Edinburgh, 19-21 October 2012: „Unwanted pregnancy - A fact of life“

  • 08:45-
    09:30
  • 09:30-
    10:00
  • 10:00-
    11:00
    L’avortement : une éventualité de vie, Pentland
    Chair:
    • Sharon Cameron, GB
    • Mirella Parachini, IT
    • close

      Conscientious commitment
      Freedom of conscience is a human right
      recognised in the Universal Declaration of Human
      Rights of 1948. Accordingly, the U.N. International
      Covenant on Civil and Political Rights provides
      that “Everyone shall have the right to freedom
      of thought, conscience and religion” (Art.18(1)).
      Conscience is thereby expressed as separate
      from religion. Individuals may, of course, base
      their conscience on their religious beliefs, but
      the Covenant establishes that religion has
      no monopoly on conscience. A common
      invocation of conscience regarding abortion is in
      conscientious objection to participation, which is 

      often based on religious convictions.
      Conscientious commitment is the reverse of
      conscientious objection. It arises when healthcare
      providers feel conscientiously committed to
      offer patients advice and services to which
      administrators of their healthcare facilities such
      as hospitals are opposed in principle, for religious
      or comparable reasons. Institutions such as
      hospital corporations cannot claim human rights
      such as conscientious objection. Health facility
      administrators must accommodate service
      providers’ rights of conscience, such as to
      recommend and offer services the providers
      conscientiously consider to be in their patients’ best
      interests, and, with patients’ consent, to provide,
      or refer patients for, such services, including lawful
      abortion, without discrimination, in the same way
      that facility administrators must accommodate
      providers’ rights of conscientious objection.

    • close

      Recent developments in Spain
      Recent events and the legal, police, political
      and social developments that have taken place
      in Spain in recent years are part of a global and
      conservative campaign and have generated in the
      new political context of this country vast concern
      for the rights of women regarding equality and
      sexual and reproductive health.
      The various recent historical stages are
      discussed, from the Second Republic (1936-
      1939) and the military dictatorship of Franco
      (1939-1975) to democracy (1975-2012)
      in relation to the legislation and practice of
      induced abortion, in particular highlighting the
      achievements and shortcomings of the Abortion
      Law of 1985 and the current Law on Sexual and
      Reproductive Health and Voluntary Termination of
      Pregnancy, in force since July 2010.
      The current political situation is described, with a
      Conservative Government and absolute majority
      in Parliament, and the statements of its main
      representatives regarding the change of the current
      law until end of year. Furthermore, we also present
      the upcoming trial of professionals from an abortion
      clinic in Barcelona and the attempt by retrograde
      sectors and anti-choice groups to use this case to
      put pressure on the Government and public opinion
      in favour of a radical restriction of the right to abortion.

    • close

      We often voice our support for
      abortion because it is necessary.
      Necessary as a back-up to
      contraception, as a ‘second-chance’ method of
      birth-control when contraception fails or we fail to
      use it. And necessary when a pregnancy becomes
      no longer wanted - because something changes
      in our lives or about how we feel.
      We present abortion as an unfortunate fact of life.
      When our opponents claim abortion is evil, we often
      reply that it is a necessary evil. Our opponents take
      the moral stance, and we claim to be of the ‘real
      world’: pragmatic realists considering health risks
      and benefits and not what is ‘right’ and ‘wrong’.
      But there is a moral case to be put for freedom
      of choice. There is an argument that it is wrong
      to deny women that freedom – because to
      take away our capacity to make decisions for
      ourselves, is to take away what makes us human.
      The right to choose is more than a matter for
      women; it’s a matter for humanity.

  • 11:00-
    11:30
  • 11:30-
    12:45
    Contraception : Pour sortir des sentiers battus, Pentland
    Chair:
    • Anna Glasier, GB
    • Andreja Štolfa Gruntar , SI
    • close

      De-medicalising contraception
      Access to contraception is a reproductive health
      right. While sex ‘just happens’, women need to
      go through several hoops to obtain contraception.
      Regulations, protocols and guidelines drive
      service provision but do affect the perceptions
      of both users and providers. Evidence-based
      de-medicalisation of contraception may remove
      personal and systematic barriers to effective use of
      family planning methods. Emergency contraception
      is a case study in this area. Other models of care
      have emerged in the last decade. These include
      over and under the counter oral contraception,
      vending condoms and emergency contraception
      and web based services. Themes emerging
      from such models suggest that research, service
      provision and advocacy schemes should aim to
      push the boundaries of contraceptive regulation
      towards user-friendly non-medicalised care.

