Abortion then and now: New Zealand Abortion
Istar Limited, New Zealand
Based on a social history book by Dame Margaret Sparrow
available from Victoria University Press www.victoria.ac.nz/vup/.
In the 1940s deaths from septic termination of pregnancy
(TOP) were an ever-present fear.
In the 1950s, due to antibiotics, deaths were less common but
there was a network of clandestine abortionists.
In the 1960s the contraceptive pill and feminism brought
changes for women but New Zealand and Australia did not follow
the 1967 law changes introduced in the UK. Those who could
afford it went overseas.
In the 1970s TOP was catapulted into the public arena with
protest and debate bringing signiﬁcant law changes in 1977–78.
Finally doctors took responsibility for safe TOP services.
From the years when illegal TOP was usually the only option
for women, the author has collected personal stories from some
70 contributors, women who had a TOP, doctors, police and
activists. Some of the stories relate to women from New Zealand
struggling with accessing abortion while living in the UK.
The themes are universal and remind us that these injustices
must never return.
Activity of a termination of pregnancy department
Scassellati, G; Bologna, M; Di Felice, M;
San Camillo Forlanini Hospital, Rome, Italy
Termination of pregnancy (TOP) has been carried out in our
hospital since 1978, the year in which TOP became legal in Italy.
Our department is one of the most important TOP departments
in Rome: during 2011, 2098 women were admitted to our hospital
for a TOP, almost 30% of TOPs performed in the Lazio region. It
is also the only hospital in Rome to use pharmacological TOP
Our department provides a complete service for women in the
event of unwanted pregnancy. Besides the clinical activity, we
guarantee psychological support during all the phases of a TOP.
Since 2001, with the increase of the number of TOP requested
by immigrant women, our department established a service of the
so-called ‘intercultural mediation’ with the aim of preventing
unwanted pregnancy and spreading the regular use of
contraception among immigrants.
A relevant part of our activity is dedicated to the clinical
follow-up of women to ensure counselling and to encourage and
help them to use a contraceptive method. We also ensure
gynaecological consultation, a speciﬁc space for reproductive
health care, with the aim of reaching women with difﬁculty
accessing gynaecological treatments (women with lower level of
education, housewives, immigrants) and to facilitate their access
to public hospitals.
- Lucy Michie, None (all speeches)
Asurvey of attitudes of staff working within a
sexual and reproductive health centre, towards
undertaking early medical termination of
Michie, L1,2; Cameron, S1,2
1 Chalmers Sexual Health Centre, Edinburgh, UK; 2 University of
Introduction: In Scotland, most termination of pregnancy (TOPs)
are provided in hospital departments of Obstetrics and
Gynaecology. Since high quality contraceptive provision should be
integral to TOP, this raises the question of whether TOP services
would be better provided by clinicians in community sexual and
reproductive health services (SRH). We aimed to determine views
of these clinicians about potentially offering TOP services
Methods: An anonymous internet questionnaire of staff working
in a large SRH service in Edinburgh (Chalmers) was conducted
between January and March 2012. The questionnaire consisted
mainly of ‘drop-down’ list options with additional free text
response to some questions.
Results: A 69% response rate was obtained. (62 out of 90;
doctor = 22, nurses = 25, admin staff = 15). The majority of
responders (69%) felt that provision of abortion services would be
a natural extension to existing services and the majority, (69%)
would be personally willing to provide abortion care. Only 11%
stated that they would refuse to be involved in TOP care due to
moral objections. Respondents agreed that TOP care from this
setting would offer advantages for women including better
provision of contraception (71%) and better management of
sexual infection (53%), amongst others. Only 23% of responders
(n = 14) felt there would be some disadvantage to offering
abortion services from this setting.
Conclusion: Most staff felt that providing TOP services within a
community SRH service is a natural extension to existing services
and that this would offer improved contraception and sexual
health care to women undergoing TOP.
- Lucy Michie, None (all speeches)
Asurvey of professionals in sexual and
reproductive health in the United Kingdom, about
attitudes towards provision of termination of
pregnancy care within community sexual and
reproductive health (SRH) clinics
Michie, L1,2; Cameron, S1,2
1 Chalmers Sexual Health Centre, Edinburgh, UK; 2 University of
Introduction: In the UK, termination of pregnancy (TOP) services
are predominantly based within National Health Service hospitals.
However, community based sexual and reproductive health (SRH)
clinics that provide specialist contraceptive services could offer an
alternative setting and may provide high quality on-going
contraception. We sought to determine the attitudes of those
working within SRH towards participating in TOP and views on
which setting is most appropriate for TOP care.
Methods: A questionnaire was distributed to attendees at a large
UK sexual and reproductive health scientiﬁc meeting in April
2012. Information obtained included demographics, respondents
current experience of TOP care and their response to a series of
statements concerning, attitude and willingness to participate in
and location of TOP care.
Results: An 82% response rate was obtained (165 of 200). Eighty-
eight percent (n = 146) of respondents were female. Ninety-ﬁve
percent (157) were doctors and 4% (6) were nurses. Almost all
responders already had some involvement in TOP care (97%
n = 160); 78% (29) refer patients on to hospital TOP services,
64% (106) assess patients and provide information, 62% (103)
sign documents authorising TOP and 14% (24) undertake the
procedure or administer medication. Whilst 78% (128) agree TOP
care services (for 1st trimester, uncomplicated cases) would be
best suited to community SRH, 51% (83) believe it should be
divided across community, hospital and charity services.
Conclusion: The overwhelming majority of doctors and nurses in
SRH agreed that abortion services would be best delivered from a
community SRH setting and would be willing to participate in
providing this service.
Continuation rate of contraceptive implant ﬁtted
on the day of a termination of pregnancy
Brown, A; Nixon, H
NHS Greater Glasgow and Clyde, UK
Sandyford is an integrated sexual health service with over 100 000
visits annually. Our termination of pregnancy (TOP) service sees
over 1500 women annually. Around 30% of TOPs are in women
who have previously had at least one TOP. As a strategy to reduce
repeat TOP, we encourage uptake of long-acting reversible
contraception on the day of a TOP. Anecdotally, clinic staff were
reporting that many women having a contraceptive implant on
the day of abortion were returning in a short time to have it
Aim: To assess: uptake of contraceptive implant on the day of the
TOP; and continuation rate at one year after the TOP.
Methods: Records of women attending from May to October
2010 were accessed to record: method of contraception provided
on day of the TOP; rate of removal at one year after the TOP;
and reason for removal.
Results: During the 6 month period, 707 women had a TOP.
One hundred and ﬁfty-two women (21%) had a contraceptive
implant ﬁtted on the day of the TOP.
During the ﬁrst year, 27 women had the implant removed for
reasons including bleeding (20), mood problems (2), weight gain
(2), planned pregnancy (2) and not sexually active (1).
One hundred and twenty-ﬁve women (82%) continued with
the implant for at least 1 year after insertion.
Discussion: Published series demonstrate implant continuation
rates of around 75% at 1 year. Implants are cost-effective at one
year of use. In our audit, women having an implant ﬁtted on the
day of the TOP do not have a higher removal rate than standard
Development of a post-termination of pregnancy
Sripotchanart, W1; Chunuan, S1; Lawantrakul, J1;
Pongpaiboon, P1; Lawantrakul, J2; Kosalwat, S1;
Kritcharoen, S1; Buranasiri, L2
1 Prince of Songkla University, Thailand; 2 Hatyai Hospital, Thailand
This participatory action research (PAR) was aimed to (i) develop
the post-termination of pregnancy (TOP) care model for women
after a TOP and (ii) examine the obstacles in implementing the
developed model for women after a TOP.
The research processes were divided into four steps based on
the PAR model: (i) assessing the existing care model and planning
to develop the initial model; (ii) developing and implementing the
developed model; (iii) revising the initial model to meet the needs
of women after a TOP; and (iv) evaluating the results. The sample
consisted of 12 nurses at a hospital in Southern Thailand and 60
women after a TOP. Open-ended questions were used to collect
data among these women. In-depth interviews, focus group
discussion, and participant observations, were also used. Personal
data and qualitative data were analysed by using descriptive
statistics and content analysis, respectively. It revealed that the
post-TOP care model for women after a TOP was a holistic care
model comprising building an impressive relationship, having
positive attitudes, giving advice and counselling and providing
continuous care to meet the needs of women after a TOP. The
identiﬁed obstacles of the model implementation were the nurses’
overwork, stress, and weariness.
