Nantes, 14-15 September 2018: „Liberating women - Removing barriers and increasing access to safe abortion care“

  • 08:00-
    The Australian National University and Marie Stopes Australia will discuss the initial qualitative research findings of an Australian-driven global research project on what women want in abortion care.
  • 09:00-
    Contraception and fertility control
    • Sharon Cameron, GB
    • Caroline Moreau, FR
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      Today, a dream has come true: for the first time in human history we have the ability to effectively separate fertility from sexuality due to an unprecedented number of highly effective contraceptive methods and the availability of safe abortion. This has allowed us to effectively limit natural fertility to the individually desired number of children.
      It began with the introduction of the birth control pill in 1960, which was hailed at the time as one of the biggest revolutions in human history. The development of effective and safe IUDs quickly followed. The ability to have sex without getting pregnant was very much welcomed by women and their partners and hormonal contraception became the standard within a few years. As a consequence, abortion rates began to decline.
      While abortion continued to decline in some countries with good contraceptive access, rates have remained stable or even increased in other countries with reliable abortion statistics, such as the UK, France and Sweden. This is even more surprising as significant further improvements in hormonal contraception have been made since the introduction of the pill, namely with long acting reversible contraceptives (LARC).
      This contraceptive paradox and the underlying reasons need to be analyzed if we want to use currently available contraceptive methods up to their full potential and effectively reduce unwanted pregnancies.

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      There is wide variability in contraceptive choices and preferences among different populations.  None of the commonly available contraceptive methods is perfect, and each method has its own merits and limitations.  Important factors that commonly determine women’s contraceptive choice include effectiveness, safety and side effects, affordability and accessibility, user friendliness as well as non-contraceptive benefits.  The relative importance of these attributes varies between different users and is influenced by one’s own fertility planning as well as her physical, social and cultural circumstances. While effectiveness is emphasised by most providers, the acceptance and satisfaction is greatly determined by the perceived or actual safety and side effect profile.  Menstrual bleeding changes may positively or negatively affect method satisfaction and continuation.  


      Concerns about weight gain, effects on sex life and other side effects are also important reasons for method discontinuation, and these may be exaggerated by myths and misconceptions. Affordability and accessibility do vary with specific populations. Improved user-friendliness can be conferred by promoting the use of long-acting reversible contraceptives which are generally easy to use, more “forgettable” and less user-dependent.  Non-contraceptive benefits such as improvement of menstruation-related symptoms and acne by hormonal methods and prevention of sexually transmitted infections by condoms are additional merits to some users.  Healthcare providers generally have great influence on the contraceptive choice of most women. The tiered-effectiveness approach combined with shared decision making can be a useful way of contraceptive counselling. Within the effectiveness framework, the most effective methods are discussed first, while addressing the user’s own concerns, preferences and reproductive goals.  This aims at achieving the optimal balance between effectiveness and other attributes based on the user’s personal circumstances.

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      Today many women are reluctant to use any of the existing contraceptive methods due to side effects or fear of experiencing such effects. Unsafe abortion is a major contributor to maternal mortality. Therefore effective methods for contraception and safe and acceptable methods for termination of unwanted pregnancies are prerequisites for reproductive health, for gender equality and for the empowerment of women. New methods for contraception are also needed including improved methods for emergency contraception and new mechanisms of action as well as mode of delivery. Additional health benefits of contraceptive methods such as protection against various cancers, and a wide range of other benefits need to be better recognized. Based on their mechanisms of action Progesterone receptor modulators (PRMs) can be used for emergency contraception as well as regular contraception by various modes of delivery. Progesterone receptor modulators have been shown to be effective when used on demand post coital, as daily pills, once-weekly or once-a-month and is a well establish method for medical first and second trimester abortion. The use of progesterone receptor modulators for contraception and positive health benefits such as the possible protection against breast cancer as well as prevention of uterine leiomyomas and endometriosis deserves to be further explored. Progesterone receptor modulators have also been studied for “late emergency contraception” and for menstrual induction. Very early medical abortion (VEMA) before an intrauterine pregnancy can be visualized by ultrasound has been shown to be acceptable, safe and effective. Medical abortion is also highly effective later in the first trimester and can be self administered by women. Thus PRMs such as mifepristone if offered in a suitable dosage provides a model for a woman centred contraceptive continuum with added health benefits and increased autonomy for women.


  • 10:30-
  • 11:00-
    Concurrent session 06: ANCIC/REHVO
    • Philippe Faucher, FR
    • Martine Hatchuel, FR
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      The health system modernization law in 2016 allows the practice of instrumental TOP without general anesthesia in primary care centers subject to partnership agreement with a hospital. The aim is to diversify the care offer and facilitate abortion access for women   : proximity, rapidity, and real ability for women to choose the method. The Regional Heath Agency (Ile de France) has commissioned REVHO to assess the feasibility and to assist primary care centers in this practice. We have developed tools and training for medical practitioners and for the staff. Five pilot primary care centers were interested and eligible. Two years have been necessary for implementing the law providing for reimbursement of such practice by French social security (February 2018) and administrative constraints have delayed the beginning of this new practice outside the hospital. Last June, the first three surgical abortions were performed in Aubervilliers with great success and women’s satisfaction. As for any new practice, it will take several years before a generalized implementation with possible extension to other structures and other professionals

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      The proposal of postpartum contraception is one of the recommended practices in the management of patients with childbirth (CNGOF recommendations post-partum 2015). Contraception should be chosen by the patient after a detailed explanation of the different contraceptive methods that can be considered based on her antecedents. Currently in France, contraception mainly proposed in the postpartum is the use of a micro progestin pill. Internationally, there are many countries offering post-delivery IUDs to women who wish to perform well on efficacy, tolerance and compliance. Patients are very often satisfied with being able to return home without having to worry about contraception. This technique is not yet part of practices in France. Firstly, we propose to evaluate the practices in France and the knowledge of the midwives and gynecologist-obstetricians and then we will present some result in a tertiary maternity unit.

    Concurrent session 07: Society of Family Planning (SFP). Innovations in abortion research and practice: Lessons learned and future directions
    • Deborah Bateson, AU
    • Mary Fjerstadt, US
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      Outcomes of various medical abortion research have been difficult to compare.  Outcomes such as “effective”, “successful”, “complete” are defined differently in various studies or sometimes not defined. “Adverse events” similarly may not be reported or reported without clear definition.

      The goal of Medical Abortion Reporting of Efficacy (MARE) guidelines is to standardize early medical abortion efficacy reporting to facilitate comparison of outcomes between studies and to enhance data synthesis from different studies. This brief presentation will discuss the MARE guidelines for research methods. 
      Eligibility: the eligibility criteria for participants should be clearly stated, including the range of gestational age, the methods used to determine gestational age, and the conditions for ineligibility.
      Interventions: the study should state the medications used, including dose(s) and route(s) of administration.  The planned time interval (in hours) between medications should be stated.
      Outcomes: researchers should define primary and secondary outcome measures, including how and when they were assessed. 