    • close

      Contraceptive development has taken place in
      3 milestones:
      1. Discovery of the fertile days by Knaus and Ogino
      in the 1920s. – For the first time ever, women
      were able to understand what was happening in
      their bodies and roughly identify the fertile days.
      But they were not able to control their fertility.
      2. Controlling fertility according to the individual
      desire and possibilities (pill and IUD) in the
      ’60s. - The dream of humankind came true:
      separate fertility from sexual activity. For the
      first time ever, women were able to control their
      fertility themselves and make their own choices
      concerning the number of children. Regular
      menstruation, however, continued. Even in
      women who take the pill and thus have no
      ovulation have their monthly bleeding.
      3. Limiting menstruation to the fertile cycles by
      continuous intake of oral contraception or the
      intrauterine system. – Women can effectively
      control both their fertility and menstruation
      according to their own wishes and limits.
      Currently we are in the process of making the 3rd
      milestone widely accessible and a free choice for
      women. The medical knowledge and technology
      are there. But social acceptance is a slow process,
      which will accompany us for some time to come.

    • close

      Post-abortion contraception:
      start immediately
      Contraceptive failure - unprotected sex or failure
      in use of the chosen contraceptive method or use
      of an ineffective method - leads to unintended
      pregnancy. Most women choose abortion in this
      situation. Avoiding the same incident in future, that is
      reducing the risk of repeat abortion, is in the interest
      of the woman and also the society both medically,
      psychologically, socially and economically. Including
      contraceptive counselling in post-abortion care is
      important and emphasized also in recent guidelines
      (WHO, RCOG). However, counselling itself has not
      been shown to have a beneficial long-term effect on
      contraceptive use and risk of repeat abortion.
      Recovery of ovarian function after abortion is
      rapid, ovulation occurs within the first month after
      abortion in most women. Thus contraception
      should be started as early as possible after
      abortion. Immediate start of both hormonal
      (pill, patch, ring) and also long-acting reversible
      (LARC) methods (implant, injection, intrauterine
      contraception) is recommended in the above
      mentioned guidelines. After medical abortion
      LARC using implants, injections can be started on
      the day of abortion, intrauterine contraception as
      soon as an on-going pregnancy is excluded. There
      is evidence that if after abortion a LARC method
      is chosen, the risk of repeat abortion is reduced.
      Well-functioning, easy-access contraceptive
      services are important in the follow-up.

    • close

      Update on contraceptive
      developments Although contraceptive use showed a steady
      increase worldwide, the needs of a significant
      percent of couples have not yet been met, as
      unscheduled pregnancies increased.
      While implants and IUDs require a health provider
      for a proper insertion, vaginal rings, a mid-acting
      method, have the advantage of being user-
      controlled. While long-acting methods seem
      preferable for women with compliance issues,
      daily transdermal gels or sprays have shown high
      acceptability as the methods can be used privately.
      Progesterone receptor modulators (PRMs) to be
      used within 120 hours of unprotected intercourse
      have a definite role as emergency contraceptives.
      Continuous low-dose administration of a PRM
      from a vaginal ring has been shown to block
      ovulation and induce amenorrhoea.
      Contraceptives combined with other agents
      should provide dual protection against both
      pregnancy and another preventable conditions.
      Dual protection methods are tested as vaginal
      gels or rings delivering both a contraceptive and
      an agent active against HIV transmission. In
      addition, the potential of PRMs to prevent breast
      cell proliferation or the neuroprotective effects
      of progesterone and derived molecules are new
      areas of research for contraception with added
      medical benefits. These dual-purpose methods
      may increase users’ compliance, thus reducing
      failures and unwanted pregnancies.

      Men now tend to accept responsibility for the
      couple’s fertility control, leading to a growth in male
      contraceptives needs. Non-hormonal methods
      for men target the maturation of germ cells, or the
      sperm motility and activity. Novel approaches in
      women target meiosis as well as genes involved
      in follicular rupture. These methods will hopefully
      enter clinical testing during the current decade.

