Ljubljana, 2-5 Oktober 2014: „Task sharing in Abortion Care“

  • 07:30-
  • 09:00-
    • Philippe David, FR
    • Allan Templeton, GB
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      Guidelines on ensuring human rights in the provision of contraception services

      Rajat Khosla WHO, Reproductive Health and Research, Geneva, Switzerland - khoslar@who.int

      Unmet need for contraception remains high in many settings, and is highest among the most vulnerable in society: adolescents, the poor, those living in rural areas and urban slums, people living with HIV and internally displaced people. The latest estimates are that 222 million women have an unmet need for modern contraception, and the need is greatest where the risks of maternal mortality are highest. International and regional human rights treaties, national constitutions and laws provide guarantees specifically relating to access to contraceptive information and services.

      In addition, over the past few decades, international, regional and national legislative and human rights bodies have increasingly applied human rights to contraceptive information and services. They recommend, among other actions, that states should ensure timely and affordable access to good quality sexual and reproductive health information and services, including contraception, which should be delivered in a way that ensures fully informed decision-making, respects dignity, autonomy, privacy and confidentiality, and is sensitive to individual's needs and perspectives. In order to accelerate progress towards attainment of international development goals and targets in sexual and reproductive health, and in particular to contribute to meeting unmet need for contraceptive information and services, the World Health Organization (WHO) has developed guidelines and recommendations on ensuring human rights in the provision of contraceptive information and services. The presentation will provide an overview of the process used to develop the guidelines and recommendations made by WHO for policy-makers, managers, providers and other stakeholders in the health sector on some of the priority actions needed to ensure that different human rights dimensions are systematically and clearly integrated into the provision of contraceptive information and services.

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      Is there a need for male contraception?

      Régine Sitruk-Ware Population Council, New York, USA - regine@popcbr.rockefeller.edu

      New contraceptive methods have been developed to meet the objectives of expanding contraceptive choices for both women and men and answering an unmet need for contraceptives with a long-term action that meet the expectations of consumers. Simplicity, reversibility and effectiveness are the desired features of a male contraceptive, but no new male contraceptive method is yet available. In comparison to female methods, the two existing male methods, condom and vasectomy, appear limited and are not always well accepted. Vasectomy is an irreversible method although new micro-surgical techniques would allow reversibility in some men. While clinical research on hormonal methods is advanced, and several combinations of androgen and progestin proved effective, no method has been fully developed and approved. Currently development of a tissue specific androgen 7-methyl nortestosterone (MENT), a molecule that does not affect the prostate, is ongoing as a method bringing additional health benefits. Non-hormonal methods are still at an early stage of research. New areas of basic research include studies on genes, proteins and enzymes involved in the reproductive system. New approaches target the maturation of germ cells, a critical component of sperm development, or the sperm motility. These methods aim at inducing reversible infertility without interfering with hormones secreted by the hypothalamus, pituitary gland, and testis. There is an obvious need to provide men with choices for their fertility regulation but advocacy for this research needs to expand and convince the industry that there is a market with unmet needs that deserves attention and investments.

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      Contraception: why it fails

      James Trussell1,2 1Princeton University, Princeton NJ, USA, 2The Hull York Medical School, Hull, UK - trussell@princeton.edu

      In this presentation, I discuss the difference between contraceptive failure rates during perfect use and during typical use. I examine the logical error that many investigators make when computing failure rates during perfect use. I then highlight the impact of simultaneous use of two methods. I next explore the reasons for observed differences in correctly computed failure rates during perfect use and during typical use. Next I discuss reasons for the “creeping Pearl” (Pearl indexes for oral contraceptives approved by the FDA have increased over time). Finally, I report on the results of clinical trials of two new contraceptive patches and the stark implications for pharma and regulatory agencies.

  • 10:30-
  • 11:00-
    W06: WHO, Linhart Hall
    • Ronald Johnson, CH
    W07: IPAS, Kosovel Hall
    • Alison Edelman, US
    • Kusum Thapa, NP
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      Getting to hard to reach places: expanding access to rural Nepal through nurse provision of first trimester medical abortion

      Alison Edelman1, Kusum Thapa2, Deeb Shrestha Dangol2, Indira Basnett2 1Ipas, Chapel Hill, North Carolina, USA, 2Ipas Nepal, Kathmandu, USA - edelmana@ohsu.edu

      In Nepal, abortion was legalized in 2002. It is permitted for any reason to 12 weeks, for rape or incest up to 18 weeks and for maternal or fetal indications at any gestational age. First trimester abortion services became more readily available in 2004. However, Nepal is a country of extremes with mountainous regions that are challenging to access and areas that are impassable at certain times of the year. Health care services are also limited by the number and type of provider. Creating access for women seeking life-saving care such as safe abortion and contraceptive services entails innovative strategies including task sharing. The Nepali Ministry of Health and Ipas have been working to increase abortion access in these hard to reach places. A pilot project was performed in 2010-2012 to train auxiliary nurse midwives (ANMs) from primary health centres/health posts in first trimester medical abortion (MA). As of June 2012, 216 ANMs were trained. Following training, 89% (233) have provided MA with 6056 women served [mean 4.6 women/month (SD=3.3)]. Overall service quality was high; 100% of women received pain management and 88% received postabortion contraception. Perceived enabling factors for MA provision identified by providers and facility managers included community awareness through media and volunteers, well-established referral mechanisms, support by facility administration and clients' beliefs about MA. Similarly, perceived barriers included a stable supply of MA drugs and equipment, insufficient counselling areas, inability to manage severe complications, medication costs and service disruption due to transfer of trained providers. Overall, 98% of women reported being very/mostly satisfied with services. Expanding the abortion provider base to include ANMs has increasing availability of safe services to Nepal's predominantly rural population. With the success of this pilot project, the Nepali government has incorporated the training of ANMs in MA into their national curriculum.

    W08: FAQ, Häufig gestellte Fragen zum Thema Abtreibung, Room E1-2
    • Philippe Faucher, FR
    • Ellen Wiebe, CA
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      FAQ, Frequently Asked Questions in abortion care

      Ellen Wiebe1, Philippe Faucher2 1University of BC, Vancouver, Canada, 2Hôpitaux Universitaires Est Parisien, Paris, France - ellenwiebe@gmail.com

      Women presenting for abortion come with questions, both voiced and unvoiced. They often believe misinformation about exaggerated risks of infertility and depression and many are worried about pain. Abortion providers want to choose the best protocols and to relieve the unnecessary anxiety and pain. In this session we will address four issues. 1. Pain control: How can we best relieve the anxiety about pain and the pain of medical and surgical abortions? We will discuss the use of local and general anaesthesia, intravenous sedation, oral medications and non-pharmaceutical methods of pain control. 2. Antibiotic prophylaxis: What is the evidence about preventing endometritis in medical and surgical abortions? We will present the number needed to treat (NNT) with antibiotic prophylaxis in order to prevent each case of endometritis so that we can make the best choices for our patients. 3. Reproductive outcome: What is the actual risk of infertility (including Asherman's syndrome), miscarriage, premature delivery and abnormal placental insertion after abortions? We know these risks are low, but we need to address the anxieties of our patients as well as our colleagues. 4. Long-term sequelae: What are the actual risks of psychological problems and of breast cancer after abortions? There has been so much bad science on these topics and we need to assess the validity of the evidence. We will also address the issue of how to communicate this evidence effectively to our patients and our colleagues.