      • Define successful medical abortion:  MARE guidelines propose that “successful” medical abortion should be defined as successful expulsion of the intrauterine pregnancy without need for surgical intervention. 
      • There are several categories of medical abortion failure:
        • Ongoing pregnancy. Continuing pregnancy should be defined as a viable pregnancy following treatment (differentiated from a retained gestational sac)
        • Incomplete abortion

      Heavy or problematic bleeding
      Assessment: Describe follow-up assessment used to determine outcome, for example, combination of ultrasound and physical exam, any pregnancy tests, symptoms checklist, etc. State the length of time planned to follow participants to determine outcomes. Reporting outcomes in a standardized manner will enhance data synthesis to produce evidence-based guidelines. 

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      Increasingly, women are obtaining abortifacient medicines through pharmacies, drug sellers, and online or telemedicine services – particularly where abortion services are restricted or access is difficult. Many of these women are using medical abortion drugs safely on their own, although data on their clinical outcomes are limited. Many clinicians consider the self-use of medical abortion to be dangerous; however, from a strictly medical perspective, mifepristone and misoprostol meet many of the FDA criteria for being available over- the- counter (OTC): an acceptable toxicity profile, unlikely to be addictive, and a low abuse potential.
      To demonstrate that medical abortion is appropriate for OTC distribution, a series of investigations would be required by the FDA. This research would need to establish that individuals can understand a Drug Facts Label for medical abortion, assess gestational age as eligible and rule out other contraindications for medical abortion, self-administer the medications according to instructions, and identify complications or need to seek medical care, including for ongoing pregnancy. In the short term, these efforts will help support a wide variety of efforts aimed at improving access to clinic-based medical abortion, and in the long-term, support regulatory approval for an OTC product.

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      Smartphone applications (apps) have been shown to increase health knowledge and agency, and to improve medication adherence and health outcomes. Given increasing restrictions on access to abortion and reproductive health services in the US and around the globe, new technologies that expand access to information about and support for comprehensive sexual and reproductive health issues, including abortion, are needed. 
      In partnership with safe abortion hotlines, abortion clinics, reproductive justice organizations, and advocate colleagues, Ibis Reproductive Health has conducted formative research examining user needs and preferences for such a smartphone app in Indonesia, Mexico, and the U.S.  Formative work has demonstrated that smartphone apps are desirable across a range of contexts, and apps that provides comprehensive SRH information, including information on abortion, delivered through a supportive and secure platform, are needed. Users want an app that can be tailored to their current reproductive health realities and can be modified to meet changing needs throughout their reproductive lives. We will additionally share preliminary findings from a randomized control trial conducted in partnership with Samsara, a safe abortion hotline in Indonesia, to evaluate feasibility and acceptability of a smartphone app that provides information and support for women self-managing medication abortion. 

    Concurrent session 08: Free communications
    • Niklas Envall, SE
    • Choon-Kang Walther, CH
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      Objective: To assess the influence of gestational age, maternal age, and reproductive history on the risk for surgical intervention of early medical abortion. 
      Methods: A nationwide cohort study with eight weeks follow-up of all medical abortions induced at a gestational age <63 days among Danish women through the years 2005-2015. A multiple logistic regression model provided adjusted odds ratios (OR) with 95% confidence intervals (CI) for all the potential risk factors of interest. A division of the data into a training and validation set provided a test of the prediction performance of the model. Reported is the area under the receiver operating characteristic curve (AUC) with 95 % CI.  
      Results: 86,437 medical abortions were included, 5,320 (6.2%) were surgically intervened. The risk of surgical intervention increased with increasing gestational age (p<0.0001). The risk of surgical intervention peaked among women aged 30-35 years and declined for lower and higher ages (p<0.0001). The OR of surgical intervention among parous women compared to nulliparous was 2.0 (1.7-2.4) for women with a history of failed birth of placenta, 1.5 (1.3-1.6) for women with previous caesarean section, and 1.1 (1.0-1.2) for women with previous vaginal births with spontaneous birth of placenta. A history of early surgical abortion implied an OR of surgical intervention of 1.5 (1.4-1.7), and women with a previous late surgical abortion had an OR of 1.2 (1.1-1.3). Previous medical abortion implied an OR of surgical intervention of 0.84 (0.78-0.90). The AUC was found to be 0.63 (0.62-0.64).
      Conclusion: In addition to gestational age, our study shows maternal age, previous delivery, and history of induced abortion to be risk factors for surgical intervention of early medical abortion. However, all these risk factors do not predict surgical intervention well, possibly indicating the subjective nature of the decision to surgically intervene a medical abortion.

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      Objectives: The objectives of this study are to describe the health sector's role in establishing or expanding abortion services following legal or policy reform, and to compare strategies used in order to generate practice-based options for the implementation of abortion services. Method: This is a comparative case study of six countries that recently changed abortion laws: Colombia, Uruguay, Portugal, Ghana, Ethiopia, and South Africa. For each, we completed a desk review of published and unpublished data, and conducted in-depth, semi-structured interviews with key stakeholders involved in the implementation of abortion services. Interview guides were tailored to each country, and stakeholders identified through a network of in-country partners.
      Results: We conducted 58 interviews with healthcare providers, public health officials, academics, and members of advocacy groups. We found that specifics of the laws did not predict their successful implementation. Ministry of Health involvement was key. Collaborations with UN agencies and international NGOs helped establish clinical and training protocols. Integration of abortion into existing public facilities led to more rapid and broader access. Key strategic decisions included a focus on medical rather than surgical abortion; the expansion of midlevel providers' role; and integration of contraception into abortion care.
      Conclusions: We observed a range of approaches to the implementation of abortion services in response to varying legal and policy frameworks.

      Public sector commitment and early involvement was key to the successful establishment of services, and thoughtful adaptations to local contexts can significantly reduce logistical and financial barriers to the equitable provision of services.

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      Objectives: To determine whether prophylactic administration of ibuprofen and metoclopramide or tramadol alone provides superior pain relief compared to analgesia when pain begins with mifepristone and misoprostol medical abortion through 63 days gestation. Methods: We conducted a multi-center randomized, placebo-controlled trial in Nepal, South Africa and Vietnam. Participants were randomized 1:1:1 to: (1) ibuprofen 400 mg and metoclopramide 10 mg ; (2) tramadol 50 mg and a placebo; or (3) two placebo, taken immediately before misoprostol and repeated four hours later. All women had supplementary analgesia to use as needed. Our primary outcome was maximum pain within 8 h of misoprostol administration. Secondary outcomes included maximum pain within 24 h, additional analgesia use, and medical abortion effectiveness. 86 women were required in each arm for 90% power to detect a 1.5 point reduction in maximal pain score using an 11-point visual analogue scale (VAS) compared to placebo; the sample size doubled to examine the effect of parity on the primary outcome. Results: 563 women (nulliparous n=275; parous n= 288) were randomized between June 2016 and October 2017. Women in both treatment arms reported lower pain scores compared to placebo (1: 6.43 (95% CI 6.10, 6.75); 2: 6.78 (95% CI 6.10, 6.75); 3: 7.42 (95% CI 7.10, 7.74). Ibuprofen and metoclopramide reduced scores more than tramadol compared to placebo (D mean 1: -0.99 (95% CI -1.45, -0.54); 2: -0.64 (95% CI -1.09, - 0.18); similar results were noted within 24 hours. Nulliparous women reported higher overall pain scores compared to parous women; but, treatment effect was similar. Women receiving prophylactic treatment generally used less additional analgesia. There was no difference in medical abortion effectiveness. Conclusion: Prophylactic ibuprofen and metoclopramide or tramadol reduced pain with medical abortion compared to placebo; ibuprofen and metoclopramide appears to offer better pain control compared to tramadol.