In conclusion, in this participatory action research led nurses to
recognise the importance of holistic care, have better attitudes
towards women after a TOP and improve their service of giving
advice and counselling by using the instructional media.
- N. Mullin, GB (all speeches)
Do women attending a termination of pregnancy
clinic wish to see the ultrasound scan image of
Mullin, N; Prabakar, I
Countess of Chester Hospital NHS Foundation Trust, UK
Objective: In our National Health Service termination of
pregnancy (TOP) clinic we have noticed an increasing number of
women and their partners asking to look at the ultrasound screen
during their gestational dating scan and some women have also
asked for a photograph.
Method: A prospective pilot study was carried out to discover
more about our patients’ wishes and their experience of
ultrasound during their pre-abortion consultation.
Results: Over 3 months, 53 questionnaires were returned,
response rate 47% (53/112). All women who completed a
questionaire had a ﬁrst trimester TOP, mean age 25 years, range
15–44 (women with a miscarriage were excluded). The majority of
respondants, 94% (50/53) were expecting a scan; 32 women
(60%) did not want to view the ultrasound image or have a
photograph. The remaining 20 women (one did not respond) said
they wished to view the image but only seven women actually did
look at the ultrasound screen, and nine women wanted a
photograph (median age 19 years, range 16–23). All the women
were satisﬁed with the way the scan was carried out and with
Conclusions: Generally women do not want to see an image of
their fetus when they attend a TOP service. However, a minority
of younger women would like the opportunity to look at the
image and this should be allowed as it may be helpful to some
women. We now inform clients that they may look at the
ultrasound screen if they wish; a partner may view the screen only
with the woman’s permission. We do not provide a photograph
due to cost.
How can we best train primary care providers to
Wiebe, E; Trouton, K; Malleson, R
University of British Columbia, Canada
The purpose of this study was to determine how best to train
primary care providers (PCP) to insert IUDs. This was a mixed
method study with interviews and questionnaires of family
physicians and nurse practitioners who presented for training in
three different settings: at a 1-hour workshop, a one-on-one
20 minute training at an exhibit booth or a 4-hour session in-
clinic with patients. Questionnaires were completed at the time of
the training and a convenience sample was interviewed 2–
12 months later. The interviews were audio-taped and transcribed.
On-going theme analysis was done and the interview guide was
changed to explore some themes in more depth in subsequent
interviews. A total of 71 PCPs completed questionnaires at the
time of IUD insertion training and 19 of these were interviewed
2–12 months later. The questionnaires revealed a signiﬁcant lack
of knowledge and skills; for example, 52% had inserted no IUDS
in the past and 65% had never recommended an IUD to women
<21 years of age. In the interviews, 16/19 PCPs said the training
allowed them to start or to increase IUD insertions and 7/19 were
now taking referrals from other clinicians. The barriers they
identiﬁed included the lack of numbers in primary care, lack of
support by colleagues and lack of equipment. Many said they
would like more support after the training. From this study, we
now have more information about how to improve knowledge
and skills training and support for PCPs who wish to insert IUDs
in their practices.
- C. Melville , GB (all speeches)
Interval insertion of IUDs after induced termination
of pregnancy: do women come back?
Melville, C; McInally, J; Struthers, G; Crombie, A
NHS Ayrshire & Arran, UK
Background: Long-acting reversible contraceptive methods are
recognised as the most effective methods of contraception. Our
termination of pregnancy (TOP) service offers IUD insertion at
the time of surgical TOPs however IUD insertion is not available
at the time of medical TOP. In 2010 we launched a post-TOP
IUD ﬁtting service. Women are offered an appointment 28 days
after their medical procedure in line with FSRH guidance. We
reviewed this service in order to inform future provision and to
determine whether women would return for this appointment.
Methods: A retrospective review of cases was performed using the
electronic patient record (Eclipse) and the ward appointment
diaries. The number of IUD appointments arranged, the number
of patients who attended, and the type of IUD inserted were
collected for the ﬁrst 12 month period of the service (January–
Results: In the ﬁrst year of the service, 76 IUD ﬁtting
appointments were made for women after induced TOP. Of these
76, 29 women attended (38%). The DNA (did not attend) rate
was 62%. Nineteen IUS devices were inserted and 10 copper
Conclusion: Although the DNA rate of 62% is high, this is
reﬂected in other similar services and for other follow up
appointments after induced TOP. Ideally, IUD insertion would be
available at the time of all induced TOPs, however with our
current stafﬁng model this is not possible. To increase attendance
at the IUD service, we recommend using a text reminder service.
- W. Hellerstedt, CA (all speeches)
Is perceived partner pregnancy intention associated
withmaternal prenatal and postpartumwell-being?
Division of Epidemiology & Community Health, School of Public
Health, University of Minnesota, Canada
Background: While ‘pregnancy intention’ is often crudely assessed
by a question concerning satisfaction with pregnancy timing, data
with this measure support that unintended and unwanted
pregnancies are associated with adverse infant and maternal health
outcomes. Few studies have examined similar associations with
perceived paternal intention.
Methods: We examined data from Minnesota’s (USA) Pregnancy
Risk Assessment Monitoring System (PRAMS), involving 7266
women surveyed 2–4 months after delivery of a live-born between
2004 and 2008. We used weighted multivariate logistic regression
to examine the associations of perceived partner intention with
maternal demographics, as well as prenatal and postpartum
behaviors and experiences.
Results: Thirty-seven percent of recent mothers reported that
their pregnancies were unintended by their partners. Compared to
those who perceived their partners intended the pregnancy, these
mothers were signiﬁcantly (P < 0.01) more likely to report that
they themselves did not intend the pregnancy, smoked prenatally,
experienced intimate partner violence, experienced postpartum
depressive symptoms and had prenatal mood problems. They
were less likely to report that they received adequate prenatal,
postpartum or well-woman care; father helped with infant care; or
that they used contraceptives in the postpartum.
Conclusions: In this population-based sample, more than one-
third reported their partner did not intend their recent pregnancy.
We cannot validate whether maternal report of perceived paternal
intention is accurate, but we also have no reason to doubt it.
Irrespective of the objectivity of this measure, perceived partner
pregnancy intention is an independent indicator of a variety of
maternal and infant risk markers.
- MRI Mejia, MX (all speeches)
Is there possible sexism in termination of
Centro de Atencio´n Integral a la Pareja, A. C, Mexico
In April 2007 voluntary termination of pregnancy (TOP) up to
week 12 of gestation was legalised in Mexico City. Since its
decriminalisation we have observed at least four hegemonic
attitudes in male sexual partners with respect to reproductive and
contraceptive decision-making in the medical services of Centro
de Atencio´n Integral a la Pareja, A. C: (i) those who go with their
partner and support the decision; (ii) the ones who decide and
pressure their partner, (iii) those who do not support the decision
and do not go with their partner in order to prevent her from
having an abortion and (iv) those who do not support the
decision but who go with their partner.
There is insufﬁcient research on the subject of males’ role in
reproductive decision-making and its implications on males’
subjectivities and in their partners’ bonding. This study responds
to the following questions: In what circumstances do men support
or deny women’s decision-making? What is the perception of
women regarding their partners’ participation in the process?
Within the context of legalisation and in light of new ways of
sexual and loving bonding practices, is it important to integrate
males and create friendly services that allow people to express
their needs and emotions without abuse. Is it fundamental, as
well, to review their contributions to the process of women’s
citizenship within this context? This study acknowledges the
fundamental role of men in the processes undergone by women,
despite the lack of services to integrate and strengthen the
democratic advance in equity contexts.
- W. Chatchawet, TH (all speeches)
Level of male participation when unwanted
pregnancy is terminated from the perspective of
Thai healthcare providers
Chatchawet, W; Sompron, J; Kritcharoen, S
Prince of Songkla University, Thailand
When unwanted pregnancy occurs and ends with termination,
women usually take responsibility for the consequences due to
such unsafe termination of pregnancy (TOP) but men typically do
not have to participate in taking care of women. This qualitative
study aims to understand the perspective of healthcare providers
from the viewpoint of male participation when an unwanted
pregnancy is terminated. The thirteen participants consisted of ten
professional nurses, two physicians and one social worker with
exerience in taking care of women who were undergoing
unwanted pregnancy termination. Individual interviews were
conducted. Data analysis was carried out through content analysis.
Member checking was conducted to establish the rigour of the
The level of male participation when unwanted pregnancy is
terminated from the perspective of healthcare providers was found
to be ‘taking care together’ because of mutual sex, men conduct,
or women hurt and ‘women taking care of themselves’ due to
male privilege or female surrender. ‘Different aspects on
termination of unwanted pregnancy’ such as understanding the
woman’s reason or prejudice from not listening to a woman’s
voice, affect the level of male participation.
