Ellen Wiebe


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    Barriers to access&use of contraception in immigrant women presenting for abortion

    Ellen Wiebe, Canada

    Background: About half of the women presenting for abortion in Vancouver are immigrants and most of these are from Asia. In previous studies of contraception and ethnicity, we found that the contraceptive practices and attitudes of immigrant women differ from those reported by other Canadian women. Specifically, we found that among Chinese and Korean immigrant groups in Vancouver, women expressed a deep suspicion towards hormonal methods of contraception, such as birth control pills, and were reluctant to use them. This study examined the experiences, attitudes and beliefs of immigrant women with regard to contraception in order to identify difficulties involved in accessing contraception in Canada.  Our main concern was to understand more about the barriers for women accessing contraception prior abortion and if there were more barriers for immigrant women.

    Method: This was a survey of women presenting for abortion using a questionnaire asking about women’s usage and experiences of both hormonal contraceptives and natural family planning methods, their attitudes towards medical contraceptive methods (hormonal and intrauterine), any barriers to contraceptive access they have encountered and the sources of information women rely on to make their contraceptive decisions. The site was an urban abortion clinic and the questionnaires were available in English, Chinese and Punjabi. Data was entered into an SPSS database for statistical analysis. The analysis included an examination of the differences in contraceptive practice, experience, and attitudes between immigrant women and other Canadian women, as well as a needs assessment.

    Results: Of the 1000 subjects planned for this study, we have data on 143 at the time of writing this abstract. Of the 77 immigrants, 64% had previously used hormonal contraception compared to 94% of the 62 non-immigrants (p=<.001); 71% of the immigrants compared to 88% of the non-immigrants believed hormonal birth control was safe (p=.02); 25% of immigrants compared to 12% of non-immigrants had some problems accessing contraception; 30% of immigrants compared to 15% of non-immigrants had become pregnant “counting safe days” (p=.04).

    Conclusion: More immigrants were using less effective methods of contraception when they got pregnant and they had more difficulties accessing contraception prior to the abortion. When the data is complete, we will be able to understand more about which groups of immigrants have the most difficulties. By determining the extent of inadequate information about contraception and barriers in access to contraceptive methods in immigrant women, we may be able to help plan solutions.

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    Comparing side effects of hormonal contraceptives in East Asian and Caucasian
    Ellen R Wiebe MD, Konia Trouton MD, Amy Fang, 
    University of British Columbia, Vancouver BC, Canada
    Introduction: Our previous studies in East Asian women have found that they perceive oral
    contraceptives to be dangerous and to have too many side effects. The purpose of this
    study was to compare side effects and discontinuation rates in East Asian and Caucasian
    Method: This was an observational cohort study of usual care. Chinese, Korean and white
    Caucasian women were recruited at two urban freestanding abortion clinics. These women
    were given one package plus a prescription of Alesse, Tri-Cyclen, Yasmin or Evra.

    Questionnaires in Chinese and English asked about the side effects and/or reasons for
    Results: Out of the 212 women recruited, there is follow-up data on 161. There were 65
    Caucasians and 96 Asians. These two groups of women were similar with respect to age
    (mean 25 years), education (mean 14 years) and obstetrical history (mean 0.2 births),
    except that the East Asian women had had more abortions than the Caucasian women.
    There was a significant difference in the discontinuation rates; more East Asian women did
    not start or quit after taking just a few pills in the first month (40% vs 17%). There was
    more acne in the Caucasian women (22% vs 7%). There was more nausea in the East
    Asian women (20% vs 7%).
    Conclusion: In women who decided to use hormonal contraception after an abortion, rates
    of discontinuing or not starting hormonal contraception were higher in East Asians
    compared to the Caucasians. Side effects were different in the two groups, indicating there
    might be different brands that would be more suitable for East Asians than for Caucasians.

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    Objectives: The purpose of this pilot study was to ensure that the insertions and early expulsion rates were acceptable in order to plan a larger trial with the IUB.