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      Objective: Provision of immediate postpartum intrauterine contraception (PPIUC) is known to be safe but not routinely practiced within the UK. Improving access to effective contraceptive methods during the postpartum period can reduce the risk of subsequent unintended pregnancy and short inter-pregnancy intervals. Our aim was to introduce an immediate PPIUC insertion facility within a large public maternity service in Scotland, UK.
      Methods: Obstetricians and labour ward midwives were trained in PPIUC insertion techniques. Women received PPIUC information from community midwives during routine antenatal contraception discussion. They could choose to receive either a copper intrauterine device or levonorgestrel-releasing system at planned caesarean section (from July 2015) or after vaginal birth (from January 2017). Women received a clinical review at six weeks to confirm device placement followed by telephone consultation at three, six and 12 months. Data from the first 300 women to receive intra-caesarean PPIUC and the first 100 women to receive PPIUC at vaginal birth were analysed in relation to complications, continuation and patient satisfaction.
      Results: The uptake rate of PPIUC at caesarean section was 13.3%.  There were 9 cases of suspected endometritis (3.8%), no uterine perforations and a cumulative device expulsion rate of 8.0%. At 12 months, the follow-up rate was 84.3% (n=253) and 79.1% (n=100) had continued IUC use. Of the first 100 women receiving PPIUC at vaginal birth, 45 (46.9%) experienced partial or complete expulsion and 82.2% proceeded to have further IUC inserted. There were no uterine perforations and 7 cases of suspected endometritis. At 3 months, 74.0% had continued IUC use. Median satisfaction scores were 10 out of 10.
      Conclusions: It is feasible and acceptable to introduce immediate PPIUC insertion within a public maternity setting. There is a low rate of complications and patient satisfaction and continuation is high. The expulsion rate after vaginal PPIUC is likely to improve with increasing provider experience.

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      Objective: There is little consensus about whether commonly used measures of Catholicism lend much to our understanding of abortion support.

      We tested whether degree of Catholicism was associated with support for abortion among Mexican Catholics and if different measures of Catholicism alter the relationship. Methods: We used data from 2,669 Mexican Catholics. Respondents were asked a question about support for legal abortion, as well as support for abortion under 10 exceptions, which we grouped into 2 categories: exceptions with traditionally majority (high) agreement and less than majority (low) agreement based on previous literature. Our independent variable was degree of Catholicism, measured in 4 ways: attendance at mass, degree of Catholicism, perception of a good Catholic, and confession after abortion. We ran multivariable logistic regression for our three outcomes, and separate models for each measure of Catholicism. Results: Perception of being a good Catholic was the only Catholicism measure that was significantly associated with all outcomes (legal abortion, high, and low agreement), controlling for covariates. Attendance at mass and self-identified Catholicism did not lend much beyond inclusion criteria. Respondents who believe a woman who helps someone who aborts can continue being a good Catholic had higher odds of support for abortion under high and low agreement exceptions. Respondents who believe a woman who aborts can confess to God or has no need to confess had higher odds of support for at least one low agreement exception. Conclusion: More nuanced measures of Catholicism that go beyond Catholicism as an identity are valuable in assessing support for abortion, especially exceptions with traditionally low support, which are the reasons most women need abortion.

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      Objectives The time between one pregnancy and the conception of the next is the interpregnancy interval (IPI). Short intervals of less than 6 months are consistently found to be associated with a range of adverse maternal and neonatal outcomes including maternal anaemia, preterm birth and low birthweight and those less 12 months increase the risk of neonatal morbidity. Amongst women attending two maternity hospitals in Sydney Australia, we sought a random sample of women to examine the timing of their IPIs and their understanding about the optimal space between pregnancies. Methods A prospective questionnaire-based study was performed at two hospitals in Sydney, Australia between Sep 2016 and May 2017. We collected demographic data, previous obstetric history, interpregnancy interval, contraceptive use and perspectives on advice and timing of the current pregnancy and ideal birth spacing from consenting women attending their second antenatal visit or immediately postnatal. Results 316 women completed questionnaires of whom 195 women were pregnant following a live birth. Of these, 119 (61%) reported that neither the hospital nor their GP had provided advice about ideal IPIs, 46.2% had not used contraception between pregnancies and 38 (19.5%) had an IPI 12 months, significantly fewer women with an IPI of < 1 2 months had used contraception after the last birth (21.6% versus 59.9%; p < 0 .001) and significantly more believed that < 1 2 months was an ideal birth interval (73.9 versus 44.5%; p=0.031). Conclusion: Most women who completed a questionnaire following a live birth reported a lack of health provider information about ideal IPIs. Where optimal IPI was understood to be less than a year, women were more likely to have a short interval between pregnancies. Almost half of women did not use any contraception.

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      After accessing safe abortion and post-abortion care (SA/PAC), clients often have an unmet need for family planning.  We used routine programme data to assess post-abortion family planning (PAFP) uptake and PAFP contraceptive methods in Kenya. 
      Methods: We analysed routine programme data for women who visited Marie Stopes centres for SA/PAC services in Kenya from 1 Jan 2015 to 31 Oct 2017. The proportion of women who chose PAFP (contraception on same day or within 14 days of SA/PAC) and uptake of contraceptive methods were examined by type of SA/PAC service (medical or surgical).  Data were analysed in Stata version 11, using chi-square tests to assess differences in proportions. 
      Results: Over the study period there were 46,531 SA/PAC services (26,084 medical and 20,447 surgical). The proportion medical SA/PAC increased from 43.8% in 2015 to 64.5% in 2017.  Almost two-thirds of clients were single (65.0%) and their age distribution was:  <15 years (0.3%), 15-19 (8.9%), 20 -24 (31.4%), 25 – 34 (45.8%), ≥35 years (13.6%).  Overall, 26,928 clients (59.8%) chose PAFP; this increased from 50.7% in 2015 to 66.5% in 2017; p<0.0001.  PAFP uptake did not vary by age, but was greater among women who had surgical vs medical SA/PAC (71.8% and 63.5% in 2017, respectively; p<0.0001).  Surgical SA/PAC clients were more likely to choose long acting or permanent methods (76.5% vs 64.2% among medical clients), with a greater proportion choosing intrauterine devices (37.3% vs 13.1% for medical clients).  
      Conclusions: PAFP uptake was consistently greater among women who had surgical SA/PAC, and uptake of long acting methods was higher among surgical SA/PAC clients. Women may prefer to complete the SA/PAC process before choosing a PAFP method, which may explain lower PAFP uptake among medical SA/PAC clients. Client-centred interventions are essential to ensure women receive family planning methods appropriate to their needs and preferences. 

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      Objectives: Major barriers in accessing abortion services for women include provider opposition, stigma associated with abortion, poor knowledge of abortion legislation, lack of trained providers, and lack of fully equipped facilities. Many providers display negative and judgemental attitudes towards women, with reports of attempts to dissuade women from undergoing an abortion. The Leading Safe Choices (LSC) programme trains and mentors mid-level HCPs in comprehensive abortion care (CAC) with a focus on surgical abortion. However, recruitment of participants for CAC training proved challenging.
      Methods: Values Clarification Workshops (VCWs) were conducted with multidisciplinary HCPs and facility managers.