    W09: IPPF globaler Ausschuss - Barriere freier Zugang - IPPF globale Erfahrungen, Room E3-4
    • Manuelle Hurwitz, GB
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      Addressing abortion stigma in service delivery: the experience of Pakistan and Burkina Faso

      Rebecca Wilkins1, Asifa Khanum2 1International Planned Parenthood Federation, London, UK, 2Rahnuma Family Planning Association of Pakistan, Lahore, Pakistan - rwilkins@ippf.org

      Restrictive legislation and limited service provision remain obstacles to women who seek abortion services. These obstacles are worsened by the impact of abortion stigma and associated secrecy, shame, guilt and fear. Stigma prevents or delays access to safe abortion services as well as making lawmakers reluctant to improve legislation to facilitate access to abortion information and services. As part of its commitment to reducing abortion stigma at all levels, IPPF commissioned research to understand its effect on women accessing services through IPPF Member Association clinics. In-depth qualitative research using semi-structured interviews with abortion clients, service providers and client partners was conducted at Member Association clinics in Pakistan and Burkina Faso. The research aimed to identify the specific causes and manifestations of abortion stigma and to inform interventions designed to reduce abortion stigma. The research found commonalities in abortion stigma in Pakistan and Burkina Faso, as well as some issues that were unique to each country setting. The clinic client pathways, misconceptions and lack of knowledge about abortion, pre-abortion counselling, and the timeliness of seeking medical care were among some of the issues found to have an impact on, or were impacted by clients' experience of stigma. In both countries women who accessed abortion services had a high level of self-stigma which impacted on their expectations of quality of care in the clinics. Abortion stigma is an unspoken reality that significantly impacts both the attitudes and practices of medical professionals and women who access abortion services. However, the nature of abortion and the stigma surrounding it makes this a challenging topic to collect data and information on. The research findings illustrate the need for the pilot testing of interventions at both the community and service delivery levels in order to address abortion stigma through a more comprehensive and systematic approach.

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      Addressing unintended pregnancies and unsafe abortions among youth in Kenya: family health options of Kenya

      Wilson Bunde Family Health Options Kenya, Nairobi, Kenya - wbunde@fhok.org

      Introduction: The Kenya Demographic Health survey 2008/9 showed that 43% of births in the preceding year were reported by women as unwanted or mistimed. Adolescent women face high risk of unintended pregnancies and therefore unsafe abortions, with devastating consequences for their lives and health. It is estimated that more than half of women with the most severe complications from unsafe abortion are adolescents. Family Health Options of Kenya (FHOK), a Member Association of IPPF, utilized strategies to minimize unsafe abortion among marginalized youth from underserved communities through clinical and community based services. Action: Implemented strategies included recruitment and training of young staff, provision of youth friendly information and services, addressing financial barriers, efforts to mitigate stigma associated with abortion services, and use of innovations such as youth camp and short-messaging system to provide information on adolescent sexual and reproductive health (SRH). Outcome: Following the implementation of these strategies at 4 locations in 2012, FHOK recorded a 61% increase in the number of young clients served for comprehensive abortion care and postabortion care services. Clinic teams have also reported a concomitant increase in the acceptance of contracep-tive services among youth. Qualitative feedback from youth in communities and clinic settings have provided positive feedback on these strategies and increased levels of information among youth. Discussion and Recommendations: Youths are the most sexually active population in Kenya yet are the most neglected group in SRH services initiatives. The lack of adequate information and access to SRH services among youths contributes to the high rates of unintended pregnancies among this group, which in turn forces them to seek unsafe abortion services. Some unique youth-friendly initiatives like the ones described above can increase utilization of services by youths even in situations where such services planning may be sensitive and difficult to address.

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      Task sharing in delivering safe abortion services: experience from Africa

      Chilanga Asmani1, Karthik Srinivasan2 1International Planned Parenthood Federation, Africa Regional Office, Nairobi, Kenya, 2International Planned Parenthood Federation, Central Office, London, UK - casmani@ippfaro.org

      Globally, Africa is hardest hit by the current healthcare worker crisis with a shortage of over 800,000 staff primarily among physicians and specialists. As an effort to overcome this shortage and expand access to critical health services, task sharing and task shifting has been promoted in the different health sectors by governments and civil society organizations. This approach has been adopted by IPPF to ensure universal access to sexual and reproductive health services. In many of its Member Associations (MA), IPPF has utilized this approach to expand access to safe and comprehensive abortion care and contraceptive services. A range of health workers comprising non-physicians, clinical officers, nurses and midwives currently provide pre and post abortion counselling, induced medical and surgical abortion and contraceptive services. As a result of these efforts, provision of abortion services by IPPF in the Africa region has increased by 42% between 2012 and 2013. Among the five MAs implementing the Global Abortion Care Initiative in Burkina Faso, Cameroon, Ethiopia, Ghana and Kenya, safe abortion service provision has increased from 6,477 to 14,653; treatment of incomplete abortion services has increased from 1,709 to 2,125 between 2011 and 2013. Although community awareness and acceptance for abortion services has increased and assessments indicate high level of quality of care and satisfied clients, the challenge of abortion stigma and staff attrition still persist. Task shifting and sharing the provision of safe abortion and contraceptive services has proven to be an extremely safe, well-accepted and feasible strategy to expand access to safe abortion care and contraception even in low-resource settings. Looking ahead, IPPF aims to conduct pre-service and in-service trainings and updates for midlevel providers, conduct operational research and develop strategies to increase access to safe abortion and contraceptive services in a stigma-free environment.

    Freie Vorträge, Room M1
    • Raïna Brethouwer, NL
    • Sam Rowlands, GB
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      The efficacy, safety and acceptability of medical termination of pregnancy provided by standard care by physicians or by nurse-midwives: a randomized controlled equivalence trial

      Helena Kopp Kallner, Rebecca Gomperts, Eneli Salomonsson, Monica Johansson, Lena Marions, Kristina Gemzell-Danielsson Karolinska Institutet, Stockholm, Sweden - helena.kopp-kallner@ki.se

      Objective: To assess nurse-midwife provision of early medical termination of pregnancy (TOP) in a high resource setting where ultrasound examination for dating of pregnancy is part of the protocol. Method: We performed a randomized controlled equivalence trial in a Univerity Hospital Family planning outpatient unit. 1180 women seeking early medical TOP were randomized, without any prior examination, to counselling, examination and treatment by either nurse-midwife or gynaecologist. Ultrasound was performed in all cases by the allocated provider. Primary outcome was efficacy defined as successful completion of TOP without need for vacuum aspiration. Secondary outcomes were safety, defined as need for hospitalization or blood transfusion, and acceptability, defined as preferred provider were the women to have a medical TOP in the future. Results: A total of 481 women in the nurse-midwife group and 457 women in the physician group were available for final analysis. The effectiveness of provision of medical TOP by nurse-midwife providers was superior to that provided by physicians (risk difference 1.6%, confidence interval 0.2-3.0% which was within the set margin of equivalence). There were no significant differences in safety parameters. Women examined and counselled by a nurse-midwife were significantly more likely (p<0.001) to prefer seeing a nurse-midwife for the consultation were they to have another medical TOP in the future. Conclusions: These findings show that nurse-midwife provision of early medical TOP in a high-resource setting where ultrasound is part of the protocol is effective and can be safely implemented with high acceptability among women.