The ﬁndings of the study help to improve the understanding
about male participation that is inﬂuenced by gender bias.
Encouraging men to participate in taking care of women without
gender bias will enhance reproductive health care to transform a
women-only framework to gender equity among women and men.
- D. Kirkham, GB (all speeches)
Long-acting reversible contraception (LARC)
take-up following termination of pregnancy.
A local audit
Kirkham, D1; Holt, E2; Agass, R3; Holland, C4;
1 Stockport NHS Foundation Trust, UK; 2 Royal Bolton NHS
Foundation Trust, UK; 3 Pennine Acute Hospital NHS Trust, UK;4 Salford Royal NHS Foundation Trust, UK
Objectives: Identify the percentage of women undergoing a
termination discharged with LARC, and factors inﬂuencing take-
Methods: Age, contraceptive history, parity, previous termination,
and discharge contraception were recorded for women attending a
termination clinic over two months. Ninety-nine cases were
Discharge contraception was discussed with 100% of cases;
92.9% made a contraception decision, 79.8% were discharged with
a chosen method, 13.1% were guided to a family planning centre,
7.8% declined contraception (condoms supplied), 59.6% were
discharged with LARC.
Relevance/Impact: Less than 10% of unintended pregnancies are
due to true contraception failure, 30–50% because no method was
used, the remainder due to incorrect/inconsistent use. In
unintended pregnancies 40.6% lead to termination of pregnancy
(TOP); 27–48% of all TOP are repeats. Women seeking TOP are
highly motivated to seek effective contraception. LARC methods
are not user-dependent, so are very effective. LARC is more cost-
effective than the combined oral contraceptive pill (COCP) after
just 1 year. A reduction in unwanted pregnancies and
terminations beneﬁts the physical/mental health of women and
the NHS ﬁnancially.
Outcomes speciﬁc patient groups may beneﬁt from targeted
counselling to increase uptake of LARC: (i) Patients conceiving
on the COCP (ii) 14–17 year olds (iii) Nulliparous women
(iv) Patients with previous terminations.
Discussion: Sixty-ﬁve percent of patients using no contraception
or condoms, and 75% of women aged 18–22 years old were
discharged with LARC. Only 32% of patients conceiving on the
COCP were discharged with LARC, and only 40% of 14–17 year
olds, with 53% being discharged on the COCP and one with
condoms. Forty-two percent of nulliparous women were
discharged with LARC. Patients with previous terminations were
no more likely to be discharged with LARC.
- I. Nisand, FR (all speeches)
Medical management of unwanted pregnancy in
France: modalities and outcomes. The aMaYa study
Nisand, I; Bettahar, K
Gynaecolgy Department CHU Strasbourg, France
Background/Methods: Since WHO recommendations in 2003, the
use of medical termination of pregnancy (MToP) has become
wider in Europe, particularly in France where it concerns more
than 50% of TOPs. However, there are still different practices
according to various guidelines or drug approvals. Following the
recent update of French recommendations (December 2010), a
new observational study was performed to assess in real life
modalities and outcomes in mToP.
Results: One thousand ﬁve hundred and eighty-seven women
(mean age: 27.6 ± 6.8; minor: 3.3%) were included by 48 French
specialised centres from September 2011 to April 2012. At the
inclusion, when women were given mifepristone, the gestation of
pregnancy was £49 days of amenorrhoea (DA) for 71.7% of
patients and >49 DA for 28.3% with >63 DA for 2.1%. Most of
the time pregnancy dating was done by ultrasound. The most
frequently used protocol was the one recommended by the French
authorities (mifepristone 600 mg-misoprostol 400 lg oral) and
concerned 35.4% of patients. But other protocols were given
(mifepristone 600 or 200 mg in association with misoprostol
800 lg) for respectively 23.4% and 13.5%. Gemeprost
prostaglandin was used by 1.4% of patients only.
Eighty-one percent of patients attended the follow-up visit
3 weeks after inclusion. There was no ongoing pregnancy although
10% of patients were lost to follow-up. Successful abortion rate
was 94.4%, 5.6% of patients requiring a secondary surgical
procedure. Seventeen serious adverse events (1.1%) were reported
(mainly major bleeding).
Conclusion: Although a relatively wide range of therapeutic
strategies in MToP, this study emphasises a satisfactory success
rate of 95% strongly consistent with the literature.
- D. Halleb, TN (all speeches)
Medical termination of pregnancy by mifepristone
and sublingual misoprostol: preliminary results of
their use in reproductive health centre of Nabeul
Halleb, D1; Temimi, F2; Belcaid, A1; Ben Khedija,
W1; Wahbi, H1
1 Centre de la Sante´ de la Reproduction, Nabeul, Tunisia; 2 Ofﬁce
National de la Famille et de la Population, Tunis, Tunisia
Introduction: Medical termination of pregnancy (TOP) is a
method increasingly used worldwide. It was introduced in Tunisia
by the National Ofﬁce of Family and Population, since 1994 as
part of research. Then it was extended in 22 of the 24
reproductive health centres. Medical TOP was introduced in the
Nabeul Centre since November 2002. We used three different
protocols; the third protocol was introduced since March 2010.
The aim of the study was to describe the effects of this protocol
on medical TOP effectiveness; frequency of side effects, and
frequency of TOP failure.
Methods: We conducted a retrospective observational study
performed in the reproductive health centre of Nabeul from April
2010 to June 2010 about women who chose medical TOP.
For all women consulting for TOP, the medical staff explained
the interest of medical TOP and the risks of this method
compared to the surgical one.
On the ﬁrst day, counselling was conducted, clinical and
ultrasound examinations were made to identify no exclusion
factors: anaemia, ectopic pregnancy, and pregnancy off the pill,
kidney failure and liver failure. Then 200 mg of mifepristone was
administered by the midwife or the physician.
On the second day, 400 lg of misoprostol was administered by
the sublingual route. On the ﬁfteenth day, a check was performed
by a clinical and ultrasound examination.
We considered as method failure: surgical aspiration for
ongoing pregnancy, a total retention or signiﬁcant bleeding.
Withdrawals were not recorded as such.
The study analysis was performed by SPSS with statistical
veriﬁcation by the v2 and ANOVA at a signiﬁcance level of 5%
(P £ 0.05).
Results: We included 562 women (27.48% single and 72.52%
married) who have chosen medical TOP during the study period.
The average age was 32 years, ranging from 18 to 50. Educational
level was illiterate for 5.1%, elementary or secondary for 78.8%
and university for 16%. In 77% of cases women had not had a
medical TOP before, 16.5% of them had one previously, 4.7%
twice and 1.9% three or more times. The age of pregnancy was in
60% of cases <6 weeks of gestation, in 34.7% of cases between 6
and 7 weeks of gestation, and in 6.9% of cases between 8 and
9 weeks. The expulsion occurred in 54.2% of cases before 4 hours
and in 44.4% after 4 hours. Pain was reported in 10.5% of cases
and need appropriate treatment. Surgical abortion was used in
1.2% (ongoing pregnancy in 1% of cases and bleeding 0.2% of
Statistical analysis showed: (i) a signiﬁcant relationship between
gestational age and the period of expulsion (P = 0.047); no
signiﬁcant relationship between the gestational age and the failure
of the TOP; no signiﬁcant relationship between educational level
and gestational age at the time of ﬁrst consultation (P = 0.243).
Conclusion: The protocol adopted in this study appeared to be
safe, effective and acceptable to women. However we must be
aware and explain to women that the use of medical TOP does
not replace contraception, contrary to popular belief.
Medical termination of pregnancy up to the 10th
week: an experience of two obstetric centres in
Ce´u Almeida, M; Bombas, T; Silva, I; Ribeiro, S;
Monteiro, J; Fernandes, T; Moura, P
Maternidade Bissaya Barreto – CHUC, Portugal
Since 2007, termination of pregnancy (TOP) on request is legal in
Portugal up to the 10th week of gestation and we perform mainly
This study investigated the efﬁcacy and the safety of medical
TOP up to the 10th week of gestation in the two major obstetric
services in central Portugal, over 16 months.
A retrospective study was performed of the clinical outcome of
women requesting a TOP, over the previous 16 months. We
considered three groups regarding gestational age: Group 1:
£49 days; Group 2: 50–62 days; Group 3: ‡63 days and studied
the efﬁcacy and the safety.