    Methods: This was an observational pilot case series. The inclusion/exclusion criteria were similar to those for non-study patients receiving IUDs. Women aged 18-50 requesting intrauterine contraception were enrolled. Exclusions included recent pelvic inflammatory disease, genital malignancy and anaemia. The main outcome measure was expulsion by the 6-8 week follow-up visit. Ease and pain of insertion as well as complications and side-effects were also recorded.

    Results: 50 women had IUBs inserted between January and April 2014 by a single clinician in Canada. Only 6 (12%) had had a previous birth and 16 had had previous IUDs. There were no failed insertions and 43 (86%) insertions were found to be "easy". The mean pain score for insertion was 5.3/10. There were 32 follow-up visits 6-8 weeks post-insertion by May 2014. There were 8 expulsions (one post medical abortion and accompanied by a "gush of blood"), there was one removal for pain and bleeding and no other complications.

    Conclusions: Including the first study of 15 women, there are now data on 65 insertions with no problems, so the insertion technique and equipment for IUBs can be considered acceptable. The early expulsion rate appears too high and may require some change in design. The lack of other complications warrants further studies with this innovative product.

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    How can we best train primary care providers to
    insert IUDs?
    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.

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    Is there a place for observing fertile periods?

    Ellen Wiebe (Canada)

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

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

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

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

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

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    Knowledge and attitudes about contraception and abortion in women of five countries: US, Canada, UK, France and Australia.

    Ellen Wiebe1, Lisa Littman3, Janusz Kaczorowski2 1University of BC, Vancouver, Canada, 2University of Montreal, Montreal, Canada, 3Mount Sinai, New York, USA - ellenwiebe@gmail.com

    Objectives: The purpose of this study was to answer the following questions: 1. Do anti-abortion women differ from pro-choice women in their knowledge about health risks associated with abortion and contraception? 2. Which countries and demographic characteristics are associated with lower knowledge about abortion and contraception risk? Methods: We surveyed an on-line sample of women aged 18-44 from US, Canada, UK, France and Australia (at least 200 per country) in January 2013 using Survey Monkey Audience panel. The survey asked demographics, attitude to abortion and knowledge about risks of IUDs and abortion vs births. For the purpose of this study, women choosing the response, "Abortion should be allowed for ANY reason, because no one should be forced to continue a pregnancy" were categorized as "pro-choice" and those choosing one of other responses were categorized as "anti-choice". Results: Within two days, 1117 surveys were completed: 233 in Canada, 223 in the US, 230 in the UK, 221 in France and 210 in Australia. Almost half (47.1%) of the participants were classified as pro-choice because they indicated that women should be allowed to have an abortion for any reason in the first 3 months: 38.7% in Canada, 37.1% in USA, 42.0% in UK, 68.7% in France and 53.6% in Australia (p<.001). Women classified as having anti-choice beliefs were more likely to provide incorrect answers to all 10 knowledge questions about abortion and contraception (p=<.001). There were few differences in knowledge between the women from different countries. Conclusions: Women from these 5 countries were similar in terms of their knowledge about the risks of abortion and contraception. The majority of women gave incorrect answers to the knowledge questions. Women classified as anti-choice, in all five countries, were more likely to overestimate the risks of both abortion and contraception.

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    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.

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    Pain management in abortion
    Ellen Wiebe MD,
    University of British Columbia, Vancouver BC, Canada
    Adequate pain control during abortion remains an important challenge in abortion practice.
    Pain control methods include general anesthesia, conscious sedation using a narcotic
    (usually fentanyl) and sedative (usually midazolam), local anesthesia, oral analgesics,
    misoprostol and „verbal anesthesia“. A survey of 640 women from a random sampling of
    National Abortion Federation clinics found that the average pain score on an 11-point
    scale was 4.65 for abortions performed using conscious sedation and 5.2 for abortions
    performed under local anesthesia.
    There is evidence that a number of specific techniques and drugs reduce the pain of an
    abortion procedure including: buffering the pH of the local anesthetic, using a deep
    injection technique, injecting slowly, pre-operative ibuprofen and cervical preparation with
    misoprostol. Different surgeons have different pain scores using the same medications
    and basic techniques indicating that actual surgical technique also affects the pain scores.
    Anxiety and depression scores are highly corelated with pain scores and various methods
    of reducing anxiety such as music, low lights, distraction, relaxation techniques etc can be
    One of the greatest challenges facing a medical director of an abortion clinic is changing
    the behaviour of the doctors working within that clinic to improve patient care and
    specifically to reduce the pain experienced during the abortion procedure.