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      Medical abortion provided by nurse-midwives or physicians: a cost-effectiveness analysis

      Susanne Sjöström1, Helena Kopp Kallner1, Emilia Simeonova2, Andreas Madestam3, Kristina Gemzell-Danielsson1 1Karolinska Institutet, Stockholm, Sweden, 2John Hopkins University, Baltimore, USA, 3Stockholm University, Stockholm, Sweden - susanne.sjostrom@ki.se

      Objective: To make a cost-benefit analysis of medical abortion provided by nurse-midwives and physicians. Study Design: A cost-effectiveness analysis is conducted based on a previously performed randomized controlled equivalence trial comparing efficacy, safety and acceptability of medical abortion performed by nurse-midwives or physicians in a high-resource setting. Materials and methods: Direct and indirect costs associated with the standard and intervention treatment have been calculated and an incremental cost-effectiveness analysis is performed. Equivalence in effectiveness was established for the primary and secondary outcomes in the original study, the outcome measures were complete abortion, and safety in terms of hospitalization, blood transfusion and acceptability. Direct costs include salaries including general payroll tax, rent, training of providers and costs for consultation (second opinions). Since the patients received the same treatment there was no difference in costs of disposables, ultrasound or medication. Indirect costs include women’s loss of salary and alternative cost for consultants (second opinions). Benefits emerging from increased prescription of long-acting contraceptives (LARCs) and also possible utility such as decreased waiting time for abortion seeking women from first contact to consultation/ treatment will be considered. All costs were taken from Karolinska University hospital where the parent study was conducted. Results: Preliminary results are that medical abortion provided by nurse-midwifes alone is more cost-effective than the standard treatment involving both nurse-midwives and physicians. The savings are mainly derived from lower salary costs for nurse-midwives but also from less total time for the visit.

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      Do as we say, not as we do: experiences of unprotected intercourse among Society of Family Planning fellows

      Abigail Aiken1, James Trussell2 1University of Texas at Austin, Austin, Texas, USA, 2Princeton University, Princeton, New Jersey, USA - araa2@utexas.edu

      Objectives: Despite our role in preventing unintended pregnancy and STI transmission, very little is known about reproductive health professionals’ own experiences of sexual risk-taking. We examined the prevalence and circumstances of unprotected intercourse among Society of Family Planning (SFP) fellows in the United States. Methods: A link to an anonymous online survey was sent via email to 477 SFP fellows. Within the first week, 321 (67%) responded, and we expect around an 80% total response rate. We asked whether respondents had ever and in the past year had unprotected vaginal intercourse when not intending a pregnancy, and if so, how many times, under what circumstances, and at what age the first time. We then asked about unprotected vaginal, anal, or oral intercourse ever and in the past year under three different scenarios: 1) partner not known to be infection-free, respondent infection-free; 2) partner known to be infection-free, respondent not infection-free; 3) partner known to have an infection, respondent infection-free, including the number of times, applicable circumstances and age the first time. Results: Among respondents so far, 46% have ever had unprotected vaginal intercourse when not intending pregnancy; 35% more than 10 times, and 13% in the past year. Sixty percent have had unprotected vaginal, anal, or oral intercourse with a partner not known to be infection-free; 38% more than 10 times, and 22% within the past year. Eight percent have ever had unprotected intercourse with an infection-free partner when they themselves had an infection, and 5% have ever had unprotected intercourse with a partner known to have an STI. Conclusions: Preliminary results suggest that despite a high level of medical knowledge, risk-taking with respect to pregnancy and STIs is common among reproductive health professionals.

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      Cervical preparation before second trimester dilatation and evacuation: a multicentre randomized trial comparing osmotic dilators alone to dilators plus adjunctive misoprostol or mifepristone

      Alisa Goldberg2 ,1, Jennifer Fortin2, E. Steve Lichtenberg7 ,8, Eleanor Drey9 ,10, Gillian Dean11 ,12, Paula Bednarek13 ,14, Beatrice Chen15 ,16, Caryn Dutton3 ,1, Sarah McKetta2, Rie Maurer3, Beverly Winikoff6, Garrett Fitzmaurice5 ,4 1Harvard Medical School, Boston, MA, USA, 2Planned Parenthood Leauge of Massachusetts, Boston, MA, USA, 3Brigham and Women's Hospital, Boston, MA, USA, 4Harvard School of Public Health, Boston, MA, USA, 5McLean Hospital, Belmont, MA, USA, 6Gynuity Health Projects, New York, NY, USA, 7Family Planning Associates, Chicago, IL, USA, 8Northwestern University, Chicago, IL, USA, 9San Francisco General Hospital, San Francisco, CA, USA, 10University of California, San Francisco, San Francisco, CA, USA, 11Planned Parenthood of New York City, New York, NY, USA, 12Mount Sinai School of Medicine, New York, NY, USA, 13Lovejoy Surgical Center, Portland, OR, USA,

      14Oregon Health Sciences University, Portland, OR, USA, 15Magee Women's Hospital, Pittsburgh, PA, USA, 16University of Pittsburgh, Pittsburgh, PA, USA - agoldberg@pplm.org

      Objectives: To evaluate adjunctive misoprostol or mifepristone versus osmotic dilators alone for cervical preparation before D&E at 16-23+6/7 weeks. Methods: This double-blind, three arm multicenter randomized controlled trial compared osmotic dilators alone, dilators plus 400 mcg of buccal misoprostol 3 hours preoperatively and dilators plus 200 mg of oral mifepristone during dilator placement for D&E. Our primary outcome was operative time. Secondary outcomes included initial cervical dilatation, D&E completion on first attempt, need for mechanical dilatation and complications. Three hundred women were required for 80% power to detect a 2 minute difference in operative time within two cohorts: 16-18 6/7 weeks (N=150) and 19-23 6/7 weeks gestation (N=150). Results: We found no difference in operative time between treatment arms in either gestational cohort. Initial dilatation was greater with misoprostol than dilators alone in the early cohort (2.4 vs. 2.0 cm, p=.007), but similar in the later cohort. More subjects in the dilators alone arm required additional dilatation in the early cohort (35.3% vs. 9.8% misoprostol vs. 14.3% mifepristone, p=.003); but not the later cohort. We found no difference in procedure completion on the first attempt. Provider satisfaction with cervical preparation was highest after mifepristone (71.8% vs. 78.8% vs. 86.8%, p<.0001). The dilators alone arm had more cervical lacerations requiring repair (4% vs. 0 vs. 0, p=.02) and more uterine re-aspirations (4% vs. 1% vs. 2%, p=.05). Conclusions: Although operative time did not differ, there may be some benefit to use of adjunctive misoprostol or mifepristone for cervical preparation before D&E.

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      The Italian case: can MTOP minimize the problem of conscientious objection?

      Anna Pompili1, Mirella Parachini2, Giovanna Scassellati Sforzolini3, Gelsomina Orlando4, Daniela Valeriani5, Cristina Francesca Damiani6, Patrizia Facco7, Marina Marceca8 1Sapienza University, Rome, Italy, 2San Filippo Neri Hospital, Rome, Italy, 3San Camillo Hospital, Rome, Italy, 4San Giovanni Hospital, Rome, Italy, 5San Camillo Hospital, Rome, Italy, 6San Giovanni Hospital, Rome, Italy, 7Sandro Pertini Hospital, Rome, Italy, 8San Giovanni Evangelista, Tivoli, Italy - pompili.anna@tiscali.it

      In Italy abortion has been legal since 1978. During these 36 years, we have seen an increasing percentage of gynaecologists who declare themselves "conscientious objectors", in contrast with women's right to stop an unwanted pregnancy. The anti-choice front, which looks to catholic fundamentalism, forced an abuse of this right, in an attempt to obstruct women's access to safe abortion. The official data about conscientious objection from the Italian Health Ministry, reports a percentage of about 70% among gynaecologists, but this phenomenon concerns also anaesthetists (about 50%) and other health personnel (about 46%). In 2012, in a survey "in the field", we showed that data about conscientious objection are critical, with rates in some regions near to 100%. This abuse of conscientious objection has the intent to make the law a dead letter, negating "de facto" the right to reproductive health for many Italian women. In March 2014 the European Committee of Social Rights, on the basis of a complaint by IPPF-EN condemned Italy because the law is not applied; so, a lot of Italian women are forced to migrate from one region to another, even to other countries, because of the inability to exercise their reproductive rights. In this paper we want to give a real picture of the Italian situation, and try to analyse how easier access to MTOP would minimize the effect of the abuse of conscientious objection on women's rights.