We included 1276 women who had had a medical TOP. Group
1: 41.5% (529), Group 2: 41.5% (530) and Group 3: 17% (217).
The mean age was 51 days. The global efﬁcacy was 99%. In three
groups, the efﬁcacy of medical TOP was 99.6%, 99.2% and 96.8%
(P < 0.01) in groups 1, 2 and 3. We performed an aspiration per
failed TOP or incomplete TOP in 1.1%, 3.3% and 6.1%
(P < 0.01) of group 1, 2 and 3, respectively. The global rate of
complications was 5.4%. Group 1: 4.2%; Group 2: 5.4% and
Group 3: 8.3% (p=NS), mainly related with an uncompleted TOP
(4.5%), haemorrhagic complications (0.6%) and infection (0.3%).
Medical TOP is a safe method up to the 10th week of gestation
with a low incidence of complications, most of them (80%) due
to incomplete TOP. In the group with a gestational age of 63 days
or more, the efﬁcacy was lower but similar to the efﬁcacy
speciﬁed on the labelling.
Midlevel versus physician provision of medical
termination of pregnancy– a randomised controlled
Gemzell-Danielsson, K1; Johansson, M1;
Salomonsson, E2; Gomperts, R1; Kopp Kallner, H1
1 Department of Obstetrics and Gynaecology, Karolinska Institute,
Stockholm, Sweden; 2 Karolinska University Hospital, Stockholm,
Objective: To evaluate feasibility, efﬁcacy and acceptability of
midlevel provision of medical termination of pregnancy (TOP) in
clinical practice through a randomised study of midwife or
physician examination and counselling prior to medical TOP.
Background: Midlevel provision of medical TOP is common in
less developed countries and has been shown to be acceptable.
However, access to a gynaecologist is a limiting factor in medical
TOP also in developed countries and causes unnecessary waiting
periods. In developed countries vaginal or abdominal ultrasound
is routinely performed before TOP and has been an obstacle to
midlevel provision of medical TOP.
Methods: Two midwives highly experienced in TOP care with no
previous training in ultrasound were trained in vaginal ultrasound
of early pregnancy. Inclusion criteria for this study were being
healthy with no ongoing medication and willing to participate.
Women signed informed consent and were randomised
accordingly. All patients with pregnancy longer than 63 days
gestational age or without having visible intrauterine pregnancy
were referred to a gynecologist.
Results: So far 1200 patients have been included. A total of 1260
women will be randomised. No serious adverse events have been
recorded. Preliminary results show that acceptability of midlevel
provision of medical TOP is higher than physician provision.
Conclusion: Midlevel provision of medical TOP in a clinical
setting in a developed country is highly feasible. Midwives can be
trained in vaginal ultrasound and thereby provide the complete
spectrum of early TOP services.
Misconceptions about termination of pregnancy
risks in pro-choice and anti-choice women having
Wiebe, E1; Littman, L2
1 University of BC, Canada;2 Mt Sinai School of Medicine, USA
Misinformation that exaggerates the risks and sequelae of
pregnancy termination is common. The purpose of this study was
to answer the following research question: Do anti-choice women
having a termination of pregnancy (TOP) differ from pro-choice
women having TOPs in their knowledge about health risks
associated with TOP? This was a questionnaire survey of women
having TOPs in an urban free-standing TOP clinic. The
questionnaire was given to women when they arrived for their
ﬁrst clinic appointment and asked about women’s knowledge,
attitude to TOP, where they received their information as well as
demographics. Women with anti-choice attitudes were compared
to pro-choice women with respect to their knowledge of risks. In
228 completed questionnaires (94% response rate), 75% of
surveyed women said that one ﬁrst trimester TOP had greater or
equal health risks compared to childbirth, 7% said that TOPs
increases the risk of breast cancer, 29% said TOP increases the
risk of depression and 26% said that TOP increases the risk of
infertility. When asked about their attitude to pregnancy
termination, 35% women said that there were reasons why some
women should not be allowed to have a TOP. These anti-choice
women were more likely to believe that TOP caused infertility
(40% vs. 17%, P = 0.001) and more likely to believe that women
had more depression after a TOP than childbirth (39% vs. 25%,
P = 0.03). From this study, we concluded that misinformation
about the risks of TOP is common in women having a
termination and anti-choice women have more misconceptions
about the risks than pro-choice women.
Outcomes of very early medical termination of
pregnancy at ££6 weeks of gestation
Heller, R; Cameron, S
NHS Lothian, UK
Background and methods: In 2010 the termination of pregnancy
(TOP) service at The Royal Inﬁrmary of Edinburgh, Scotland, UK
introduced a protocol that allowed women at very early gestation
without ultrasonic evidence of an ongoing intrauterine pregnancy,
but who fulﬁlled certain criteria (£6 weeks of gestation by dates,
eccentric placed intrauterine gestational sac of £3 mm, decidual
reaction, no risk factors for ectopic) to proceed directly
with medical TOP, without the need for further investigations
or ultrasound scans. Follow up consisted of routine
telephone follow up with home low sensitivity urine pregnancy
A retrospective audit of the management of this group of
women attending in 2011 was conducted. Hospital computerised
records and case notes were used to determine the number of
visits made, investigations performed and outcome of the
Results: Five hundred and eighty women attended over the audit
period requesting a TOP at £6 weeks of gestation. Of these
women 3.7% (n = 21) had a serum hCG performed prior to TOP,
and 2% of women (n = 12) had more than one ultrasound before
TOP. Seventy-three percent of women (n = 414) had routine
follow up (telephone follow-up with LSUP) only, 24.4% (n = 138)
had one post-TOP ultrasound, and 1.5%, (n = 9) returned for
more than one post-TOP ultrasound. At follow up ultrasound,
two women were found to have ongoing pregnancies (0.3%).
There were no ectopic pregnancies.
Discussion and conclusions: Most women at early gestation
(£6 weeks) without deﬁnite evidence of a viable intrauterine
pregnancy can proceed to medical TOP without the need for
additional pre-TOP or post-TOP ultrasonography
Risk factors for repeat termination of pregnancy:
implications for addressing unintended pregnancy
Ngo, T1; Keogh, S1; Nguyen, T1; Le, H2; Kiet, P2;
1 Marie Stopes International; 2 Hanoi Medical University, Vietnam
Objective: Vietnam has one of the highest pregnancy termination
rates in the world; 26 terminations of pregnancy (TOPs) per 1000
women. We explored factors associated with having repeat TOPs
in three provinces in Vietnam.
Methods: A cross-sectional survey was conducted from September
to December 2011 among abortion clients at 61 health facilities in
Hanoi, Khanh Hoa and Ho Chi Minh City. After their procedure,
women participated in an exit interview asking about socio-
demographic factors, contraceptive use, and knowledge and
experience of TOP services. The primary outcome was repeat TOP
Results: A total of 1233 women were interviewed. The median
age was 28 years; 92.5% had secondary education; 77.8% were
married; and 31.9% had no children. Half the respondents were
not using contraception prior to their recent pregnancy. The
prevalence of repeat TOP was 32.9%. A signiﬁcantly higher
proportion of repeat TOP compared to ﬁrst time TOP clients
intended to adopt long-acting contraceptive methods, particularly
the IUD (35% vs. 23%, P £ 0.001), in future. In a multivariate
model, individuals living in Hanoi, older women, and those with
two (vs. fewer) children were more likely to have a repeat TOP
(P < 0.001). While women with ‡2 daughters (vs. 1) were more
likely to have a repeat TOP (P = 0.03), women with no sons
(vs. 1) were less likely to have one (P = 0.03).
Conclusions: Repeat TOP remains high in Vietnam. Strengthening
post-TOP family planning interventions is critical to reduce the
high number of repeat unintended pregnancy in Vietnam.
- V. Lavoue, FR (all speeches)
Screening for chlamydia trachomatis using
self-collected vaginal swabs at a public pregnancy
termination clinic in France: results of a screen-
Lavoue´, V; Vandenbroucke, L; Lorand, S;
Pincemin, P; Bauville, E; Boyer, L; Martin-
Meriadec, D; Minet, J; Poulain, P; Morcel, K
CHU de Rennes, Centre IVG, Service d’obste´trique, Hoˆpital Sud,
Objective: To assess the prevalence of Chlamydia trachomatis
(CT) infection and the risk factors for CT infection among
women presenting for a termination of pregnancy (TOP) at a
clinic in France.