      The objectives of the VCWs included exploring assumptions, myths and realities about unwanted pregnancy; providing accurate legal information about abortion; and understanding the difference between personal views and professional responsibilities. Between March 2017 and March 2018, 18 VCWs were conducted with 272 participants.
      Results: Uptake of CAC training increased with the introduction of VCWs. In the 15 months prior to the introduction of VCWs (December 2015 to February 2017), 35 providers attended CAC training with 5 being signed off as competent to provide services. In the 12 months following the introduction of VCWs (March 2017 – March 2018) the number of CAC trainees increased to a total of 81 with 19 being signed off as competent after receiving mentorship at their facilities. Since the introduction of VCWs, 11 new CAC sites have been established in the Western Cape. We suggest that VCWs have contributed to this.
      Conclusion: Increased uptake of CAC training suggests VCWs have led to improvements in the provision of, and access to, abortion care services. VCWs should be conducted with multidisciplinary teams including facility managers and attendance at VCWs should be a pre-requisite for undertaking CAC training to enable health care providers to offer holistic, respectful and woman centred abortion care.  

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      Introduction: Increasing proportions of womenwho access abortion services in Europe choose to have an early medical abortion (EMA) (<= 9 weeks). Provision of quality information on EMA(medications, process, confirmation of success of the procedure and signs/symptoms after the procedurethatnecessitate medical review) is important. However, the quality of information provided to women on EMA may be variable and provider dependent. There is some evidence that audiovisual information (e.g. film or animation) can be an effective way of providing information about abortion. Objective To evaluate an audiovisual animation as a method of information provision on EMA for women seeking EMA in four European countries.
      Method: We developed a short animation (3 mins) about EMA that summarises the key steps in theEMA process but is also adapted to reflect subtle differences in EMA practice and law in Scotland, France, Portugal and Sweden. Fifty women choosing EMA in each country (total 200 participants)will be randomisedto information provision on EMA delivered by the animation(n=35) versus a face-to-face consultation with a provider (n=15). Outcomes include information recall on EMA and womens acceptability of provision of information on EMA by the animation.
      Results: The study is ongoing. Preliminary data (one country) indicate high levels of acceptability and utility of the animation and comparable levels of information recall to face to face consultations. Free text responses from women indicate that they feel positive about the diversity of female characters depicted in the animation.
      Conclusion: Provisional data suggests that even a short audiovisual animation might adequately and acceptably deliver key information about EMA. If shown to be acceptable in the other countries, then this intervention could be used routinely to provide standardised and high quality information to women seeking EMA throughout Europe.

    Concurrent session 09: Second trimester abortion
    • Raïna Brethouwer, NL
    • Patricia Lohr, GB
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      The RCOG stipulates that 'Feticide should be performed before medical abortion after 21 weeks and 6 days of gestation to ensure that there is no risk of a live birth.' Live birth is to be avoided for 'emotional, ethical, and legal reasons.' But live births happen with medical abortions at earlier gestations and can occur prior to surgical abortions in the second trimester if labour is precipitated by cervical preparation agents. Furthermore, the very same emotional and ethical matters apply to surgical termination in the second trimester, because the same questions are raised regarding how best to end both a woman's pregnancy and a fetal life. I argue that if there are compelling reasons to perform feticide prior to second trimester medical termination, the reasons are even more compelling prior to surgical termination. Both women undergoing abortion in the second trimester and their care providers should have the choice of using feticide, regardless of the method chosen.


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      Wondering how to manage second trimester medical abortion or dilation & evacuation in the setting of an abnormally implanted placenta?

      Looking for advice on advancing the gestational age at which you and your team provide? Have questions about cervical preparation, offering a choice of method, managing prolonged inductions, or anything else related to medical or surgical methods of abortion after the first trimester? Bring your questions along to this panel of five leading experts in second trimester abortion care. Experienced, new and curious providers are all welcome to contribute to what should be a lively and wide-ranging discussion.

    Concurrent session 10: Quality abortion care and quality contraception care
    • Ann Furedi, GB
    • Anne Verougstraete, BE
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      IPPF monitors quality of care throughout its abortion programme in order to assess and improve clinical service delivery. However, the current measures are largely focused on clinic and staff capacity, and do not fully capture the client’s perspective of abortion care beyond broad measures of satisfaction. IPPF aimed to explore women’s perception of quality abortion services to better understand their concerns and priorities. In collaboration with Ibis Reproductive Health and IPPF’s Member Associations in India and Kenya, data was gathered from women who had previously obtained abortion services. 24 women in Kenya were interviewed, while in India 10 women were interviewed and 11 took part in two focus group discussions. A structured set of questions was developed and refined to elicit responses on what women felt comprised a good quality abortion, how they felt about the abortion care they received and the impact of abortion-related stigma on their experience. These responses were coded and analysed by Ibis. Results showed that women in both countries had low expectations of the abortion experience before their procedure, had little knowledge of what it would involve and feared pain, dangerous side-effects and stigmatising treatment from providers. Aspects of care mentioned as most important included kind and polite staff, a successful and safe procedure, and clear explanations to prepare clients. IPPF will use these findings to inform its abortion programme and improve quality in abortion care. Abortion quality of care monitoring will be refined so that these dimensions of quality are adequately captured and measured. This will involve developing indicators that focus on these concerns and integrating these into client exit interviews and other methods of monitoring.

  • 12:30-
  • 13:00-
    Lunch session 1: European Society for Contraception and Reproductive Health (ESC)
    • Gabriele Halder, DE
    • Sam Rowlands, GB
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      Majority of research about the protective and risk factors of repeated teenage pregnancy has been carried out in the US. Worldwide, there is more information available about subsequent adolescent deliveries than abortions. The main reason here is that the availability and quality of abortion statistics vary largely in countries. In many countries with restrictive laws abortion statistics hardly exist. Estonia is considered to be a country with liberal legislation and complete abortion data since 1992. From the same period, after regaining independence from Soviet occupation in 1991, Estonia has undergone major socio-economic changes including profound educational and health care reforms. According to the World Bank Analytical Classification of countries Estonia has turned from upper/lower income country in 1990-ies to high-income country since 2006.
      The objective of this presentation is to analyze trends in adolescent pregnancies in Estonia from 1992 until 2017 and the proportion of repeated pregnancies from 1996 until 2017.
      Methods. Data on abortions were obtained from the Estonian Medical Statistical Bureau (1992–1995) and the Estonian Abortion Registry (EAR, 1996–2017).