  • 12:45-
    14:00
    Déjeuner de travail 1 : Réseau européen de l’IPPF, Carrick
    Chair:
    • Joanna Dec, PL
    Lunch session 2: National clinical practice guidelines in abortion care, Tinto
    Chair:
    • Elisabeth Aubény, FR
    • Nathalie Kapp, FR
  • 14:00-
    15:30
    Atelier 1 : Voyager pour avorter, Harris
    Chair:
    • Gunta Lazdane, DK
    • Sam Rowlands, GB
    Atelier 2 Débat: Avortement chirurgical ou médicamenteux au 1er trimestre – le pour et le contre, Pentland
    Chair:
    • Elisabeth Aubény, FR
    • David Baird, GB
    Atelier 3 Éducation et formation à la prise en charge de l’avortement, Carrick
    Chair:
    • Teresa Bombas, PT
    • Kristina Gemzell-Danielsson, SE
    Atelier 4 Sujet d’actualité: Le sabotage de la contraception, Tinto
    Chair:
    • Rebecca Cook, CA
    • Kelly Culwell, US
    Atelier 5 Communications libres, Ochil
    Chair:
    • Rodica Comendant, MD
    • Alberto Stolzenburg, ES
    • close

      Acceptability of medical termination of pregnancy
      up to 63 days of gestation with home
      administration of misoprostol: assessment of
      significant factors
      Kopp Kallner, H1; Fiala, C2; Gemzell-Danielsson, K1
      1 Department of Obstetrics and Gynaecology, Karolinska Institute 7,
      Stockholm, Sweden; 2 Gynmed Clinic, Austria
      Objective: The objective of this study was to identify significant
      factors affecting acceptability of home administration of
      misoprostol for medical termination of pregnancy (TOP) up to
      63 days of gestation.
      Methods: This study was conducted in a University Hospital
      Outpatient Family Planning Clinic. Women who were in good
      general health, above 18 years of age, with no contraindication to
      medical TOP, requesting medical TOP with home administration
      of misoprostol and with pregnancies up to 63 days of gestation as
      evaluated by ultrasound were asked to participate. Women
      received 200 mg of mifepristone in the clinic and were instructed
      to self-administer 0.8 mg of misoprostol vaginally at home 36–
      48 hours later. Women filled in questionnaires which were
      answered after the TOP and at follow up. Patients also filled in
      daily symptom diaries. Follow-up was 2 weeks later with physical
      examination and low sensitivity urine-hCG according to clinical
      practice. All factors extracted from the questionnaires which could
      potentially affect acceptability were analysed using multivariate
      logistic regression.
      Results: In total, 395 women who opted for home administration
      of misoprostol for medical TOP were recruited. We found that
      the presence of a partner/friend during the TOP affected
      acceptability in a positive direction (P = 0.021). In contrast,
      having a positive low sensitivity urine hCG at follow up affected
      acceptability negatively (P = 0.002), although most of these
      women had a successful and complete TOP. In contrast to other

      studies on medical TOP, we could not find an influence of age,
      gestational length or the requirement of extra pain medication on
      overall acceptability of the procedure.
      Conclusions: Home administration of misoprostol for medical
      TOP up to 63 days of gestation is highly acceptable. Women
      should be encouraged to have a partner/friend present during the
      TOP if possible as this affected acceptability of the procedure in
      this study. In order to further increase acceptability of home
      administration of misoprostol, focus of future research should be
      directed towards increasing the number of complete TOPs in a
      shorter time frame.

    • close

      Results: Two prospective cohort studies (n = 3821) and two
      randomised controlled trials (RCTs) (n = 3821) were included.
      Three thousand seven hundred and forty-nine women underwent
      a procedure administered by an MLP and 3893 women underwent
      a physician-administered procedure. Three studies used surgical
      TOP with maximum gestational ages ranging from 12 to 16+
      weeks; a medical TOP study had maximum gestational ages up to
      9 weeks.
      There was no difference in incomplete/failed TOP for
      procedures performed by MLPs compared to doctors in RCTs of
      surgical (OR: 2.00; 95% CI: 0.85, 4.68) and medical TOP (OR:
      0.69; 95% CI: 0.34, 1.37). One prospective cohort study showed
      increased odds of incomplete/failed TOP among MLPs versus
      physician groups (OR: 4.03; 95% CI 1.07–15.28).
      None of the included studies found a difference in the odds of
      overall complications between provider groups.
      Conclusions: Based on this evidence, there is no indication that
      procedures performed by MLPs are less effective or safe than
      those provided by physicians. 

      Conclusion: Women undergoing a TOP who wish to avoid
      another unintended pregnancy should consider immediate
      initiation of either intrauterine contraception or the progestogen-
      only implant. Service providers should be trained and supported
      to provide these methods to women at the time of TOP.