Methods: Women seeking surgically induced TOP were
systematically screened by PCR on self-collected vaginal swabs
between January 1, 2010, and September 30, 2010. CT-positive
women were treated with oral azithromycin (1g) prior to the
Results: Out of the 978 women included in the study, 66 were
CT-positive. The prevalence was 6.7% (95% CI 5.1–8.3%). The
risk factors for CT infection were the following: age <30 years
(Odds ratio [OR] = 2.0 [95% CI 1.2–3.5]), a relationship status of
single (OR = 2.2 [95% CI 1.2–4.0]), having 0 or 1 child
(OR = 5.2 [95% CI 2.0–13.0]), not using contraception (OR = 2.4
[95% CI 1.4–4.1]) and completing 11 weeks or more of gestation
(OR = 2.1 [95% CI 1.3–3.6]). Multiple logistic regression
indicated that four factors – having 0 or 1 child, a single
relationship status, no contraceptive use and a gestation of
11 weeks or more – were independently associated with CT
infection. The rate of post-TOP infection among all patients was
Conclusions: These results reveal a high prevalence (6.7%) of CT-
positive patients among French women seeking induced abortions.
A cost-effectiveness study is required to evaluate this screen-and-
Self-assessment of success of early medical
termination of pregnancy: a service evaluation
Cameron, S1,2; Glasier, A1,2; Dewart, H1,2;
Johnstone, A1,2; Burnside, A1,2; Paterson, B1,2;
Hunt, L1,2; Rahimi-Rizi, J1,2
1 NHS Lothian, UK; 2 University of Edinburgh, UK
Introduction: In a recent study, we demonstrated that telephone
follow- up with a self-performed low sensitivity urine pregnancy
(LSUP) test was effective to determine the success of early medical
TOP (<9 weeks of gestation). In the latter study, one half of
women surveyed stated that they would have chosen self
assessment (without a telephone call), if available. We
subsequently introduced self-assessment with a self-performed
LSUP test to our hospital TOP service in Edinburgh, Scotland.
Women choosing this option were given detailed information on
symptoms that may indicate an ongoing pregnancy and advised to
contact the service if symptoms or LSUP suggested ongoing
Methods: Ongoing service evaluation of self assessment with
LSUP test as a method of follow up after early medical TOP,
consisting of review of the proportion of women choosing this
follow-up, contacting the service, and the efﬁcacy for detecting
Results: To date, out of a total of 89 women having early medical
TOP, 66 have opted for self-assessment (74%), 18 for telephone
follow-up (20%) and four for a clinic follow up with ultrasound
(4%). Only three of the ﬁrst 66 women (4.5%) choosing self
assessment have contacted the service, because of pain/bleeding
(n = 1), discharge (n = 1) and a positive LSUP (n = 1). To date
there have been no known ongoing pregnancies in the self
Conclusion: Initial ﬁndings suggest that self-assessment with a
LSUP test is a popular choice for women. Few women contact the
service, suggesting that women are conﬁdent in managing follow-
up in this way.
- R. Baig, GB (all speeches)
Situation analysis of family health hospitals of
Rahnuma-FPAP about the preparedness to provide
effective post-termination of pregnancy care
Rahnuma-Family Planning Association of Pakistan (FPAP), MA of
IPPF London, UK
This study is a situation analysis of 10 family health hospitals of
FPAP regarding their preparedness to provide effective PAC
services. There were 14 service providers in 10 hospitals in the
study. The most common procedure used for treating women
coming with miscarriage or incomplete termination of pregnancy
(TOP) was manual vacuum aspiration (MVA) (71.4%), followed
by D&C (64.3%). The most common procedures followed for
women coming with complications of induced TOP done
elsewhere were MVA (85.7%) and D&C (57.1%). In 71.4% cases,
surgical procedures for incomplete TOP were performed on the
same day. The three most common complications were infection
(92.9%), haemorrhage (78.6%) and pelvic inﬂammatory disease
(78.6%). Length of gestation up to which surgical procedures for
incomplete TOP was performed, was up to 4 weeks (14.3%), up
to 12 weeks (42.6%), followed by 13–20 weeks (21.4), more than
20 weeks (14.3%). A majority of the providers used analgesia,
anxiolytic/sedation/tranquilizers for conducting surgical
procedures for incomplete TOP of <8 weeks (64.3%), 9–13 weeks
(57.1%), 13–20 weeks (21.3%) and >20 weeks (14.2%). The
aborted fetus/products of conception were incinerated (35.5%),
burnt (14.2%), thrown in open pit or garbage (14.2%), burnt and
covered (21.3%) and others (14.2%). Three main reasons of
choosing the hospital were doctors/staff being well behaved
(52.8%), good reputation/better care (40%) and less waiting time
(16.7%). In the present study, 51.4% clients were very satisﬁed
and 22.2% were satisﬁed, while 20.8% classiﬁed the services as
average. Only 4.2% were dissatisﬁed or highly dissatisﬁed.
- MRI Mejia, MX (all speeches)
Taking care of teenage termination of pregnancy
during the second trimester of pregnancy with
Zavala, AMC; Mejı´a, MRI; Zavala, AMC
Centro de Atencio´n Integral a la Pareja, A. C, Mexico
If we think that termination of pregnancy (TOP) within the
second trimester is only an issue of public policy or legality, we
would minimise a more complex problem of a sexual modern age.
If we consider that TOP within the second trimester of pregnancy
presents a higher morbi-mortality risk than the ﬁrst trimester of
pregnancy, we could think that it is urgent to create alternative
spaces to facilitate access to services for a teenage population. It is
also urgent to train well prepared professionals to prioritise this
topic within the present conditions of poor countries or emerging
citizenships with sensibility. However, the tendency of legal
openness–modern and conservative–has set important limits in
order to reduce this phenomenon. Most research focuses on
service providers and moral codes that rule contemporary science
instead of focusing on the women who take advantage of those
services. In this paper we will present the results of a qualitative
and quantitative analysis of 100 teenagers who had a TOP in both
clinics of the Centro de Atencio´n Integral a la Pareja, A. C. during
the second trimester within a legal context where a woman’s
decision is only possible up to week 12. This will lead us to
discuss and contribute the teenagers’ experiences living in contexts
of vulnerability which include legal restrictions, stigmatisation,
and a lack of recognition of women as people in charge of their
lives and sexuality.
- C. O’Callaghan, NZ (all speeches)
Te Mahoe Unit-Wellington NZ-an overview
Te Mahoe Unit, Wellington, New Zealand
The poster will contain an overview of the Te Mahoe Unit which
is the Early Pregnancy Counselling and Termination Unit in
Wellington, New Zealand.
There will be a brief description of the New Zealand law with
regard to termination of pregnancy (TOP). The referral process
and certiﬁcation process will also be explained.
All procedures that are provided will be described e.g. surgical
termination with local anaesthetic and conscious sedation up to
14 + 5 weeks of gestation — early medical termination with
miferistone and misoprostol up to 9 weeks of gestation.
A section on products of conception and what happens to
them. Some explanation around Maori cultural beliefs.
Also nursing care, after care, on call issues and statistics. The
latest complication rates and causes of same.
Finally, law reform issues and looking to the future.
- C. Dufey-Liengme , CH (all speeches)
Termination of pregnancy among teenagers – why
more surgical terminations?
Dufey-Liengme, C; Coquillat, F; Demierre, M;
Centre for Sexual Health and Planned Parenthood, Unit for Psycho-
social gynaecology and obstetrics, ObGyn Department, Centre
Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Introduction: In 2012, a study by K. Chatziioannidou and S-C.
Renteria showed that teenagers chose to undergo a surgical
termination of pregnancy (TOP) more often than a medical TOP
(mifepristone followed by misoprostol) when they decided to
terminate a pregnancy. It also showed that the teenagers’ choice
for a medical versus surgical method is inversely proportional to
the adults’ choice although the efﬁciency of the medical method
showed even better results for teenagers than for adults.
Objectives: The aim of this retrospective and qualitative study is
to analyse the reasons why, in case of a TOP, teenagers chose the
surgical method more often than their adult counterparts.
Material: (i) All teenagers who were admitted for an abortive
procedure during 2011 in the in- or outpatient ward.
(ii) The professional team (midwives and sexual and
reproductive counsellors) in charge in the case of a TOP request.
Methods: The information about the patient’s history and the bio-
psycho-social data was retrieved from thepatient ﬁles ﬁlled out by
midwives and sexual and reproductive healthcounsellors during the
ﬁrst appointment for a TOP request orduring its process.
The professionals’ appreciation was evaluated by means of a
Results: Concerning the choice of the method for a pregnancy
termination, the results of our research show that:
(i) Out of 47 teenagers, 27 chose the surgical method and 17
the medical method.