      The completion and return of an anonymous record card to the EAR for each abortion is obligatory for every institution licensed to perform pregnancy terminations. Data about births were obtained from the Estonian Medical Birth Registry, which was established in 1992. The number of women in the 15–19-year age group was obtained from the Statistical Office of Estonia.
      Results. The percentage of teenage mothers from all parturients was 14.6% in 1992 and 2.0% in 2017, the proportion of adolescents from all women terminating pregnancy was 11.4% in 1992 and 7.2% in 2017. During the same period teenage abortion and fertility rates have decreased 81.7% and 79.8% respectively. In 1996–2017 the average proportion of teenage abortion patients with repeat abortion has been 18%, over the years no clear increasing or decreasing trend can be observed (lowest 15.8% in 2005 and highest 22.3% in 1996), the same is true concerning delivery before the index abortion (average 16.1%, lowest 13.0% in 2015 and highest 20.4% in 1996).  In average, 8.4% of teenagers were multipara during 1996–2017 (lowest proportion - 6.0% - in 2005 and highest in 2015 - 11.8%).
      Conclusions. During the period of remarkable changes in the Estonian society and economic growth teenage fertility and abortion rates have decreased substantially and become a rather rare event. During the study period a little less than one fifth of teenage abortion patients have experienced previous delivery or abortion, around one tenth of teenage parturients are multipara. Thus the proportion of repeated pregnancies among adolescents has remained the same.

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      The scientific community emphasizes the evident need to utilize an effective contraceptive method as rapidly as possible following an abortion. After surgical procedure: There is no question in regards to the convenience of inserting intrauterine contraceptives immediately after a surgical termination, if the woman so desires. Like many other groups we offer this presentation with 250 IUD inserted immediately after a surgical termination, at the end of the procedure through out 2015 and 2016. The results after a year of follow up, are equivalent to others that are usually published on the the subject of continuation, expulsion, failure and satisfaction of the IUD. When shall the IUD be inserted following a MToP? In our opinion, as soon as possible, that is, in the first follow up visit after the procedure. There is no benefit in delaying the insertion. Therefore we refuse the notion of delayed insertion (3-4 weeks after the abortion) and we recommend an early insertion (between 5 and 14 days after the MFP intake.) Often, the follow up visit is the only opportunity for the patient to begin using an adequate  contraceptive. The benefits of LARC over SARC are evident. We will present a study of the early insertion of 115 IUD after MToP through out 2015 and 2016. The results, as we will prove, are similar to in IUD users in general.
      Our recommendation:
      -Insert the IUD as soon as possible
      -Take advantage of the opportunity of follow up visit
      -Let none leave the follow up visit without an adequate contraceptive.
      1.-Heikinheimo O, Gissler M,Suhonen S. Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion. contraception. 2008;78:149-154
      2.-Cameron ST, Berugoda N,Johnstone A, et al.Assesment of a “fast track” referral service for intrauterine contraception following early medical abortion. J Fam Plann Reproductiva Health Care. 2012;38:175-178
      3.-National Institut for health and Welfare. official Statistics from Finland. Induced abortion 2015 (Internet). Published Oct 2016. Available from: http/

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      Unintended pregnancy can disrupt treatment and recovery for women of reproductive age with cancer. Although some cancers and treatmentss impair infertility, many women with cancer are physically capable of conceiving. Little is known about contraception counseling and abortion in cancer care. Several studies indicate that cancer surviviors in different countries have more abortions than their siblings. Women are overloaded with information at cancer diagnosis adn fertility isues are freuqently forgotten. In a Swiss study of reproductive-aged women with breast cancer 62 of 100 participants needed contraception counseling at time of cancer diagnosis. 17% of women in an Australian sample never had the question: What should I do about contracpetion ? answered during their cancer care. Also some women believe that they could not get pregnant during and after treatment, despite having no clinical diagnosis of infertility. One study found that women who had contraceptive counseling had alomost even times higher use of effective contraceptive methods. A US study demonstrated a higher use of emergency contraception among female young adult cancer survivors. In conclusion using contraception to time pregnancies for periods of better health, is highly relevant for women with a recent cancer diagnosis. Improving reproductive health care for women with cancer is essential. Collaboration between healthcare providers couselling involved into cancer treatment and family planning doctors/nurses/midwifes needs improvenment.  


    Lunch session 2: Counselling for difficult clinical situations – small group discussions
    • Nausikaä Martens, BE
    • Carine Vrancken, BE
    Lunch session 3: Nursing/ midwifery management of midtrimester medical abortion. A round table discussion of practical issues and caring for women
    • Linda Hunt, GB
    • Oona Nyytajä, FI
    • Sandra Rubio, SE
    Lunch session 4: Highly recommended posters platform
    • Shelley Raine, GB
    • Allan Templeton, GB
    Lunch session 5: Levoplant event - Session on the indications, counseling, and insertion and removal techniques for the Levoplant contraceptive implant. Organised by WomanCare Global.
    • Matthew Reeves , US
  • 14:00-
    Concurrent session 11: IPPF Session theme - Removing barriers and facilitating access to abortion care – A global perspective
    • Teresa Bombas, PT
    • Lena Luyckfasseel, BE
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      In Georgia during last decade medical service providers became decentralized and universal health care provision were launched. These changes in health system triggered increase in number of health providers and proportionally need for regulation of service provision and financing. 
      Non-preventable abortion in Georgia is legal and provision of service is distributed to primary and secondary health providers. Law of Georgia on health care allow abortion on request up to 12 weeks of gestation therefore mandates 5-day mandatory waiting time between consultation and abortion procedure. State policy regarding abortion is to increase childbirth while women’s choice and health is unsatisfactory level.

      Despite liberal policy there still is low accessibility and availability to safe abortion services which is caused by uneven distribution of service providers that provide abortion service, ununiformed referral system, and diminishing number of abortion provider physicians (church influence, conscientious objection). As a result, women are forced to travel for service.
      In Georgia unsafe abortion is widespread in spite of medical activity regulation on physician and medical facility levels. Due to no medical service quality appraisal, it is impossible to track standards of service provision and identify medical facilities where quality is not sufficient. For example, system does not track service providers where only D&C method is used or how frequently it is used. If consider D&C method, along with general anesthesia, no counseling, no post-abortion family planning and etc. as unsafe way of abortion service provision. Two above-mentioned issues make it difficult to prevent unsafe abortions.
      Women searching for abortion services encounter accessibility and availability barriers that are Not enough Abortion Providers, Cost and Travel, Judgmental Gatekeepers, Conscience Clauses, Bad Referrals, Anti-choice Organizations (church), which makesprevention of unintended pregnancy difficult, leading to high abortion rates, low quality.

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      In West Africa, the number of deaths due to unsafe abortion is 540 per 100,000 unsafe abortions. In Benin, legal restrictions and prevalent stigma create barriers to access for safe abortion.
      Since 2014, the IPPF Member Association in Benin, Association Béninoise pour la Promotion de la Famille (ABPF) has implemented a project aimed at reducing abortion stigma amongst young people. An adapted “Stigmatizing attitudes, beliefs and actions scale” (SABAS - Shellenberg, 2014) implemented to measure community attitudes to abortion, revealed that 84% of respondents have a negative perception of abortion and they do not favour access to safe abortion services. Young people often use unsafe methods of abortion because of stigma they face in the community. The double stigma of being sexually active and seeking abortion care experienced by young people disempowers and leaves them without accurate information and support, increasing the risk of unsafe abortion.
      Through the project, ABPF has empowered young people to lead initiatives to reduce abortion stigma. ‘Youth Champions’ have been trained on abortion rights and they work with their peers, providing information about sexual health and abortion, and refer young people to clinics for safe abortion services. Some specific strategies that the youth champions have implemented include conducting outreach activities in schools, with students and teachers as well as specific sessions for young people that are out of school. The Youth Champions have conducted advocacy with community leaders to influence policies in support of young people’s access to safe abortion services. The Youth Champions are active on social media, answering questions from other young people and working to destigmatize abortion. Since October 2016, the number of abortion and abortion related services provided to young people is 4561, in addition the Youth Champions have referred 153 young people themselves to ABPF services