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    Sexual and Mood Side Effects of Hormonal Contraception

    Ellen Wiebe MD, Lori Brotto PhD, University of British Columbia Vancouver, Canada

    Objectives: To determine the rate and characteristics of women who reported mood and/or sexual side effects with previous hormonal contraceptives. Three cohorts were compared: women presenting for abortions, for IUDs or for primary care.

    Method: Women presenting for abortions or IUDs at an urban women’s clinic were given a questionnaire in the waiting room asking if they have ever used hormonal contraception in the past and, if yes, whether they ever had problems with sexual or mood/irritability side effects from hormonal contraception. Women age 15-50 presenting for primary care at family doctors offices were given the same questionnaires. Descriptive statistics were prepared to discover the rate of these side effects and compare the women who had or did not have these side effects. The three cohorts were compared.

    Results: There were 1243 women who completed questionnaires; 77% (954) had previously used hormonal contraception and 169 of these were from primary care, 560 were abortion patients and 221 were IUD patients. Of the ones who had previously used hormones, 51% (482) said they had at least one mood side effect on at least one brand and 38% (358) said they had at least one sexual side effect on at least one brand. Self reported ethnicity in these women was: White/Caucasian 66% (663), East Asian 17% (161), South Asian 8% (71), other 9% (88). The three groups of women who had used hormonal contraception were similar except that the primary care group were older (p<.001) and had a higher proportion of Caucasians (p=.009). The 289 women who had never used hormonal contraception were less likely to be Caucasian (p=<001), more likely to have children (p=.003) and had less education (p=.001).

    Women presenting for abortion and primary care had similar rates for all side effects but women presenting for IUDs had higher rates of mood side effects (p=.002). Women who complained of sexual side effects were more likely to also complain of mood and physical side effects (p=<.001). Women who complained of mood side effects were more likely to be younger (p=.03), unmarried (p=<.001), nulliparous (p=<.001) and presenting for an IUD rather than primary care or abortion (p=.002). Women complaining of sexual side effects were more likely to have more education (p=.03), be unmarried (p=.02) and nulliparous (p=.004). Caucasian and South Asian women complained about more hormonal side effects than East Asian women (p=.001).

    Conclusion: Women have a high reported rate of sexual and mood side effects from previous hormonal contraception. These rates are similar to two studies which found sexual and mood side effects the most important reasons women discontinued hormonal contraception.

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    The feasibility of offering medical abortions by telemedicine: two years’ experience

    Ellen Wiebe1 ,2, Cheryl Couldwell2 1University of BC, Vancouver, Canada, 2Willow Women's Clinic, Vancouver, Canada - ellenwiebe@gmail.com

    Objective: To describe the results of our programme of providing medical abortions by telemedicine. Methods: We did a retrospective chart review May 2012 - May 2014. Women saw a physician and counsellor by Skype videoconferencing for screening, information and consent. They went to a local laboratory for hCG tests for initial screening, the day of the medication and one week later. The medications were couriered or a prescription was faxed to a local pharmacy. At the follow-up visit by Skype we discussed her experience and her blood test results. If the hCGs had fallen by 80% in one week, we told her the abortion is completed and she needed no further follow-up. If she needed more medication, surgery or further blood tests, we arranged these. See www.willowclinic.ca. Results: In 24 months we saw 23 women for medical abortions by telemedicine and 65 were seen in clinic for the first visit and booked for telemedicine follow-up. Of the 88 women, three women were lost to follow-up (3.4%), four had surgery (4.5%) and 14 (15.9%) needed another follow up (more misoprostol or just another hCG). During that time, we saw 3757 women for the usual in-clinic medical abortions. Conclusions: This method of providing telemedicine abortions is feasible in our setting and may improve access to abortions. The main innovation in this programme is that the patients were in their own homes using their own technology (a computer or smart phone) and yet we provided the same physician and counseling services as we did in our clinic. Most women prefer to come to the clinic.