(ii) Three had a second trimester abortion (which includes use
of the medical method).
(iii) Fifteen teenagers out of the 27 who chose a surgical
method consulted between the 9th and 14th weeks of
amenorrhoea and therefore did not have any other choice.
The reasons for their ‘late arrival’ will be explained in detail.
The 12 teenagers who arrived before the 8th week of
amenorrhoea and chose to undertake abortion by suction &
curettage under general anaesthesia did it for the following
(i) Four were afraid of bleeding and pain.
(ii) Five thought that the organisation of the surgical procedure
(iii) Two did not trust the abortion pill.
(iv) One was taken to her mother’s gynaecologist where she
had a D&C.
Conﬁdentiality was requested nine times out of 27 when
choosing the surgical method, and six times out of 17 when
choosing the medical method.
Therefore, although conﬁdentiality concerns a third of the
teenagers’ pregnancy termination requests, it does not seem to be
a signiﬁcant element for the choice of the method.
As for the subjective appreciation of the professionals, the ﬁrst
results of the discussions seem to show that teenagers were
reluctant or resistant towards the medical method.
Conclusion: This study shows that the reasons why teenagers still
prefer the use of the surgical over the medical method compared
to adults, seem to include the late request for an appointment,
fear of pain and bleeding and organisational issues.
Conﬁdentiality does not seem to greatly inﬂuence the teenagers’
choice. Nonetheless, medical professionals seem to favour the
suction curettage procedure performed under anesthesia because
they associate young age with vulnerability and psychological
frailty and consequently diminished ability to cope with pain and
emotional distress during the medical procedures.
- L. Vicente, PT (all speeches)
Termination of pregnancy at women’s request in
Portugal – data from the national registry
Vicente, L; Henriques, A; Almeida, T; Freire, A;
Nogueira, P; Ramos, M
Directorate General of Health, Portugal
Termination of pregnancy (TOP) at women’s request was legalised
in Portugal up to 10 weeks of gestation, in June, 2007. All public
and private services that deliver TOP care are recorded in a
national web-based database. It is a record of episodes of TOP
and not a register of users, in which anonymity and
conﬁdentiality is guaranteed, to be used for statistical purposes of
public health. Induced TOP at a woman’s request represent 97%
of all legal induced TOPs. Sociodemographic charactristics of the
users, distribuition by time of the procedure and contraception
after TOP, will be presented and analysed. In Portugal more than
65% of terminations are performed within the National Health
Service (NHS), where medical TOP is mainly used (96%). Annual
variation of the induced TOP at women’s request: the largest
annual growth occurred between the years 2008 and 2009 – with
an increase of 6.7%. Between 2009 and 2010, the variation was
1.8% and 1.2% between 2010 and 2011.
Termination of pregnancy in Lothian: a health
Cochrane, R; Milne, D; Cameron, S
NHS Lothian, UK
Introduction: The rate of termination of pregnancy (TOP) in
Scotland remains high, with 12 681 TOPs performed in Scotland
Most TOPs are hospital procedures or early medical
termination. In 2011 a new centre for SRH (Chalmers) opened in
Edinburgh; most provision of early medical termination will be
delivered from here in the future. Some TOPs will continue to be
performed within hospitals.
Whilst much research has concentrated on the efﬁcacy and
acceptability of TOP, little has been written about women’s
experience and the patient pathway.
How the current service is viewed by users and providers, and
the impact of future change to the service, was uncertain.
This health needs assessment aims to:
(i) describe population accessing TOP services in Lothian
(ii) describe current service
(iii) identify areas of delay in service provision
(iv) identify areas of unnecessary complexity in patient’s
(v) elicit stakeholders views
(vi) consider evidence of and recommend effective intervention
to improve termination services
(vii) support planning for change from 2011.
Methods: Women attending TOP services were interviewed and
then telephoned approximately two weeks after TOP and
questioned about their views of the TOP service.
Staff members within the TOP service including management
Results and conclusions: Seventeen women and 17 staff members
were interviewed. Difﬁculty with patient recruitment and follow-
up is discussed.
Patients overall were happy with the service; several pertinent
negative points were raised.
Staff have mixed feelings about the service, and useful ideas for
improvement were garnered, and form part of an action plan as
part of the Lothian Sexual Health and HIV Strategy.
- F. Bloomer, GB (all speeches)
Termination of pregnancy rights in Northern
Ireland – the role of pro-choice activists
University of Ulster, UK
This paper considers the protests and activism led by the Alliance
for Choice movement, an organisation that campaigns for the
extension of the 1967 Abortion Act to Northern Ireland. The role
of women in the movement is considered with particular focus on
its most recent period of activism which began in the months
preceding a proposed debate in Westminster in 2008 where a
tabled amendment to the Human Fertilisation and Embryology
Bill by Diane Abbot MP sought an extension of the 1967
Abortion Act to NI. In response to this a series of events and
activities were held to raise awareness amongst MP’s, trade unions
and the wider public. The Alliance for Choice campaign took a
strong pro-choice approach, focusing on the issue of equality with
women in the rest of the UK. Despite the withdrawal of the
amendment to the Bill in late 2008 the movement has continued
on with its campaign, including preparation of a submission to
the United Nations Convention on the Elimination of all forms of
Discrimination Against Women (CEDAW).
This paper will review the actions of the Alliance for Choice
movement, considering the motivations for participation in the
movement and reﬂect on the impact of the movement in
achieving its goal of termination of pregnancy legislation
extending to Northern Ireland.
- M. Rajic, SI (all speeches)
Termination of second trimester pregnancies with
mifepristone and misoprostol
Rajic, M; Vrhkar, N; Stritar, BS; Tul Mandic, N
Division of Gynaecology and Obstetrics, Department of Perinatology,
University Medical Centre Ljubljana, Ljubljana, Slovenia
Objective: To evaluate the safety and efﬁcacy of termination of
pregnancy (TOP) for medical reasons (structural fetal congenital
anomalies, fetal chromosomal abnormalities, intrauterine fetal
death, early preterm prelabour rupture of membranes) using
mifepristone and misoprostol (MI-MI) between 11 and 22 weeks
Methods: We collected data from all women requiring TOP with
MI-MI for medical reasons. The protocol consisted of 200 mg of
mifepristone orally, 36–48 hours later 800 lg of misoprostol
vaginally, followed by 400 lg buccally every 3 hours until TOP
(maximum of four doses in 24 hours). If the placenta was
retained, uterotonics were adminsitered, and a decision was made
whether to evacuate the uterus surgically. The data were analysed
using the statistical software program SPSS, version 18.
Results: A total of 435 women were enrolled in the study (we
analysed 157 cases, the remainder will be analysed by the
beginning of FIAPAC Conference 2012). The mean gestational age
was 16.5 weeks. For 58 (36.9%) women this was their ﬁrst
pregnancy. The method was successful in 156 (99.4%) cases. The
average time interval from the beginning of the procedure till
TOP was 47.3 hours (13.8–168 hours). The average duration of
hospital stay was 39.3 hours (25.0–167 hours). In 40 (25.5%)
cases surgical evacuation of the uterus after TOP was performed.
Conclusions: The use of MI-MI is safe, effective and non-invasive
regimen for TOP for medical reasons between 11 and 22 weeks of
The effects of bad storage conditions on the
quality and the related effectiveness of Cytotec
Be´rard, V1; Fiala, C2
1 University of Bourgogne, France; 2 Gynmed Ambulatorium, Vienna,
Cytotec (Misoprostol 200 lg tablet) has been extensively studied
in reproductive health, and is widely used for various indications
including induction of pregnancy termination (MToP).
Misoprostol, a PEG1 is chemically unstable except under very
speciﬁc conditions. This is due to susceptibility to relative
humidity and temperature factors. If these factors are not strictly
respected until the moment of intake, misoprostol turns into three
main degradation products: A-form and B-form prostaglandin
patient2ormore200 lgtabletsofCytotec totake24–48 hours
The aim of this research is to study the effect on the stability of
misoprostol if a tablet has been exposed to normal air/humidity if
the alveoli has inadvertently been opened when 2 or more tablets
have been cut from the blister. A possible instability would have a
potential negative effect on the treatment of MToP.
Methods: To study the changes of Cytotec tablets from a
technical-pharmaceutical and analytical viewpoint, once they have
been taken out of their blister pack, they are stored over a period
of time (a few hours to 1 month) at 25 C and 60% RH
(standard condition of ambient air in Europe),
After the time elapsed, the pharmaco-technical characteristics of
Cytotec tablets were studied according to the European
Pharmacopeia i.e. Mass uniformity, friability, disintegrating time,
dissolution time (by HPLC). The dimensional measure of tablets
were also measured.