    Concurrent session 12: Providers and services in crisis
    • Dimitar Cvetkoff, BG
    • Ann Furedi, GB
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      Medical abortion in Bulgaria is available in unusual circumstances. Abortion in Bulgaria is allowed up to 12 weeks upon wish, up to 20 weeks - for medical conditions or foetal anomalies, and after that - in extreme circumstances.
      The legislation regarding abortion has been made in 1990 and last reviewed in 2000. Medical abortion doesn’t exist in it. It is written envisaging surgical procedures only. It requires blood tests (FBC, MSU, clotting, blood group, Rh) and vaginal swab prior to every abortion. It also requires the abortion to start and end in a medical facility. It otherwise classifies the act as a criminal offence and envisages imprisonment of up to 5 years and if repeated - up to 8 years.
      Medical abortion, however, has been performed in the country over the past 10 years or so. Prior to the official availability of registered drugs, Cytotec was in wide circulation. It still is, regardless of the lack of registration in the country.
      Mifepristone and Misoprostol have been first registered in 2012, reaching the market in the end of 2014. Their registration is for distribution in pharmacies, by prescription. The obs&gynae society, however, is largely against the wide availability of the medications, being afraid women will self medicate, and are reluctant to prescribe them, seeing it as illegal to participate in abortion outside medical facility. Very few hospitals offer MTOP or medical management of miscarriage as an inpatient procedure. Professional knowledge on medical abortion is limited. It is widely believed that every pregnancy must end with delivery or curettage.
      A few hospitals and doctors do provide medical abortion, albeit in variation of regimens, and more and more women request it.
      It is because of women’s increasing interest and the few doctors fighting for the cause, that medical abortion is surviving in Bulgaria.

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      The future would be to expand this service to the legal gestation age of 23+6 weeks. This service has exponentially expanded over the past 3 years to cater for women with complex co-morbidities, which require a multi-disciplinary team involvement. I shall present the unit’s case load, complexities and methods of achieving a safe outcome with the focus for ensuring a high uptake of long acting reversible contraceptives. 

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      Australia is a prosperous country which endeavours to provide equitable access to high-quality healthcare. Yet this is not the case for abortion.

      With the introduction of government-subsidised medical abortion in 2013 it was envisaged that women would be able to access affordable abortions, medical or surgical, across the country. Unfortunately, this promise has not been met, especially for those who are financially disadvantaged or who live in rural and remote areas. 
      Australia has a complex patchwork of abortion laws across its 8 states and territories, ranging from legal abortion available on request up to 24-weeks with potential supply of early medical abortion drugs by nurses in Victoria, to abortion provision still residing in the Crimes Act of 1900 in the most populous state of New South Wales. While decriminalisation has not always led to improved access, the risk of prosecution serves as a barrier to service provision, particularly in the public setting. Publically-funded hospital services, except for fetal abnormality, are difficult to access or non-existent in most states and territories and costs for private medical and surgical abortion services vary widely and can be substantial and unaffordable. While General Practitioners are potentially able to provide low cost medical abortion to their patients only a very small number do so due to perceived stigma, poor remuneration and concerns about managing complications in the absence of clear referral pathways into local hospitals. Australia’s innovative telemedicine service has the potential to overcome barriers to access but reports of obstruction and psychological abuse of women by health care providers providing radiology and other necessary support services highlights that abortion is far from stigma-free in Australia.  Despite these challenges key steps are being taken by professional colleges and other leading health organisations to integrate abortion care within their training pathways and in calling for policy reform focussing on reducing costs and enhancing early access.

    Concurrent session 13: Free communications
    • Rodica Comendant, MD
    • Martine Hatchuel, FR
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      Objective: To study the effect of a public program providing long-acting reversible contraceptive (LARC) methods at no-cost on the risk of unintended pregnancy.
      Methods: The City of Vantaa in the Helsinki metropolitan area (approximately 220,000 inhabitants) implemented a program entitling all women their first LARC method at no-cost in January 2013. During 20132014, altogether 9,685 women entitled to a no-cost LARC visited a public family planning clinic and 2,035 women initiated a no-cost LARC. Lacking data on intendedness of pregnancies, we used induced abortion as a proxy for unintended pregnancy. In this register based cohort study, we used Poisson regression to estimate the risk of abortion among women who chose a LARC method (no-cost group) and among women who visited the clinics, were entitled to a LARC but chose otherwise (visitor group), and in an age matched population cohort (1:4) consisting of non-sterilized women entitled to LARC method (n=36,399). The follow-up started on the date of LARC initiation (no-cost group), date of visit (visitor group) or at start of follow-up for the population controls. Follow-up ended at start of gestation, date of sterilization or move abroad, or on 31.5.2016.
      Results: In the full model we adjusted for age, age2, previous pregnancies and abortions, and socioeconomic status. The Incidence Risk Ratio for abortion among women initiating no-cost LARC was 0.27 (95%CI 0.170.39) compared to the matched population control. The abortion rate among visitors did not differ from the population controls (IRR 1.09, CIs 0.951.25).
      Conclusions: Among women seeking counseling on contraception, initiation of a LARC method is associated with a significantly lower need of subsequent abortion.

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      Introduction: In 2015, mifepristone was approved in Canada, making it the 61st country to do so.  Prior to mifepristone, there were only 60 physicians providing medical abortion in Canada. In anticipation of the commercial availability of mifepristone in 2017, clinicians prepared clinical practice guidelines and an online medical abortion training course.  Health Canada mandated training  prior to prescribing or dispensing mifepristone, however, in late 2017, the regulation was relaxed from “mandatory” to “recommended”.
      Methods: We present participant data on the first 16 months of medical abortion training to provide an estimate of clinicians who are currently eligible and/or likely to provide mifepristone medical abortion across Canada.
      Results: Overall, 167 Obstetrician/Gynaecologists, and 408 Family Physicians (which make up the majority of abortion providers in Canada) have completed the Medical Abortion Training Course.  1346 pharmacists have completed the course and are eligible to dispense the medication. 173 nurses (of which 112 are nurse practitioners with prescribing privileges), 6 midwives, and 151 medical students and residents also have been trained in medical abortion.  There is a physician trained in every province and territory, however there is no pharmacist trained in Nunavut, a northern territory.
      Conclusion: There is widespread interest and uptake of mifepristone medical abortion in Canada.  Within the first year of availability of mifepristone, over 2000 medical professionals have completed the medical abortion training course.  In contrast to pre-mifepristone, where very few physicians provided methotrexate-based medical abortion, there are at least 575 physicians currently eligible to prescribe, and 1346 pharmacists eligible to dispense mifepristone.