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    Verifying successful aspiration, routine ultrasound etc.

    Ellen Wiebe, Canada

    Most of the common complications of surgical abortion (such as incomplete abortion leading to bleeding, pain and infection, missed ectopic pregnancy, and failed abortion) can be avoided if the procedure has been verified to be completed. The National Abortion Federation Clinical Practice Guidelines state that “either tissue exam or ultrasound must be used to confirm evacuation” in all cases but that tissue exam should be used when no fetal pole has been seen by ultrasound pre-op and also in second trimester cases. This presentation will go through the practical details of verifying completion of the abortion through tissue examination, post- and intra-op ultrasound as well as using serial beta HCG measurements for cases with inadequate tissue.

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    Women’s perceptions of viewing ultrasound before
    termination of pregnancy: comparing first and
    second trimester
    Wiebe, E; Trouton, K
    University of British Columbia, Canada
    Objectives: The purpose of this study was to gain a better
    understanding of women’s choices, perceptions and experiences of
    viewing the ultrasound before having a first or second trimester
    termination of pregnancy (TOP).
    Methods: A questionnaire was offered to women prior to their
    ultrasound asking if they wished to view it. For women who chose
    to view the ultrasound, a second questionnaire asked them about
    their experience. Women in the first trimester (up to 12.0 weeks
    by ultrasound) were compared to those in the second trimester.
    Results: There were 234 women who completed the first
    questionnaires: 172 first trimester and 62 second trimester. Of the
    first trimester patients, 50% (86) and of the second trimester
    patients 47% (29) wanted to see the images (NS). More second
    trimester women were unsure about how they would feel about it
    (P = 0.01). There were 77 first trimester and 27 second trimester
    patients who completed the second questionnaire. When asked if
    viewing the ultrasound made it harder emotionally, 21% (16/77)
    of the first trimester patients and 44% (12/27) of the second
    trimester patients said ‘yes’ (P = 0.01).
    Conclusions: About half of the women in this study wanted to see
    the ultrasound before the TOP. Second trimester patients were
    more likely to be unsure about what to expect and were more
    likely to find it harder emotionally. It is important that we
    prepare our second trimester patients more carefully for the
    experience of viewing the ultrasound.

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

    Ellen Wiebe (Canada)

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

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

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

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

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

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    FAQ, Frequently Asked Questions in abortion care

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

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

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    National guidelines on Rhesus (Rh) testing and treatment with Rh (anti-D) immune globulin (RhIg) for spontaneous and induced abortion vary between countries. Rh alloimmunization (also called isoimmunization) may harm subsequent pregnancies, but there is a lack of evidence that this occurs in early gestations. We should stop testing Rh status and administering RhIg to women having an induced or spontaneous abortion at early gestations if this is shown to be unnecessary, because this interferes with access to abortion and incurs extra cost. In the Netherlands, the policy is to not treat Rh-negative women having medication-induced or spontaneous abortions under 10 weeks’ gestation and surgical abortions under 7 weeks’, while in Canada all Rh- negative women are treated. We compared the clinically significant Rh alloimmunization rates in Canada and the Netherlands to determine whether the Dutch policy could be safely adopted by other countries. National guidelines from Canada and the Netherlands were obtained for the period of 2006 to 2015, and public databases were consulted to obtain national rates of abortions, births, Rh negativity, and the number of women with clinically significant perinatal antibodies. For Canada, the total fertility rate was 1.56, the abortion rate was 1.9%, and the Rh negativity rate was 13.0%. For the Netherlands, the total fertility rate was 1.66, the abortion rate was 1.2%, and the Rh negativity rate was 14.5%. In Canada, out of 573,206 samples tested in pregnant women, 0.0043% had clinically significant perinatal antibodies. In the Netherlands, out of 1,816,457 samples tested, 0.0040% had clinically significant perinatal antibodies.




    This provides evidence that the Dutch policy of not treating Rh-negative women having medication-induced or spontaneous abortions under 10 weeks’ gestation and surgical abortions under 7 weeks’ can be safely adopted by other countries.