    • close

      FC1.03
      Most women choosing termination of pregnancy
      are certain of their decision and do not need more
      counselling
      Caird, L1; Cameron, S2; Glasier, A3; Hough, T1
      1 Raigmore Hospital, NHS Highland, UK; 2 Chalmers Sexual and
      Reproductive Health Centre, UK; 3 Department of Reproductive and
      Developmental Sciences, UK
      A self-administered questionnaire using a validated measure of
      pregnancy intention (London Measure of Unintended Pregnancy)
      was introduced as part of routine assessment for women
      requesting a termination of pregnancy (TOP) at a NHS hospital
      clinic in Inverness, Scotland, UK aimed at identifying those who
      may need more discussion on their decision to proceed with a
      TOP. We wished to determine the proportion of women for
      whom the pregnancy was clearly unintended, the proportion who
      were not certain of their decision and who would like more
      detailed discussion, and the proportion who subsequently
      proceeded with a termination of pregnancy.
      Methods: A retrospective review was conducted of the outcome
      of the pregnancies amongst women attending the service between
      January and July 2011.

      Results: One hundred and eighty-five women with a viable
      pregnancy completed a questionnaire. The pregnancy was clearly
      unintended in 166 (90%) cases. One hundred and sixty-seven
      women (90%) stated that they were certain of the decision to
      have a TOP and 150 women (81%) did not want further
      discussion about this decision. One hundred and sixty-three
      women (88%) proceeded with a termination of pregnancy.
      Conclusion: Most women referred to a clinic requesting an
      induced TOP have a clearly unintended pregnancy, are certain of
      their decision and do not wish further counselling. Subjecting
      women to compulsory counselling about their decision to have a
      TOP is in conflict with their wishes and would waste resources.

    • close

      Review of telephone follow-up of women having
      early medical termination of pregnancy
      Michie, L1,2; Cameron, S1,2; Johnstone, A1,2;
      Dewart, H1,2
      1 NHS Lothian; 2 University of Edinburgh, UK
      Introduction: Telephone follow-up2 weeksaftermedical
      terminationofpregnancy(TOP)(£9 weeksofgestation)withaself-
      performedlowsensitivityurinepregnancy(LSUP)test,was
      introducedatahospitalTOPserviceinEdinburgh.Womenwho
      screened‘positive’attelephonefollow-up(ongoingpregnancy
      symptoms,scantbleeding,orLSUPresult)subsequentlyattended
      foranultrasound.Apreviousserviceevaluationconfirmedthatthis
      waseffectivefordetectingongoingpregnancyandhadgoodfollow-
      uprates.Wesoughttodetermineifthismethodoffollow-up
      continuedtobesuccessfulduringtheyearfollowingitsintroduction

      Methods: Retrospective computerised database review of outcome
      of telephone follow-up of women having a medical TOP
      (£9 weeks of gestation) over 12 months (March 2011–February
      2012).
      Results: One thousand and eighty-four women of mean age
      25 years had a medical TOP during this period. One hundred and
      twelve women were scheduled to attend the clinic for follow-up
      and three women did not require follow-up as complete TOP was
      confirmed on the day of treatment. Ten women (out of 969)
      attended hospital before the planned telephone contact (1%). Of
      the 959 requiring telephone follow-up, 656 (68%) were
      successfully contacted. Two of those who were not contactable
      had ongoing pregnancies. Five hundred and seventy-three (87%)
      of those contacted, screened ‘negative’ with no false negatives
      occurring. Of the 83 (13%) who screened ‘positive’, three had
      ongoing pregnancies. The sensitivity of follow-up was 100% and
      specificity was 88% (95% CI 84.9–90.1).
      Conclusion: Although slightly lower follow-up rates were obtained
      in the 12 months following initial introduction, telephone follow-
      up with LSUP was shown to be effective for detecting ongoing
      pregnancy.

    • close

      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.