Furthermore Cytotec tablets were analysed to determine the
uniformity of dosage units of misoprostol (by HPLC),
decomposition products dosage (by HPLC): A-form misoprostol
(Pharm. Eur. impurity C), B-form misoprostol (Pharm. Eur.
Impurity D) and 8-epi misoprostol (Pharm. Eur. impurity A).
Water content by Karl Fischer determination was also done.
Conclusions: The results of this research clearly show that
Cytotec tablets suffered from a signiﬁcant time dependent
decrease in their technical-pharmaceutical characteristics and
effectiveness if they come into contact with normal air because
they were either taken out of their blister or kept in a blister
which was damaged during cutting out some tablets. As early as
the ﬁrst day of storage, (with a maximum 48 hours after) in
humidity and temperature corresponding to normal conditions in
Europe the mass (+4.3%), the diameter (+1.2%), and the
thickness (+4.8%) of the tablets increases, which is a sign of the
swelling of the HPMC. However the hardness of the tablets
decreases dramatically ()32.0%).
The water dosage by Karl Fischer clearly shows that there is a
rapid increase of water inside each tablet (+78.8% after 48 hours).
This water penetration, associated with a storage temperature
of 25 C speeds up the process of transforming the misoprostol
into decomposition compounds. This leads to a decrease in
Cytotec’s active ingredient dosage ()5.1% after 48 hours) with
related consequence on effectiveness. It is clear that under the
current conditions of Cytotec use for MToP, cutting up the
blister packs should not be recommended because the risk of
damaging the heat formed alveoli around the tablets is too high
(we have no data to make such a strong statement, even if it is
true). This drastic change is observed in chemical composition
after 6 hours only of storage and reaching a maximum on the 2nd
day, which is the day the patient normally takes the tablet.
If a Cytotec tablet is kept in a damaged blister (previously cut
to deliver tablets to the previous patient) and stored in normal
environmental conditions, its effectiveness will be likely seriously
decreased for the next patient.
This research concerns all uses of Cytotec for MToP and even
when used as gastric protection, where the tablets, which can be
divided into equal parts, can be taken by halves, the second half is
stored in the open alveoli for an undetermined period.
In conclusion, special caution must be taken in delivering
The impact of implants and intrauterine
contraceptives provided at an index surgical
termination of pregnancy (Jan–June 2008) on
repeat termination of pregnancy within 3 years:
Latham, F1; Guthrie, K2; Trussell, J1
1 Hull York Medical School; 2 Community Health Care Partnership
Background: Implants and intrauterine contraceptives have lower
failure rates and higher continuation rates than the other
reversible methods of contraception. We hypothesised that the
patients who chose these long lasting reversible methods after
their index surgical termination of pregnancy (STOP) would have
a reduced incidence of subsequent termination of pregnancy
(TOP) in comparison to those who chose other reversible
methods (injections, oral contraceptive pills, patch, ring and
Methods: Index cases were recorded retrospectively from theatre
registers at Hull Royal Inﬁrmary for all STOPs between January
and June 2008. Type of contraception chosen at procedure was
recorded: Implanon, Mirena, IUD, Depo-Provera, Sterilisation and
‘Other’ (oral contraceptives, patches, rings, condoms). The
hospital information system for the subsequent 3 years was
searched for another TOP (surgical or medical). The data were
analysed. A secondary objective was to record contraceptive
choices in two age groups (<25 and ‡25 at index STOP).
Results: Women choosing Implanon, Mirena and IUDs had a
signiﬁcantly lower repeat TOP rate than those choosing other
reversible methods at 2 (3.4% vs. 9.3%, P = 0.008) and 3 (6.8%
vs. 12.4%, P = 0.04) years. As age increased, use after an index
STOP of Implanon decreased (32% vs. 8%) and Mirena increased
(13% vs. 41%) signiﬁcantly.
Conclusion: A 50% increase in the uptake of implants and
intrauterine contraceptives would decrease the repeat TOP rate
within three years by 16%.
- G. Horgan, GB (all speeches)
The politics of termination of pregnancy in
University of Ulster, UK
Policy and politics in relation to termination of pregnancy (TOP)
remain mired in issues of religiosity, morality and class
everywhere in the world but perhaps nowhere more so than in the
one part of the UK where TOP remains illegal – Northern Ireland.
There, the Health Minister is a creationist and avowed ‘pro-life’
advocate who has failed to comply with a court ruling to clarify
for doctors when it is legal to perform a TOP.
Control over TOP was not devolved to Scotland or Wales,
despite Scotland having the same control over matters of criminal
justice as the NI Assembly. Instead, it was admitted in
Westminster that in relation to TOP, the UK government was
making ‘….a distinction between Northern Ireland and the rest of
the United Kingdom for a multiplicity of pressing political and
other reasons’. As a result, women in NI are not guaranteed even
life-saving TOPs, still less ‘social’ ones.
The ‘multiplicity of pressing political and other reasons’ which
led to TOP being a devolved issue has much to do with British
politicians needing the votes of the fundamentalist Democratic
Unionist Party to pass controversial measures, and nothing to do
with the social or health needs of women in Northern Ireland.
This paper looks at the politics of TOP in NI and how religious
fundamentalism has inﬂuenced the development of policy in
relation to TOP in this part of the United Kingdom.
‘Trust me to be the awkward one’: young women’s
experiences with the contraceptive implant
Hoggart, L; Newton, V
University of Greenwich, UK
This paper will present the ﬁndings of a recently completed
qualitative study examining ‘premature’ implant removal amongst
young women (aged 16–24) in London. The paper will explore
young women’s contraceptive journeys with the implant and
examine how and why the implant was initially selected as a
contraceptive of choice and then removed within one year or less
of ﬁtting. The focus of the paper is on the complex process of
contraceptive decision-making, and how this may change as a
result of bodily experiences subjectively associated with the
implant. The paper will begin by discussing young women’s
reasons for choosing the implant. We will then examine how
individual and collective experiences of the method contribute to
the decision to have the implant removed. These experiences
include a range of perceived side effects, issues concerned with
bodily control, and changes in sexual relationships, as well as
service related factors. The research has shown that young women
who have made a positive choice in favour of the implant will
tolerate a considerable amount of discomfort before reaching a
‘tipping point’ at which they decide to have the implant removed.
During this period they often feel unsupported and isolated, and
even attach blame to themselves for the ‘failure’ of their body to
accept the implant. We also suggest that negative experiences and
a lack of support may contribute towards negative attitudes
towards other long-acting reversible contraceptive methods.
Unplanned pregnancy- a common reason for
Kopp Kallner, H
Karolinska Instiutet, Department of Obstetrics and Gynecology,
Danderyd Hospital, Stockholm, Sweden
Objectives: The primary objective of this study was to investigate
what proportion of ectopic pregnancies arises as a consequence of
unplanned pregnancies and the proportion of women receiving
contraceptive counselling after treatment.
Background: Ectopic pregnancy is a potential life threatening
condition. It has a negative impact on future fertility which is
often desired. It is often forgotten that an ectopic pregnancy can
be a consequence of an unplanned pregnancy.
Methods: This was a retrospective study of a total of 68 patients’
electronic medical records. Inclusion criteria were a certain
diagnosis of an ectopic pregnancy and ﬁrst visit at Danderyd
Hospital AB between 1 June 2011 and 30 November 2011.
Results: Fifty-four percent of the ectopic pregnancies were a
consequence of an unplanned pregnancy, 31% were planned and
information was missing for 15% of the patients. In the group of
patients with unplanned pregnancy 70% of the patients in need of
counselling on future contraceptives did not get it upon
Conclusions: A large proportion of ectopic pregnancies are a
result of unplanned pregnancy. The individual and the healthcare
system have a lot to gain by ectopic pregnancy prevention which
can be achieved by increased use of contraceptives which protect
patients against all unplanned pregnancies. Patients with
unplanned ectopic pregnancies should receive counselling on
future contraceptives after ﬁnished treatment.
Uptake of independent counselling in addition to
termination of pregnancy consultation
Nixon, H; Brown, A
Sandyford, NHS Greater Glasgow and Clyde, UK
Sandyford is an integrated sexual health service with over 100 000
visits annually. Our termination of pregnancy and referral
(TOPAR) service sees over 1500 women annually and offers
information, assessment and admission for medical and surgical
termination of pregnancy (TOP). There is access to a trained
counsellor if wished.