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      First trimester abortion in the Arabic world

      Selma Hajri NGO, TUNIS, Tunisia - selmahajri@gmail.com

      According to a WHO report, 100,000 abortions are performed per year, and 160 to 260 women die each year from unsafe abortions in the North / Middle East region. Unintended pregnancies remain high and the number of abortion seems very important although there is no reliable data. In most Muslim countries abortion, even in cases permitted by law, seems unacceptable to many. Illegal abortion is punishable by imprisonment. In some countries abortion is tolerated in the private sector and abortions are available in private clinics in many Arab countries, in good conditions for the well-off. But given the difficulty of their situation, many women, the poorest, use unsafe and risky methods of abortion.

      Only Tunisia in 1973 (14 weeks LMP) and Turkey (1981 until 10 weeks LMP) have legalized abortion in the first trimester without restrictions. The majority of countries in the MENA region, that have the most restrictive laws in the world, have not evolved since independence. Policy changes and growing influence of conservatives are leading to maintenance of negative attitudes among providers and denial by most physicians and state institutions. Moreover, the latest changes with the “Arab spring“ have not improved the situation. Even where abortion is legal it is now increasingly inaccessible. Recently in Turkey the government reduced access to abortion in the public health service. After the revolution, in Tunisia where abortion is free and available in all clinics of ONFP (Family Planning) and public hospitals since 40 years, many family planning clinics and hospital units are stopping providing abortion. When they still provide abortions, new restrictions are appearing on access to abortion with a change in attitude of providers, concerns and "self-censorship", coupled with greater hostility of the medical and paramedical personnel against abortion.

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      Medical abortion with mifepristone + misoprostol at 13 – 22 weeks: how long between the mifepristone and the misoprostol?

      Dina Abbas1, Nguyen thi Nhu Ngoc2, Jennifer Blum1, Nguyen thi Bach Nga3, Huynh Kim Chi4, Roxanne Martin1, Beverly Winikoff1 1Gynuity Health Projects, New York, NY, United States Minor Outlying Islands, 2Center for Research and Collaboration in Reproductive Health, Ho Chi Minh City, Viet Nam, 3Hung Vuong Hospital, Ho Chi Minh City, Viet Nam, 4Huynh Kim Chi, Binh Duong Hospital in Obstetrics and Newborn, Binh duong Province, Viet Nam - dabbas@gynuity.org

      Objective: To compare a regimen that initiates misoprostol dosing at the same time as mifepristone to a regimen where misoprostol is started 24 hours after mifepristone for termination of pregnancy of 13 – 22 weeks. Method: Double blinded randomized placebo controlled trial where participants received mifepristone either 24 hours before, or at the same time as, misoprostol (repeat doses of 400 mcg buccal every three hours). If abortion was not completed within 48 hours after induction with misoprostol the participant received standard care. Results: 504 women were enrolled in Vietnam. 87.1% of women who received the two drugs simultaneously experienced complete uterine evacuation within 24 hours after induction with misoprostol, compared to 95.1% of women who received misoprostol 24 hours after mifepristone. At 48 hours, this increased to 96% in both study arms. The mean misoprostol treatment duration and total misoprostol doses received was significantly lower in the group that received the misoprostol 24 hours later 9.13 vs. 14.66 (p=.000) and 3.47 vs. 5.44 (p=.000) respectively. Mean duration of the process, defined as receipt of mifepristone to complete abortion, was significantly shorter for women who received the drugs simultaneously 14.66 vs. 33.37 (p< 0.0001). In both groups the side effect profile was similar and overall satisfaction was high (>98%). Results will be presented by gestational age group (13 – 16; 17 – 22 weeks). Conclusion: Preliminary findings suggest that taking mifepristone and misoprostol simultaneously significantly lowers clinical efficacy at 24 hours; results in a longer mean misoprostol treatment duration; and requires more misoprostol doses. However there may be trade-offs as the simultaneous regimen significantly shortens the total time of the overall process and may require fewer clinic visits in some settings. The study provides evidence that allows providers and women to choose among two viable second trimester medical abortion regimens.

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      Feasibility of a self-performed urinary test for the follow-up of medical abortion: the Betina study

      Danielle Hassoun1, Ines Perin2 1Private Practice Office, Paris, France, 2Gynaecology Department, Delafontaine Hospital, Saint Denis, France - sbarbeau@gecem.com

      Background: Medical Termination of Pregnancy (MToP) implies a follow-up visit (14 to 21 days after mifepristone intake) to verify the effectiveness of the abortion procedure and the absence of any complication. Studies have shown that a level of hCG in the serum less than 1000 IU, two weeks after the intake of the mifepristone means the success of the method in 90% of the case. Objectives and method: We set up an observational study among French specialized centres either private practice offices, academic hospital centres or family planning facilities. The objectives were to assess the benefit of a self-performed urinary semi-quantitative test in the follow-up of MToP, assessing the feasibility, acceptability and user-friendliness of the test as well as the women’s capacity to interpret it correctly. Concordance between qualitative results from the test and quantitative values from the blood hCG measurement was also assessed. Results: 322 women were included by 17 centres (47% private practice, 35% hospital practice, 18% family planning centers) from May to October 2013. The mean age was 28.1 ± 6.4 years. 82% (N=264) of patients attended the follow-up visit and 13% (N=42) of patients were lost to follow-up. 69% (N=183) patients had performed the two tests on the same day ± 1 day. Concordance between urinary test and hCG blood measurement was 94.5% [90.2%; 97.4%]. A large majority of women (90%, N=198)) read the urinary test correctly whatever the levels of hCG. Performing the test at home was found reassuring for 40% (N=71) of them, and satisfactory for 26% (N=46) of them but 3% (N=5) considered it to be alarming and 12% (N=46) unsettling. Conclusion: The semi-quantitative urinary test shows good concordance with plasma level. Proposing a urinary test for the women to control the success of the procedure appears to be relevant, efficient and safe.

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      Women´s experiences of second trimester medical termination of pregnancy and their feelings and thoughts about viewing the fetus

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

      Objectives: To explore women´s experiences of second trimester medical termination of pregnancy and their feelings and thoughts about viewing the fetus. Method: A cross-sectional and descriptive study using both a questionnaire and semi-structured interviews for data collection. Thirty-one women filled out the questionnaire and among them 23 women were later interviewed. The questionnaires were analyzed by descriptive statistics. The answers from the questionnaires were followed up in the interviews. The interviews were recorded, transcribed verbatim and then analyzed with qualitative content analysis to identify common themes. Results: Indication for the abortion was fetal malformation or unintended pregnancy. Independent of the reason for the abortion similar feelings were expressed by the women. After having divided the feelings into positive or negative, we found that 57 % of the women had chosen both positive and negative feelings, and 40 % of the women had chosen just negative feelings. Concerns for a suffering fetus and a curiosity of what it would look like or what kind of person it could have been were expressed. Thoughts that viewing the fetus would cause increased grief or mental weakness in the future were expressed by some women. The analysis of the interview texts revealed five themes mirroring the women´s experiences, thoughts and feelings related to the abortion: "Not knowing what to expect", "To suffer", "To manage", "To get support" and "To remember", each theme is divided into subthemes to clarify the meaning. Conclusions: Women undergoing second trimester abortion need to have time and the opportunity to reflect on their feelings and thoughts in connection with the abortion. Independent of the indication for the abortion feelings of grief and sadness are seen as well as feelings of having killed their child. It is important to listen to the woman´s individual needs and give the opportunity to view the fetus if the woman wishes regardless of the reason for the abortion.