    • close

      Women’s preference for medical or surgical
      method of termination of pregnancy at 9–12 weeks
      of gestation
      Dewart, H1; Johnstone, A2; Cameron, S2
      1 Royal Infirmary of Edinburgh, UK; 2 Chalmers Sexual and
      Reproductive Health Service, UK
      Background and methods: Medical termination of pregnancy
      (TOP) at less than 9 weeks of gestation and in the second
      trimester, using mifepristone and misoprostol is well established
      in Scotland. Although there is good evidence to support the
      efficacy, safety and acceptability of medical TOP in the late first
      trimester (9–12 weeks), it is not widely available. The TOP service
      in Edinburgh, Scotland, UK currently offers only a surgical
      method at this gestation band. A survey of women presenting to
      this service at 9–12 weeks of gestation was conducted to
      determine whether these women would choose a medical method
      if this were available.
      Results: Questionnaires were completed by a convenience sample
      of 77 women over 5 months, representing 49% of all women at
      this gestation during the study period. Women were of mean age
      24.7 years (range 15–42). Most women (n = 51; 66%) stated that
      they would choose a medical TOP if able to do so and a further
      10 (13%) were unsure about preference of method. Most women
      (n = 43; 56%) stated that they would still choose the medical
      method, if they had to travel to another hospital (40 km away) to
      have this. The commonest responses (out of 46 given) for
      preferring a medical method was a perception that it was safer
      (37%), easier (30%) and less invasive (28%).
      Discussion and conclusions: Most women in our survey at 9–
      12 weeks of gestation would in theory choose a medical method
      of TOP, if this were available. Consideration should now be given
      to offering this method to women as an alternative to surgery.

  • 15:30-
    16:00
  • 16:00-
    17:30
    Avortement : le point sur la situation mondiale
    Chair:
    • Christian Fiala, AT
    • Helena von Hertzen, CH
    • close

      Stereotyping in Reproductive
      Health Gender stereotyping refers to the treatment
      of the sexes according to social and cultural
      constructions of women and men, due to their
      different physical, biological, sexual and social
      functions, not according to their individual
      attributes. This presentation will examine how
      wrongful stereotyping of women harms their
      dignity and prevents them from accessing abortion
      services according to their own individual needs
      and circumstances. It will explain how international
      and regional human rights treaty bodies and
      national constitutional courts are holding states
      legally accountable for failing to eliminate harmful
      gender stereotypes. In conclusion, it will explore
      what implications the evolving law against harmful
      gender stereotyping might have for abortion laws
      and policies more generally.

    • close

      Trends in induced abortion Background: Abortion levels and trends often
      mirror patterns in the incidence of unintended
      pregnancy. We present estimated safe and unsafe
      abortion levels globally and in all the major world

      regions and subregions for 2008, the most recent
      year available, and trends in abortion incidence
      between 1995, 2003 and 2008. We also explore
      the association of the legal status of abortion with
      the abortion rate. Finally, we examine abortion
      rates and the distribution of abortion by age, and
      variations in these measures across geographical
      areas and over time.
      Select Findings: The global abortion rate was
      steady between 2003 and 2008 following a period
      of decline between 1995 and 2003. Worldwide,
      49% of abortions were unsafe in 2008, compared
      to 44% in 1995. About one in five pregnancies
      ends in abortion. Restrictive abortion laws are not
      associated with lower abortion rates. Adolescents
      account for a smaller share of abortions than their
      population size would predict in most countries
      with data. The proportion of abortions obtained
      by adolescents is higher in North America than
      in Europe, though Northern Europe resembles
      North America in this respect. Findings and their
      implications will be discussed in greater detail.

    • close

      Update on unsafe abortion Despite technological advances, unsafe abortion
      continues as a public health problem and
      important cause of maternal mortality globally. As
      per WHO’s recent estimates, currently, about 22
      million unsafe abortions occur every year—98%
      of them in the developing world. The global rate
      is 14 unsafe abortions per 1,000 women 15-44
      years, but there are wide disparities across

      geographic regions, with Eastern and Middle
      Africa having the highest rate of unsafe abortion
      at 36 unsafe abortions per 1,000 women aged
      15-45. Adolescents and poor women also bear a
      disproportionate burden.
      Sexuality education, access to affordable,
      effective contraception and to lifesaving care to
      treat complications can all help to reduce the
      unintended pregnancies or the morbidity and
      mortality from unsafe abortion, but access to
      safe, legal abortion care remains central to
      dealing with the problem. Barriers include health
      system, finances, regulations, and policies,
      stigma and the ways existing laws and regulations
      are interpreted and implemented.
      Effective interventions do exist and progress
      has been made in recent years, as is evidenced
      by a decrease in case-fatality rates from unsafe
      abortion. The Safe Abortion: Technical and
      Policy guidance for health Systems (WHO, 2012)
      presents the public health and human rights
      based evidence to address the issue.

    Assemblée générale de la FIAPAC (réservée aux membres uniquement)
  • 18:00-
    19:00
  • 19:30-
    00:00