the-counter post-coital contraception

In France since December 1999 it has been possible to buy the morning-after pill/emergency contraception containing only a gestagen without prescription (OTC, over the counter). In 2000 OTC was approved in Portugal and Norway, in 2001 in Sweden, Belgium, Denmark and England, and in 2002 in South Africa and Sri Lanka.
Fears that women/couples would neglect regular contraception because of this possibility have proved unfounded. In France this is confirmed by the growing sales of contraceptives. Also the knowledge that its effectiveness is lower and the costs are higher lead to it only being used as emergency contraception.
With more than two million applications, there have so far been no incidents, no increase in fallopian pregnancies and no reports of complications.
A Swedish study researched the knowledge, behaviour and experiences of women in relation to the prescription-free dispensing of the post-coital pill. Prescription-free dispensing is an attempt to guarantee the immediate availability of the post-coital method, as its effectiveness is closely related to the interval between unprotected intercourse and taking the tablets. All women surveyed welcomed the prescription-free dispensation. Saving time was an important aspect here. The main source of information for the women was the media. Both positive and negative experiences were described in contact with pharmacists; different attitudes and inconsistent readiness for routine dispensation were mentioned in this context. Women expected up-to-date information on the post-coital method, which underlines the importance of all health professionals communicating information objectively and correctly.
A study comparing various post-coital methods was also presented at the conference.

Mifepristone as a post-coital method

Numerous studies on this subject have been undertaken, the first in England as early as 1992. The studies carried out by WHO in 1999 and 2002 with 10 mg, 50 mg and 600 mg doses of mifepristone within 120 hours of unprotected intercourse gave a pregnancy rate of 1.5 per cent. Mifepristone has shown a high level of efficacy as a post-coital method in these studies. Unfortunately research in this subject and the introduction of mifepristone for this indication is hindered or obstructed by political reasons.
Further results from the studies were: The pregnancy rate increases with increasing delay in taking the tablets after an unprotected intercourse. The higher the dose, the higher is the incidence of menstrual irregularities, especially a delay in the onset of the next menstruation. The dose had no influence on other side-effects. In the case of is further unprotected intercourse during the same cycle, the risk of pregnancy increases. This can be explained by the mode of action of mifepristone, which leads to a delay of ovulation. With repeated administration in one cycle there were no further side effects other than delayed next menstruation. There is 80 per cent efficacy to avoid pregnancy for each occasion mifepristone is taken after an unprotected intercourse. This reduces efficacy with repeated administration.

Why are there still unwanted pregnancies?

Why are abortion rates not falling in countries like France, in which more than 80 per cent of women/couples are using contraception? A sociological study in France researched the reasons behind stable abortion rates. “Only” 54 per cent of women who wanted an abortion had used no contraception at all. 18 per cent took the pill as their current contraception method, 9 per cent had an IUD and 6 per cent relied on condom. True, at least in the developed countries, an obligation to contraception is recognised (contraception norm), however compliance with this norm (in this case readiness of the woman/ the couple to play their part) can be disrupted by various factors:

• method failure (with recognition of the norm)
• wrong or incomplete information on contraception
• assumed infertility
• ambivalence
• inadequate application of the method (without giving reason)
• failure because of the dominance of the man
• magical thinking
• rejection of contraception (no recognition of contraception norm)
• careless behaviour
• social, economic problems (contraception is not thought of in this situation)
• the wanted unwanted pregnancy (i.e. actually a wanted pregnancy)

Alongside these possibilities the change in contraceptive methods over different periods of life plays a role.

Contraception after abortion

Advice on contraceptive methods is an important aspect in pre-abortion counselling. Hormonal methods can be prescribed immediately after the abortion. Waiting until the first menstruation is not recommended. With the coil (IUD), for abortions in the second trimester a delay is recommended because of a slightly increased rate of spontaneous expulsion.
Also women should be encouraged to have a backup method (as a rule, post-coital) available at home.

General remarks

The report has only been able to give extracts of the lectures and studies presented. The citation of studies and names has been dispensed with. Two names, however, should be mentioned in closing: Madame Elisabeth Aubèny, largely responsible for the introduction and scientific oversight of the use of Mifegyne® in France and currently active on the issue of prescription-free dispensing of the gestagen only post-coital pill, passed on the presidency of FIAPAC. Her successor is Christian Fiala, who was also from early on greatly committed to the introduction of Mifegyne® in Austria and who professionally supported the introduction in Germany through publicity (from interviews to start-off) and through training. He has been working closely with the German association in the Pro Familia model project to support the introduction of Mifegyne®.