  • 12:30-
  • 14:00-
    W11: Gynuity - Vereinfachte Nachsorge beim medizinischen Abbruch, Linhart Hall
    • Beverly Winikoff, US
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      Can we eliminate the mifepristone visit in medical abortion?

      Elizabeth Raymond Gynuity Health Projects, New York, USA - eraymond@gynuity.org

      The requirement to present to a clinician in person to receive abortifacient drugs is problematic for some women. Eliminating this requirement would enable intriguing new service delivery options, including provision of medical abortion in non-traditional, non-clinical venues and provision by prescription or mail. This presentation will review data regarding the utility of examination and ultrasound prior to medical abortion and will discuss potential alternative approaches to assess eligibility that could be used over the telephone or internet.

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      Outpatient medical abortion in the later first trimester: is it possible? desirable?

      Ilana G. Dzuba Gynuity Health Projects, New York, USA - idzuba@gynuity.org

      First trimester medical abortion is typically provided through 63 days gestational age as an outpatient service. Nonetheless, many women with pregnancies more advanced than 63 days wish to avoid a surgical procedure and would opt for medical management if offered. But can women with 64 day gestations or 72 day gestations or 80 day gestations avoid facility-based management with multiple repeat doses of misoprostol and, therefore, heightened side-effects? Recent studies explored the use of an outpatient approach with more advanced first trimester pregnancies to establish efficacy, side-effect profile, acceptability to women and to determine any change in outcomes compared with medical abortions in the previous gestational week. Results support the use of outpatient regimens through 77 days of gestation and suggest new counselling considerations. Successful medical abortion appears to decrease in the 12th gestational week. Expanding provision of medical abortion for additional weeks of pregnancy would increase access, including for those women for whom suction curettage is not feasible.

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      Alternative schemes for follow-up, including use of a semi-quantitative pregnancy test

      Wendy Sheldon Gynuity Health Projects, New York, USA - wsheldon@gynuity.org

      Semi-quantitative urine pregnancy tests are a recent innovation with the potential to revolutionize abortion care worldwide. Sequential use of such tests enables women to monitor the success of their abortion procedures in the privacy of their own homes and can be an effective replacement for serum hCG and/or transvaginal ultrasound, thus reducing overall abortion-related costs and, for many women, the need to return for clinic-based follow-up. This presentation will summarize data from multiple studies conducted in the United States, Mexico, Tunisia and Vietnam using a semi-quantitative test with five bracketed hCG ranges (25-99, 100-499, 500-1,999, 2000-9,999, and 10,000 mIU/ml). The studies explore the effectiveness, feasibility and acceptability of using a semi-quantitative pregnancy test for at-home medical abortion follow-up at various points in time up until 14 days after initiation of the abortion procedure.

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      How do women manage antibiotic pills after medical abortion?

      Laura Frye, Erica Chong, Beverly Winikoff Gynuity Health Projects, New York, USA - bwinikoff@gynuity.org

      Is it time to move away from routinely giving doxycycline to medical abortion patients? Objectives: Routine provision of antibiotics following medical abortion is common, yet practitioners and professional societies differ on the utility of this practice. Our study compares the side-effects experienced by women who were prescribed doxycycline following medical abortion to those who were not and assesses the adherence to one regimen. Methods: 581 women seeking medical abortion were enrolled in this prospective, observational study in nine study sites. They were recruited from 1) clinics that routinely prescribe a seven-day course of doxycycline (Doxy Arm) and 2) clinics that do not routinely prescribe any antibiotics (No Doxy Arm). Seven to fourteen days following the administration of mifepristone, women were asked to self-administer a computer-based survey. The survey asked about side effects experienced (both arms) and adherence to the regimen (Doxy Arm only). Results: Self-reported adherence to the doxycycline regimen was moderate: 44% reported missing at least one dose and 34% stopped taking the doxycycline before 7 days. There was a trend toward increased nausea in the Doxy Arm (48% vs. 41%; p=.06) and a statistically significant difference in vomiting (25% vs. 19%; p=.03). A small but noteworthy number of women were confused about various aspects of the different medicines they received or were prescribed, including misunderstanding the purpose of a medicine, claiming to not have received a drug despite medical chart confirmation and noting costs of filling prescriptions that were not received. Implications: In the absence of robust evidence that prescribing 7 days of doxycycline following medical abortion is effective at reducing serious infections, these data can assist in deciding whether routine provision is the most appropriate strategy. Given the limits of any patients' ability to follow multiple and varied instructions, it is worth considering the impact of adding doxycycline, especially when it is frequently advised to be taken with an anti-emetic.

    W12: IPPF EN, Kosovel Hall
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      Gender-biased sex selection

      Lena Luyckfasseel IPPF European Network, Brussels, Belgium - lluyckfasseel@ippfen.org

      Sex selection can take place before a pregnancy is established, during pregnancy through prenatal sex detection and selective abortion or following birth through infanticide or child neglect. Nevertheless, the discussion seems to focus especially on abortion. Sex selection is sometimes used for family balancing purposes but far more typically occurs because of a systematic preference for boys. Practised on a large scale it can result in skewed sex ratios at country-level. The root causes of gender-biased sex selection are situated in persistent gender inequality leading to son preference. Other conditions that need to be present for prenatal sex selection are low fertility (people choosing smaller sized families) and the availability of the technology. In 2011 the Parliamentary Assembly of the Council of Europe in their resolution on "Prenatal Sex Selection" stated that there is "strong evidence that prenatal sex selection is not limited to Asia [...] and has reached worrying proportions in Albania, Armenia and Azerbaijan". This has put gender-biased sex selection firmly on the European agenda. It is important to frame the discussion on gender-biased sex selection in such a way that it does not impede women's access to safe abortion services. Following a short introduction to the topic a diverse panel will explore the following questions: What does gender-biased sex selection mean for us? How do we respond to gender-biased sex selection; towards individuals, practitioners, decision makers and anti-choice?

    W13: Frauen und Betreuung auf globaler Ebene, Room E1-2
    • Ann Furedi, GB
    • Jon O´Brien, US
    W11: Internet und neue Kommunikationstechnologien - Vorteile und Gefahren, Linhart Hall
    • Nausikaä Martens, BE
    • André Seidenberg, CH
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      Using mobile phones to strengthen medical abortion provision: opportunities and dangers identified from the South African experience.

      Deborah Constant1, Katherine de Tolly2, Marijke Alblas3,4 1University of Cape Town, Cape Town, South Africa, 2Cell-Life, Cape Town, South Africa, 3Association des sages femmes, Douala, Cameroon, 4CSU/CNRS, Paris, France - deborah.constant@uct.ac.za

      Objective: To report the South African experience using text systems on mobile phones to provide support and a self-assessment of completion of their procedure to women undergoing medical abortion. Methods: A randomized controlled trial during 2011-2012 recruited 469 women seeking medical abortion at clinics in South Africa. All women received standard abortion care with mifepristone and home administration of misoprostol and were asked to return to the clinic to assess completion 14 - 21 days later. Consenting women were randomized to standard-of-care or intervention groups. The intervention group received timed SMSs over the period between their clinic visits, with reminders on what to expect, alerts to complications and encouragement to complete the self-assessment. They were also prompted to access a contraception mobisite. Interviews were conducted at both clinic visits and one month later by telephone. Results: Most found the SMSs helped them manage the abortion symptoms and would recommend them to a friend; however 20% of recipients had concerns around phone privacy. The intervention group were significantly better prepared (p<0.05) for the pain, bleeding and side effects of the abortion. Of the 5471 messages sent, there was only a 5% failure rate. Seventy-eight percent completed the self-assessment and of these, 93% found it easy to do, however the questions did not predict all cases requiring further surgical management or additional misoprostol. More in the intervention group chose long-acting reversible contraception at their follow-up clinic visit. Conclusions: Support SMSs were effective in assisting women manage their abortion symptoms between clinic visits. Most could conduct a self-assessment of abortion completion on their mobile phones and promotion of contraception can succeed using mobile text systems. The self-assessment showed promise but was not sufficiently accurate; problems with privacy can be of concern for some women and a mechanism for stopping the SMSs is required.