Recently in the UK, there have been demands to make
additional counselling or a ‘cooling off’ period compulsory.
Aim: To assess: uptake of counselling in addition to the TOPAR
consultation; and relationship between time to TOP and eventual
Methods: Records of women attending from September to
November 2011 were accessed to record:
(i) certainty of decision at ﬁrst visit.
(ii) uptake of additional counselling.
(iii) waiting time to TOP date and ﬁnal outcome to proceed to
TOP or continue the pregnancy.
Results: Of 384 women with conﬁrmed pregnancies at
(i) Twenty-six decided to continue the pregnancy.
(ii) Three hundred and forty-one wanted a TOP and this was
(iii) Twenty-eight subsequently did not attend for a TOP and
continued the pregnancy.
(iv) Seventeen women wished more time to consider their
decision and were offered an appointment with a trained
counsellor – two women accepted.
(v) Sixof the undecided women continued thepregnancy,
including the two women who attended for counselling and 11 had
(vi) Neither time to the TOP or gestation inﬂuenced the
decision to abort or continue the pregnancy.
Our results suggest that the vast majority of women do not
wish or need additional counselling and that introducing a
‘cooling off’ period or delay would not alter the decision.
Post Abortion Family Planning (PAFP) is a key part of any
comprehensive TOP service as this is a vital opportunity in which
to provide family planning, to avoid future unwanted pregnancies.
In order to understand the factors that may impact on the
uptake of PAFP, MSI undertook a baseline survey of all clients
accessing services in four of the MSI country programmes. The
data was collected for 1 month, September 2011.
In total 4081 clients availed themselves of TOP services across
MSI centres in Ethiopia (1974), Nepal (1160), Vietnam (888), and
The average age of clients was 27–29 years. Ethiopia was the
only programme with a lower than average age of 22 years.
Eighty-three percent of TOP were performed at under 9 weeks
of gestation. Medical TOP was chosen by an average of 61% of
women: Zambia (90%), Vietnam (76%), Ethiopia (62%), Nepal
Sixty-eight percent of women had not been using any
contraception when they became pregnant. Thirteen percent were
using male condom, 9% the oral contraceptive pill, 4% injection,
1% emergency contraception, and 1% traditional methods. No
one had been using implants, IUDs, male or female sterilisation as
a method of contraception when they became pregnant.
This review reﬂects the baseline factors of MSI clients,
including the low use of contraception in women seeking TOP,
and highlights variables to consider when providing PAFP and
informing the ongoing MSI PAFP project that focuses on
increasing levels of PAFP uptake.
- M. Olver, GB (all speeches)
What is the outcome of pregnancies that continue
following administration of mifepristone?
Olver, M; Scherf, C; Noble, N
Cardiff and Vale NHS Health Board, UK
Introduction: The number of medical terminations of pregnancy
(TOPs) in England and Wales in 2010 compared with the year
2000 shows an 8% increase. Despite the rapid increase there is
little published evidence regarding the risks to a continuing
pregnancy after mifepristone administration.
Objectives: To investigate the outcome of all cases of continuing
pregnancy after administration of mifepristone +/- misoprostol in
the Cardiff and Vale University Health Board over a period of
Methods: A retrospective case note review of all women with
unplanned pregnancies who wished to continue their pregnancy
after administration of mifepristone. Women were identiﬁed by
non-attendance or cancellation for misoprostol, follow-up cases
and searching antenatal records. The review period was 2007–2011.
Results: Twenty cases of continuing pregnancies were identiﬁed.
Of these, 10 resulted in live birth, ﬁve in miscarriage, two were
lost to follow-up and three needed a second TOP procedure (one
of them was given Clause E, fetal abnormality).
Conclusion: This case series shows the most common
complication following mifepristone administration is miscarriage
in the ﬁrst trimester. Those pregnancies leading to live birth did
not result in adverse fetal outcomes. However, due to the small
sample size, damage to the fetus cannot be ruled out and
therefore close monitoring throughout pregnancy should be
performed. This detailed case review highlighted the need for
more work in this area to enable clinicians to provide correct
advice to women in these difﬁcult situations.
- G. Preti, CH (all speeches)
Who consults for an emergency pill? Survey about
users proﬁle. Comparison between 2008 versus
2011 at the sexual and reproductive health and
family planning centre, Geneva’s University
Preti, G1,2; Bettoli, L1,2
1 Unite´ de sante´ sexuelle et de planning familial de Gene`ve;2 Association Romande et Tessinoise des Conseille`res en Sante´ Sexuelle
et reproductive (ARTCOSS), Suisse
Context: In Switzerland, the sexual health and family planning
centres ensure the provision of the emergency pill (EP) at reduced
cost with relevant counselling on sexual and reproductive health
Which kind of proﬁle do women visiting for the emergency pill
at the SRH centre in Geneva have? Can we observe an evolution?
Methods: The ﬁrst survey took place in 2008 and was repeated in
2011. Both occurred in the months of December and January
(2008: 139 women, 2011: 90 women).
Conclusions: The age of women requiring EP at the SRH centre
was between 14 and 30 years with a majority of women aged
between 16 and 17. Younger women often visit Geneva’s centre
with a friend or a partner. Seventeen percent of all women visit
with their partners.
Lack of contraception is the main reason for EP requests with
40% prevalence, second in line of all requests is condom failure at
Women from other countries have a higher percentage request
for non-use of contraception than Swiss women.
Approximately a third of the situations have complex psycho-
Between 2008 and 2011, we observed an improvement in time
lapses between sexual risk and the EP requests (within 12 hours:
22% in 2011, against 9% in 2008). Also, there are fewer repeated
EP requests when comparing the second survey with the ﬁrst.
In 2011, we observed that at least 11% of surveyed women had
had repeated unprotected sex, before and after their EP request.
- N. Mullin, GB (all speeches)
Who refuses chlamydia screening in a termination
of pregnancy clinic?
Mullin, N; Robinson, K; Carter, J
Countess of Chester Hospital NHS Foundation Trust, UK
Background: National United Kingdom guidelines recommend all
women requesting a termination of pregnancy (TOP) are screened
for Chlamydia Trachomatis (CT) infection beforehand. Two years
ago in our hospital we had a gravely ill woman with a post-TOP
pelvic infection, and after a signiﬁcant event analysis the staff were
trained to become more effective in offering screening to all
Objectives: To audit the documented offer, uptake and refusal of
CT screening pre-TOP.
Method: Retrospective case notes review.
Results: In 12 months, 471 women attended the pre-assessment
(pre-TOP) clinic, age range 14–48 years, 250 (53%) were under
24 years. All clients had a documented offer of CT screening,
including women whose pregnancy was found to be non-viable or
who decided to continue with their pregnancy. There were 143
women who declined a test in clinic and in 68 (50%) cases there
was a documented CT test taken prior to attending the TOP
service. Of the remaining 75/471 (16%) clients (mean age
25 years, range 16–43) these women mostly (94%) declined
screening because they were in a long term relationship or had
recently been tested in a new relationship.
Conclusion: Despite staff strongly recommending CT screening to
all women attending our TOP service, one in six women decline.
However, this appears to be a self selected low risk group of
women. No severe post-TOP infections have occured in our
service recently (universal antibiotic prophlaxis is given as well as
screening). Further work is needed to encourage referring agencies
to offer CT screening at the ﬁrst discussion of pregnancy options
to ensure maximum uptake.
- G. Brady, GB (all speeches)
Young women’s experiences of termination of
pregnancy and miscarriage
University of Coventry, UK
In Britain, the politics and policy of teenage pregnancy places the
emphasis on ‘prevention’ of teenage pregnancy, positioning
parenthood for young people as a negative choice; this dominant
discourse is likely to inﬂuence young people’s reproductive
decisions and experiences. With this in mind, this paper focuses
on a key ﬁnding from a multidisciplinary empirical research
study, conducted in a city in the West Midlands of England, UK,
which considered and explored young people’s experience of
support before and following termination and miscarriage. Data
were collected via indepth interviews with professionals and
practitioners, young mothers and one young father. Although
termination and miscarriage are generally perceived as distinct
and different issues, the data suggest that the issues become more
blurred where younger women are concerned. The experiences of
young, ‘inappropriately pregnant teenagers’ often remain
unacknowledged and devalued. This paper highlights the social
and political context in which young women experience
termination and miscarriage, and suggests that termination and
miscarriage should be acknowledged as signiﬁcant medical, social
and emotional events in the lives of young people.