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      In Nigeria, abortion is illegal except to save a woman’s life, and data on abortion are limited. Performance, Monitoring and Accountability 2020 (PMA2020), in conjunction with the Centre for Research, Evaluation Resources and Development, are collecting nationally-representative survey data on abortion perceptions, norms and stigma in seven states in Nigeria. This study aims to characterize abortion stigma and its correlates, and assess its relationship to perceptions of abortion in the community and the performance of survey-based abortion estimation techniques. 
      Using a two-stage cluster design, women aged 15-49 in households are interviewed by resident enumerators using smartphones. Women are asked about a range of reproductive health issues, including their perceptions and experiences around abortion, as well as those of their closest confidantes. Survey administration will be complete in May 2018 with a final sample of approximately 11,000 women. Here we report on preliminary analyses of bivariate associations and estimates of lifetime abortion experience. Multivariate regression analysis will be conducted upon attainment of the final sample.
      Overall, approximately 70% of respondents felt that a woman who has an abortion brings shame to her family, and 45% reported abortion as common. A higher percentage of women who perceived abortion as shameful reported it as uncommon compared to women who didn’t perceive it as such (47% vs 43%, p<0.001). Estimates of reported lifetime prevalence of a likely abortion amongst a woman’s closest confidante were lower among women who perceived abortion as stigmatized versus not stigmatized (18% vs 22%, p<0.05). We recorded a difference in self-reported lifetime likely abortion prevalence among women who perceived abortion-related stigma versus those who did not (13% vs 17%, p<0.001).
      Our study incorporates data on stigma, perceptions of abortion prevalence, and two methodologies (self-report and confidante) for abortion estimation, allowing consideration of the empirical associations between stigma and these measures.

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      Objective: The safety of abortion is well established, yet quality abortion care must reflect domains beyond safety. We document quality of care definitions, conceptual frameworks, and measures used in the literature and agency practices to inform ongoing efforts to develop quality metrics for abortion.
      Methods: We reviewed the abortion and contraception literature, the broader health services and quality in healthcare literature, and agency definitions and tools for quality measurement. We identified seminal definitions and frameworks as well as criteria for quality measures. Results: Health care quality is the degree to which services produce desired health outcomes and rely on best available evidence. Key frameworks from the Institute of Medicine (IOM) and World Health Organization (WHO) articulate domains of quality, focused on whether health care is effective, efficient, accessible, acceptable/patient-centered, equitable, and safe. Quality is further classified as technical (appropriate care) and interpersonal (interaction with provider). Evidence exists to guide clinical practice in abortion. However, assessment of the quality of clinical practice remains unstandardized, and very little evidence exists documenting client perceptions of both technical and interpersonal quality. Satisfaction, a common quality measure, is limited: women are nearly universally satisfied when they receive needed care, and global satisfaction does not tell us where or how to intervene to improve quality. A wide variety of measures and indicators have been used in the literature and by implementing agencies, but little evidence exists to link these measures with health or behavioral outcomes.
      Conclusions: Quality abortion care includes, but is not limited to, safety. We lack both common terminology and measures to assess abortion services across diverse health system settings, especially in low- and middle-income countries. Such measures would allow us to build evidence about the effectiveness, efficiency, accessibility, patient-centered-ness, equity, and safety of abortion services, and ultimately to improve abortion care for women across the globe.

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      Background: Unsafe abortion causes an estimated 43 000 maternal deaths each year. Telemedicine abortion services today abridge the lack of access to safe abortion in many countries. We aimed to evaluate the safety and acceptability of abortion through telemedicine at above nine gestational weeks (gw).
      Methods: A retrospective cohort study comparing self-reported adverse outcomes among women in Poland at ≤ and > 9 gw who requested abortion through the telemedical service Women on Web between June 1st and December 31st 2016, confirmed intake and provided follow-up (n=615).
      Results: Among women ≤ and > 9 gw respectively, 3.3% vs 11.7% went to hospital within 0-1 days of the abortion for complaints related to the procedure (AOR 3.82, 95% CI 1.90-7.69). In a stratified analysis the corresponding rate in the highest gestational age group, 11w0d-14w2d, was 22.5% (AOR 9.20, 95% CI 3.58-23.60). Among women ≤  and > 9 gw respectively, the rate of surgical evacuation post-abortion was 12.5% vs 22.6% (AOR 2.04, 95% CI 1.18-3.32),  the rate of overall medical interventions post-abortion was 18.3% vs 29.0% (AOR 1.84, 95% CI 1.13-3.00), the rate of heavy bleeding was 6.8% vs 10.1% (AOR 1.65, 95% CI 0.90-3.04), the rate of low satisfaction was 2.4% vs 1.6% (AOR 0.69, 95% CI 0.14-3.36), the rate of bleeding more than expected was 45.6% vs 57.8% (AOR 1.26, 95% CI 0.78-2.02), and the rate of pain more than expected was 35.6% vs 38.8% (AOR 1.11, 95% CI 0.71-1.71).
      Interpretation: Medical abortion through telemedicine above nine gw is associated with a higher rate of hospital visits for complaints in the days following the abortion compared to abortion at or below nine gw but not with a higher risk of heavy bleeding. It is associated with an increased risk of post-abortion treatment and intervention but not with a lower rate of satisfaction or met expectations.

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      Objectives: In October 2017, The Scottish Government approved a patient’s place of residence as a place where treatment for abortion can occur. Women up to 9+6 weeks gestation, can be administered mifepristone in a medical facility and given misoprostol to take home and self-administer 24-48 hours later. The option of early medical abortion at home (EMAH) has been available in our service since April 2018. Following ultrasound assessment of gestation, women who are under 9 weeks are offered the options of EMAH, medical abortion in hospital or surgical abortion.  We aim to identify any demographic characteristics which may determine if a woman is more likely to choose EMAH, as opposed to hospital management.
      Methods: A prospective review of the records of all women who attend over 4 months from April to July, who are 9 weeks or less and choose medical abortion. To be eligible for EMAH they must live in Scotland, be 16 years or over, have an adult with them on the day of abortion, not require an interpreter and have no significant medical conditions. We will analyse demographic data for those who choose EMAH and those who have medical abortion in hospital. 
      Results: In the first four weeks of offering EMAH to eligible patients, 184 women have been less than 9 weeks gestation and chosen medical abortion. 92 of them were booked to have medical abortion in hospital, and 92 EMAH. Upon completion of data analysis for the first 4 months, we will present the proportion of women who wished medical abortion that were eligible for EMAH, the proportion who chose EMAH and any demographic differences that exist between those choosing home and hospital management.
      Conclusions: We will determine if any demographic differences exist between women who opt for home or hospital management of medical abortion.

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      Much attention is given to the alleged right of healthcare professionals to refuse treatment under the guise of “conscientious objection,” especially abortion. But what about those who conscientiously commit to providing this life-saving care despite stigma, obstacles, and legal risks?  The organization Women Help Women believes in the ethical value of conscientious commitment to provide abortion care as a way to break the taboo around provision regardless of legal settings. WHW does this by equipping local activists and health workers to guide women through self-managed abortion in countries where abortion is illegal.

      This presentation will share aspects of WHW’s unique partnership model, which is based on collaborative, participatory, feminist efforts to advance access and knowledge. WHW works horizontally, promotes local ownership of joint initiatives, and strengthens and develops capacities of local and regional movements. One example is WHW’s “Mobilizing Activists for Medical Abortion” network (MAMA), which operates in at least eight African countries.