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      Telemedicine for abortion care: the Highlands experience

      Lucy Caird1, Sharon Cameron2, Tracy Hough1 1Raigmore Hospital, Inverness, UK, 23 Department of Reproductive and Developmental Sciences, University of Edinburgh,, Edinburgh, UK - lucy.caird@gmail.com

      In NHS Highland we provide an abortion service in a geographically challenging environment especially in terms of providing care within the context of the UK Abortion Act. Travel time to and from our service will be a consistent barrier to providing early medical discharge with those excluded consistently at around 35%. Our aim was to improve care by streamlining care with fewer visits and thus remove some inequity in providing abortion care in our remote and rural area. To reduce visits we offer a telephone consultation option with information sharing that affords women the chance to reflect on their choices and for us to 'one stop' their visit especially where flights or ferries are involved. Women from further away have to choose either day case medical or surgical abortion in hospital and this has resource implications for the gynaecology service. Manual vacuum aspiration can offer women the advantages of same-day treatment and as with all surgical abortion the easy insertion of intrauterine contraception chosen by 55% of the women having MVA. In this paper we discuss how we have developed new ways to deliver this service remotely and have aimed to make it as streamlined as possible for women.

    Freie Vorträge, Room M1
    • Lucy Caird
    • Ingrid Sääv , SE
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      Improved access to safe abortion in Ukraine: Comprehensive Care for Unwanted Pregnancies project results, 2009-2013

      Anastasiya Dumcheva1, Galina Maistruk2 1World Health Organization, Kyiv, Ukraine, 2Charitable Foundation "Women Health and Family Planning", Kyiv, Ukraine - ada@euro.who.int

      Introduction: Before 2009, most of the pregnancy terminations in Ukraine were unsafe, which contributed from 8.5% to 16.0% to the maternal mortality in Ukraine over the period from 2003 to 2009. To address this issue, Comprehensive Care for Unwanted Pregnancies (CCUP) project was introduced in 2009 in partnership with Swiss Agency for Development and Cooperation, MoH Ukraine, NGO "Women Health and Family Planning", and WHO. Objective: The project goal was to improve availability, accessibility and quality of safe abortion in Ukraine. Methods: The project included activities at the national - improving legislation, monitoring and evaluation system, and regional levels - strengthening capacity of health care professionals, improving quality of abortion services and enhancing communication in five pilot regions of Ukraine. Results: Over the period from 2009 to 2012, the contribution of unsafe abortions into overall maternal mortality in Ukraine has steadily decreased from 9.2% (12 cases) to 4.6% (3 cases). The main reason for the overall decrease was the development and endorsement of new national legislation documents - organizational and clinical protocols, which adapted WHO recommendations on safe abortion. The percentage of women undergoing safe abortion methods in the first trimester (medical abortion, manual or electrical vacuum aspiration) vs unsafe (dilatation and curettage) has increased in pilot regions from 25-32% in 2011 to 53-75% in 2013 (variability is due to the regional context and time of project start in the region). The percentage of women who received local vs general anaesthesia has increased from 11% in 2011 to 29-37% in 2013. By the end of 2013, most of the women received pre- and post-abortion counselling sessions (82-95% compared 59-62% in 2011). Conclusion: The project interventions contributed to the overall decrease of abortion-related maternal mortality in Ukraine. Interventions piloted at the regional level are acceptable for healthcare professionals and women and can be disseminated nationwide.

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      Distress and dyadic coping when opting for induced abortion: an interactional analysis within couples

      Joke Vandamme, Ann Buysse, Tom Loeys, Guy T'Sjoen University of Ghent, Ghent, Belgium - jokel.vandamme@ugent.be

      Introduction. For decades, the psychosocial literature on induced abortion has focused on women's coping mechanisms. To date, little attention has been paid to the ways of dealing with an abortion decision from the male partner's point of view and no study has questioned how couples deal with it together. In this study, we investigate bidirectional relationships between dyadic coping mechanisms and both partners' emotional distress associated with the abortion decision. Method. In four Flemish abortion centres, Dutch speaking adult women with a gestational length of less than 8 weeks and their accompanying partners were asked to participate in a study on abortion method preferences (N=232 and 59 respectively). Both partners filled out a questionnaire in which the Dyadic Coping Inventory (DCI; Bodenmann, 2008), the Positive and Negative Affect Scale (PANAS; Watson et al., 1988) and the Impact of Event Scale (IES; Horrowitz et al., 1979) were included. The DCI measured received and provided positive and negative support, delegated dyadic coping (taking over responsibilities), common dyadic coping (dealing with the distress together), and satisfaction with the dyadic coping. The PANAS measured the presence of positive and negative feelings since one learned about the unintended pregnancy and the IES examined the degree of avoidance and intrusion since that moment. The Actor-Partner Interdependence Model will be used to investigate actor and partner effects of dyadic coping mechanisms. Results. Preliminary analyses show that the negative support that is provided to the partner is significantly affected by the negative support received from that partner, both for the abortion-seeking women as for their male partners. Detailed dyadic analyses and results will be discussed in the presentation. Conclusions. Partners can strengthen each other in negative support interactions during the unintended pregnancy situation. Counsellors should investigate the bidirectional coping process in couples who decide on induced abortion.

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      Marie Stopes International UK Abortion Study: "And then I fell pregnant with my second child". Young women's accounts of multiple unintended conceptions

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

      Objectives: The overall aim of the study was to explore the behavioural, social and service related factors that are associated with one or more unintended and unwanted pregnancy amongst young women (under 25 years). The aim of this paper is to explore the contraceptive journeys and decision-making of young women who have had more than one pregnancy resulting in abortion and/or live birth. Methods: Data is drawn from a longitudinal investigation using in-depth qualitative interviews with 36 young women, 12 of whom had experienced more than one unintended pregnancy. Results: A number of factors contributed towards participants experiencing more than one unintended pregnancy. Of particular importance, was their difficulty in finding a method of contraception they were happy with. For many this was combined with unpredictable personal lives. Some spoke about their difficulty in addressing their ‘need' for contraception due to complex sexual relationships. For each pregnancy, they discussed their decision-making with regard to continuing or terminating the pregnancy based on individualised and situational circumstances. However, their accounts of becoming unintentionally pregnant on more than one occasion were characterised by feelings of shame. Abortion stigma was an integral part of the young women's reflections about their experiences, even when they believed that they had made the right choice. Many were left with feelings of guilt that they had been in the situation more than once. Conclusions: The difficulties that some women experience establishing a contraceptive regimen need to be recognised and respected. It would be helpful to work towards continuing flexible and individualised support, recognising that a contraceptive choice made at the time of abortion may be subject to change. Condoms should be routinely provided following an abortion, and women should also be channelled into their local contraceptive services. Abortion stigma remains an issue that needs to be addressed.