      MAMA expands community access to information and provides reproductive health training about misoprostol use and self-induction. In 2017, MAMA member organizations reached over 19,000 women with information and services.

      In Latin America, WHW collaborates with activists throughout the region, with a focus on Central America, Brazil, and Chile. The group helps local collectives launch and maintain new safe abortion hotlines, trains activists in counseling skills and medical abortion, and supports access to safe abortion via locally-led campaigns and awareness actions. For example, in Chile, the “Misoprostol for All” campaign used radio spots and street actions to promote information about the local safe abortion hotline and the use of misoprostol.


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      Objective: About 26 million women refugees worldwide are affected by emergencies and face multiple sexual and reproductive health and rights (SRHR) risks, requiring access to key services. Women in humanitarian emergency settings face increased exposure to unintended pregnancies while lacking access to SRHR services, including safe abortion.

      An overall growth in institutional capacity in SRHR in humanitarian settings has been reported, however with an exception for abortion-related services. Suggested reasons for this are legal uncertainties, health care providers’ personal moral/attitudes, and lack of quality commodities. However, research confirming or rejecting these hypotheses is lacking.

      The aim of this study was to gain a better understanding of health care providers’ readiness to provide safe abortion services in humanitarian settings, and to identify obstacles and facilitators in service provision.
      Methods: Ten individual in-depth interviews were conducted with health care providers with experience in working in humanitarian settings in Nepal and Pakistan. An inductive qualitative approach was used for analysis. 

      Preliminary results: Induced abortion is rarely prioritized or discussed in medical training. Health care providers are willing to provide safe abortions, but often have inadequate knowledge, poor access to updated guidelines, and lack equipment and supplies. Despite being legal, access to abortion is limited. Stigma surrounding abortions consist a barrier both for patients and health care providers, since abortion services often are frowned upon by surrounding communities. Health care providers’ personal values, and involvement of influential people, such as religious leaders, were mentioned as both barriers and facilitating factors.  

      Conclusions: Further training addressing caregivers’ knowledge, attitudes and values is needed. Information on local legal situations, support to health care providers, in-service training and updated guidelines are lacking. As research on this topic is scarce, this study is of high importance for humanitarian actors with mandate and aim to provide safe abortion services.

    Concurrent session 14: Abortion in Humanitarian settings
    • Antonella Lavelanet
    • Allan Templeton, GB
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      In recent years, conflict, violence and disas­ters have brought a dramatic rise in the number of displaced people, both within and across national borders. There are an estimated 26 million women and girls of reproductive age living in emer­gency situations, all of whom need sexual and reproductive health (SRH) information and services. The average length of time an individual now spends displaced is 20 years, and three quarters of countries with the highest maternal mortality ratios are fragile states as defined by the Organisation for Economic Co-operation and Development.  Sexual violence is also prevalent. A recent Global Review demonstrated that significant gaps remain in access to safe abortion and reproductive health care in humanitarian settings.
      Providers are an essential component of safe abortion care globally. In humanitarian settings providers have unique needs to provide safe, competent care. To support providers in offering safe, evidence-based reproductive health care, the WHO has recently developed a process for adapting reproductive health guidelines to the humanitarian setting, and developing provider tools. This process was developed following a review of the literature, and in consultation with experts in guideline methodology, emergency response, SRH and rights, epidemiology, implementation research, and program managers. The methodology has been applied to the Medical Eligibility Criteria for Contraceptive Use, and a tool of the adapted guidelines developed and field tested. Similar efforts may further provision of safe abortion care in the humanitarian settings.


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      The International Rescue Committee, a multi-sector humanitarian response organization, has embarked on an ambitious strategy to enhance the quality and reach of our programs to help our beneficiaries achieve key outcomes. A central pillar of IRC2020 is achieving gender equality, which requires improved sexual and reproductive health outcomes for women and girls. The global evidence demonstrating that the burden of unsafe abortion falls most heavily on poor women and girls in low resources countries, many of which are affected by conflict and natural disaster, led the IRC to develop a strategy to integrate safe abortion care (SAC) into our programs. This strategy has four main objectives:

      • Clarify our organizational commitment to increasing access to SAC;
      • Transform staff attitudes toward SAC and the women and girls who request the service;
      • Build context-specific knowledge around abortion in each country program; and
      • Implement country program-driven approaches to increase access to SAC.

      As a result of this strategy, three IRC country programs offer safe abortion care and an additional 9 are developing strategies to do so. The IRC’s experience offers a road map and lessons learned for other organizations hoping to increase access to SAC and demonstrates that it is feasible to provide safe abortion care in humanitarian settings.

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      Even as the climate for sexual and reproductive health funding and research has become more tolerant, abortion in humanitarian settings remains under-studied. Systematic reviews have documented significant limitations of funding for abortion-related research as well as evidence gaps on both the need for and provision of safe abortion in humanitarian settings. Additionally, many implementing and research institutions lack the networks, skills and/or time to conduct challenging research in this complex environment. Evidence is needed to generate and sustain interest, document the scope of the problem, and ultimately to help promote an agenda for bridging this gap and turning research into action to meet women’s abortion care needs. This presentation will discuss the evidence gaps, types of needed research, promising partnerships, funding, and describe examples of on-going research and documentation. 

    Concurrent session 15: Catholics for Choice. Moral & ethical thinking: from global abortion providers, an interactive discussion
    • Laura Gil, CO
    • Eddie Mhlanga, ZA
    • Jon O´Brien, US
    • Willie Parker, US
    • George Thomas, US
  • 15:30-
  • 16:00-
    Best oral communications, young researcher & posters and FIAPAC/Exelgyn grant
    • Sharon Cameron, GB
    • Nausikaä Martens, BE
  • 16:30-
    The impact of stigma & future service provision
    • Sharon Cameron, GB
    • Nausikaä Martens, BE
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      Abortion remains a contentious and stigmatised medical procedure, despite being a commonly performed gynaecological procedure. 

      It is often framed as a moral, religious or legal issue rather than a medical one and is reinforced at structural, policy, community, and individual levels.  Abortion stigma is a multifaceted phenomenon, impacting on the experiences of women who undergo abortion and the health care professionals involved in abortion care.  Public discourses focussed on particular types of abortion that are viewed as problematic – ‘repeat, ‘late’ – are further stigmatising and potentially discriminating.  Even the language itself is inherently judgemental.  This presentation will review contemporary evidence of the experience of abortion stigma among women and providers, the implications of this for health and wellbeing and inequalities, and how abortion stigma can be countered and challenged.

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      All restrictions to access abortion services, legal logistic financial, creates social inequality.  Women with access to financial means and information will always be able to access safe abortion services and women without the financial resources are most affected by these obstacles. abortion laws.  Women on Waves and Women on Web use new technology (drones, robots, internet, apps) and research, to break the taboo around abortions and change policies and laws and in the same time make sure women have access to contraceptives and safe medical abortions. This presentation will highlight some of the work, achievements and challenges in the past years.

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      The final session in Plenary 4 looks at how we can build a resilient cadre of abortion providers that is proud to offer women the means to control their fertility and will respond to some of the problems raised throughout the conference.




  • 17:45-
    • Sharon Cameron, GB
    • Clare Murphy, GB