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      Adherence of health workers in the Republic of Kazakhstan to the use of hormonal contraceptives

      Nadezhda Kobzar, Nafisa Mirzaraimova, Hadi Leimoyeva Kazakhstan-Russian Medical University, Almaty, Kazakhstan - nafisa.mirzaraimova@mail.ru

      The number of abortions has reduced by 29% in the period 2000-2013 in the Republic of Kazakhstan (RK). However, abortion rate remains very high per 1000 of fertile age women: 2000 - 30.9, in 2013 - 20.8. Study goal: Identification of the incidence of hormonal contraceptive use in the RK. Study materials:Reports of the MoH RK covering female population health for 2000-2013, reports of pharmacies featuring sales volumes of hormonal contraceptives in the RK for 2004-2013. Study outcomes and their discussion: High rate of abortion per 1000 of fertile age women in the RK is due to low use of contraceptives. Thus, only 30.4% of reproductive age women used contraceptives in 2000, while in 2013 their proportion amounted to 38.2%. Within the structure of contraceptives used in 2000-2013 the first place belongs to IUDs. Regardless of their proved high efficiency the rate of use of hormonal contraceptives among women remains low in the RK. The given indicator made up 2.1% in 2004 and in 2013 - 2.2%. Conclusions: 1. Though abortion numbers have gone down in the RK its rate per 1000 of fertile age women remains rather high; 2. Use of contraceptives for unwanted pregnancy prevention is low. 3. Within the structure of contraceptive use in 2000-2013 the first place belonged to IUDs; 4. The use of state-of-the-art hormonal contraceptives remains inadequate, which implies that abortion remains the principal family planning method.

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      Experiences of providing abortion care and contraceptive counselling to immigrant women in Sweden

      Elin C. Larsson1, Kristina Gemzell-Danielsson1, Birgitta Essén2, Marie Klingberg-Allvin1 ,3 1Dept of Womens and Childrens Health, Karolinska Institutet, Stockholm, Sweden, 2Dept of Womens and Childrens Health,Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden - elin.larsson@ki.se

      Universal access to health care services is a public health goal in Sweden and one cornerstone is to promote universal access to safe and secure sexuality and good reproductive health. Immigrants represent 15% of the total Swedish population. Evidence suggests that immigrants might have different sexual and reproductive health (SRH) care needs as compared to non-immigrants. Previous research indicates sub-optimal reproductive health care and adverse SRH outcomes among immigrants living in high-income settings. Family size and contraceptive use is marked by deeply rooted cultural values and norms. A culturally competent approach in service provision has been described to improve reproductive health care utilization among immigrant women. Unintended pregnancies and induced abortions are considered a public health problem and add substantial costs to both the individual women and society at large. Research from Nordic settings has shown higher rates of induced abortion among immigrant women as compared to native-born women. Objective: The aim of this ongoing study is to explore health care providers’ experiences of abortion care and contraceptive counselling to immigrant women in Sweden. Method: Data collection will be completed in September 2014. Individual interviews are carried out to reach a total of approximately 30 health care providers involved in abortion care. A purposive sampling technique is being used to recruit participants with a variety of backgrounds. An inductive approach, using thematic analyses will be applied. Conclusions: Healthcare providers experiences of abortion care and contraceptive counselling has not been described earlier. Healthcare providers are key actors in order to achieve equity in SRH. The results from this study will be used to revise health promotion programmes and healthcare provision to meet immigrant women’s needs and is expected to increase equity within the healthcare system in Sweden.

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      Making medical abortion woman-centered and accessible in Kazakhstan: a study of 600 mcg sublingual misoprostol following 200 mg mifepristone for abortion up to 70 days’ gestation

      Ingrida Platais1, Tamar Tsereteli1, Galina Grebennikova2, Beverly Winikoff1 1Gynuity Health Projects, New York, NY, USA, 2Kazakhstan Association on Sexual and Reproductive Health, Almaty, Kazakhstan - iplatais@gynuity.org

      Objective: To assess whether the option to take mifepristone at home is feasible and acceptable to women with pregnancies up to 70 days' LMP seeking medical abortion in Kazakhstan. Method: Typically, medical abortion in Kazakhstan consists of four visits. This study consisted of two visits. During their initial visit, women were given the option to swallow mifepristone at the clinic or take it home, and all women were instructed to take misoprostol at home. The follow-up visit was scheduled two weeks after mifepristone. This open-label study enrolled women with pregnancies ≤70 days' LMP. The study regimen consisted of 200 mg mifepristone, followed by 600 mcg misoprostol 24-48 hours later. Results: As of April 2014, 106 women were enrolled. Ninety-eight percent of women had successful abortions. All women took mifepristone and misoprostol at the scheduled time, and no woman took mifepristone after 70 days' LMP. No serious adverse events were reported. Most women (99.0%) reported that the ability to plan when the abortion would occur was important for them. More than half of the women (61.3%) chose to take mifepristone at home, citing compatibility with home and family duties as the top reason for their choice in location of mifepristone administration. For clinic users, the presence of a provider was the most common reason for their choice. Almost all women (99%) were satisfied with the abortion procedure and most (98.1%) would choose medical abortion in the future. Most home users (90.8%) said they would choose to take mifepristone at home again if they needed another abortion, whereas only 12.2% of the clinic users would choose to take mifepristone in the clinic again. Conclusion: An outpatient medical abortion procedure up to 70 days’ gestation using mifepristone and misoprostol, taken at a place of women's choosing, is safe, effective and acceptable.

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      Prescription of contraceptive methods in relation to repeated abortions: a longitudinal population study

      Helena Kilander1, Siw Alehagen1, Linnea Widen1, Karin Westlund1, Johan Thor1, Jan Brynhildsen1 1Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 2Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 3Division of Nursing Science, Department of Medicine and Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden, 4Department of Obstetrics and Gynaecology, Norrköping, Sweden, 5Jönköping Academy for improvement and welfare, Jönköping, Sweden, 6Obstetrics and Gynaecology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden - helena.kilander@lj.se

      Background: Use of long-acting reversible contraception (LARC) has been reported to reduce the risk of repeated abortion compared with use of other contraceptive methods. Swedish women have a long tradition of using intrauterine devices in comparatively large numbers. Despite good access to LARC, Sweden has a high proportion of repeated abortion. Objective: To study the prescription of contraceptive methods in relation to an abortion in a Swedish population and relate them to the likelihood of repeated abortions. We hypothesized that the prescription of LARC after abortion leads to reduced number of repeated abortions compared with other prescribed contraceptive methods. Method: A retrospective cohort study of women seeking abortion at three Swedish hospitals during 2009. The medical records of these women were scrutinized from the date of the index abortion during 2009 to the 31st of December 2012. The study population comprised 1032 women. Results: A total number of 266 (25%) women requested abortion(s) during the follow-up time. Oral contraceptives were prescribed to 43. 6% of the women and LARC were prescribed to 32.4% at the time of the index abortion. Prescription of LARC was associated with a reduced number of repeated abortions compared with prescription of oral contraceptives (OR 0.39 CI 0.26-0.56). Conclusions: The results of this study show that use of LARC is associated with reduced repeated abortion compared to other contraceptives. Implication: Abortion care needs an increased focus in motivating women and professionals to switch from oral contraceptives to LARC.

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      Access to safe abortion reduces the number of complications and financial costs

      Galina Dikke1, Dmitry Kochev2 1Russian Peoples Friendship University, Moscow, Russia, 2JSC "Pentkroft Pharma", Moscow, Russia - pentcroft@mail.ru

      The main method of terminating unwanted pregnancies in Russia remains a D&C (62%, 2012). Medical abortion (MA) is 8% and vacuum aspiration (VA) 30%. In several regions administrative measures have been taken to implement usage of safe methods into clinical practice. Objective: To evaluate the dynamics of the numbers of early complications and financial costs. Material and methods: We choose two regions in the Ural - Sverdlovsk region (SR) and Tyumen region (TR). SR implemented VA in outpatient and inpatient hospitals up to 12 weeks of gestation (N = 2640). TR introduced the method (the combination of mifepristone/misoprostol (200 mg/400 mcg) up to 42 days of amenorrhoea (N=2758). Results: In 2013, in the SR VA was used in 99.2 % of cases (compared to 45.3% - in 2012). Ambulatory holds 35 % VA procedures, the rest - in the hospital. The number of early complications decreased by 3 times (2.0 % vs. 6.0 % respectively), mainly due to incomplete abortion and postpartum endometritis. MA in the TR was used in 97% in early pregnancy, 34.8% of all medical abortions up to 12 weeks. Numbers of early complications decreased by 3.5 times (4.0 % vs. 13.7% respectively), mainly due to bleeding, haematometra and postpartum endometritis. Costs of treatment of early complications observed were 3 times lower in both regions. Cost savings to perform an abortion is 44 % due to the lack of need for inpatient beds, operating, disinfectants, instruments, medicines, including narcotic drugs, equipment, anaesthesia, etc. Conclusions: The introduction of sound technologies and accessibility of abortion contributes to the preservation of reproductive health (reducing complications 3-3.5 times) and lower financial costs of the procedure to perform an abortion (2 times) and the treatment of early complications (3 times).

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      Medical abortion in the United States and Canada: why so different?

      E. Steve Lichtenberg1, Heidi Jones2, Katharine O'Connell White3, Maureen Paul4, Edith Guilbert5, Christopher Okpaleke6, Wendy Norman7 1Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA, 2CUNY School of Public Health, Hunter College, New York, New York, USA, 3Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA, 4Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA, 5Institut National de Sante Publique du Quebec, Quebec, Canada, 6University of British Columbia, Vancouver, British Columbia, Canada, 7University of British Columbia, Vancouver, British Columbia, Canada - jodotter@aol.com

      Objectives: To understand differences in medical abortion provision in the United States compared to Canada. Methods: We conducted a cross-sectional survey of abortion facilities identified via publicly available resources simultaneously in the United States (n=705) and Canada (n=94) from June through December 2013, which included questions on socio-demographic characteristics and medical abortion procedures for up to 5 clinicians per facility. Results: In Canada 78 (83%) and in the US 379 (54%) of all abortion facilities participated, with respectively 60 and 348 medical abortion clinicians participating from 32 and 286 facilities providing medical abortions. In Canada all medical abortions are provided by physicians with nearly two thirds of these (59.3%) being family physicians/general practitioners compared to over three quarters of physician providers in the US (84.9%) who are specialists. In the US, 56% of providers were physicians, 26% nurse practitioners, 11% physician assistants and 6% certified nurse-midwives. In both countries, the majority of providers were female (78.7% in the US and 79.7% in Canada). Providers reported 2706 (Canada) and 135,129 (US) first trimester and respectively 322 and 1646 second trimester medical abortions. Among reported procedures in each country, medical abortion comprised 3.8 % (Canada) and 35.6 % (US) of all first trimester abortions, and 6.7% (Canada) compared to 4.3% (US) of all second trimester abortions. In the US, the majority provided medical abortions through 63 days LMP (79.1%) compared to 49 days LMP in Canada (63.3%). Providers in both countries reported practices predominantly aligned with evidence-based guidelines. Conclusion: Medical abortion is provided much less commonly in Canada where mifepristone is not an approved drug, and is more often provided by family physicians compared to the United States, where specialists or non-physicians provide most medical abortions.

  • 15:30-
  • 16:00-
    • Nausikaä Martens, BE
    • Natasa Tul Mandic, SI
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      Barriers to presenting sooner

      Roger Ingham University of Southampton, Southampton, UK - ri@soton.ac.uk

      This paper will provide a review of what is known about factors associated with women seeking termination of pregnancy after the first trimester. A few introductory comments will be made about terminology in this area, especially the use of the term ‘late' and its possible stigmatizing effect. Attention will then turn to the extent to which delays in seeking and obtaining terminations are linked to service provider factors and/or women-centred factors. Data from a recently published chapter (in Sam Rowlands' edited collection) which features an international literature review will be presented to illustrate how the relative importance and balance between these factors vary across cultures and contexts. Finally, data from a recent UK-based study will be summarized, and some reflections as to the likely impact of changing the upper limit will be presented.

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      Methods of surgical abortion in the second trimester

      Patricia Lohr British Pregnancy Advisory Service (BPAS), Stratford Upon Avon, UK - patricia.lohr@bpas.org

      Vacuum aspiration, hysterotomy, hysterectomy, dilatation and evacuation (D&E), and a variant of D&E called intact dilatation and extraction (D&X) are all procedures used for second trimester surgical abortion. Vacuum aspiration is effective up to 16 weeks' gestation, but forceps are often required to remove larger fetal parts. Hysterotomy and hysterectomy are reserved for cases where neither a medical induction nor a trans-cervical surgical approach is feasible. Dilatation and evacuation remains the most commonly performed method of surgical abortion in the second trimester, with D&X often utilized when preservation of fetal anatomy is desired. This talk will briefly review the safety and prevalence of second trimester surgical abortion and then will focus on pre-operative assessment, cervical preparation, surgical technique and post-operative care.

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      Medical methods at later gestations

      Allan Templeton University of Aberdeen, Aberdeen, UK - allan.templeton@abdn.ac.uk

      Induced abortion is one of the most common medical interventions. Most abortions are carried out in the first trimester, but there is a continuing need to provide services for those presenting later, about 10% of the total, and including most abortions carried out for fetal abnormality and for medical reasons. Medical, rather than surgical, methods became safe and effective with the advent of prostaglandins and this approach was greatly facilitated with the introduction of mifepristone around thirty years ago. Regimens employing mifepristone and a prostaglandin, usually misoprostol given vaginally or sublingually, are now available at all gestations. From about nine weeks onwards it will be necessary to repeat the misoprostol dosage perhaps two or three times or more, usually at three hourly intervals. Misprostol alone can be used in this way, where mifepristone is unavailable, but the efficacy is much reduced, a higher total dose is needed, the abortion interval is increased and there are more side effects. With the combined regimen the overall incomplete abortion rate is around 5%, necessitating the removal of the placenta (usually) surgically. Trials comparing medical and surgical approaches are few, but point to a greater preference among women for surgical approaches, although a good number choose medical. Pain and bleeding is higher with medical abortion, but the risk of serious injury, although rare, may be higher following surgery. Infection screening and antibiotic policies should be as for early abortion, as should the offer of immediate long-acting contraception.

  • 17:15-
    • Elisabeth Aubény, FR
    • Bojana Pinter, SI
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      Giving women choices in reproductive health

      Philip Darney University of California San Francisco, San Francisco, CA, USA - darneyp@obgyn.ucsf.edu

      The world's health, prosperity and peace are determined by the choices women have for their own reproductive health. Women nurture children and families and do most of the world's work. Women's unpaid work alone accounts for a third of world GDP and the fate of her family depends on a woman's health: the death of a woman increases the risk of her children's death ten times. Since pregnancy and delivery are by far the most hazardous experiences women have, choice about beginning or completing pregnancies is imperative. The Global Health Policy Summit of 2012 identified two interventions as the most cost effective in preventing women's deaths during their reproductive years: access to contraceptives and to safe abortion. These two reproductive choices have a dramatic effect because half of the pregnancies that lead to maternal mortality and reproductive injury are unintended. These unintended pregnancies also result in high rates of premature birth - the most important cause of neonatal death and injury. In places where women do not have access to the highly effective contraceptives they want or where they are denied the choice of safe abortion when they become pregnant unintentionally, maternal and neonatal mortality rates are high and societies are poor and chaotic. The cost of making these choices available to women is trivial - 0.1% of GDP in countries that succeeded in substantially reducing maternal mortality - but the costs of denying them are huge in health and economic losses and personal happiness.

  • 18:15-