Lisbon, 13-16 Ottobre 2016: „Improving women’s journeys through abortion“

  • 08:00-
  • 09:00-
    • Teresa Bombas, PT
    • Sharon Cameron, GB
  • 09:30-
    Successes in improving women’s journey
    • Sharon Cameron, GB
    • Ana Campos, PT
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      PS01.1Improving the journey through medical abortion.

      Rebecca Gomperts1 ,2

      1Women on Web, Toronto, Canada, 2Women on Waves, Amsterdam, The Netherlands, 3Karolinska Institute, Stockholm, Sweden

      Women on Web, a telemedical abortion service was founded 10 years ago and today answers 10,000 emails per month. Telemedicine has a great potential to improve the journey though medical abortion especially for women in rural and remote areas, as well as urban areas with a shortage of health care providers or where access to abortion is legally restricted.

      So far scientific research has been published about three telemedical abortion services Women on Web (WoW), Willow Women’s Clinic and Planned Parenthood of the Heartland. Lately several new telemedical abortion services were initiated including one in Australia by the Tabbot Foundation and in the USA by Gynuity.

      In this talk I will present

      1. Examples of women who contacted Women on Web because they could not obtain regular abortion services even if they are living in countries where abortion is “legal” and “available” due to economic and social circumstances and domestic violence. 

      2. Criminal prosecution of women using Women on Web in a high resource setting. 

      3. Criminal prosecution of women using Women on Web in a low resource setting. 

      While these cases are caused by the local, legal context it shows clearly that, even if telemedical services can give access to medical abortion in places where this is not available, we have to continue to work on changing abortion laws and making sure local, safe abortion services will become more easily accessible even in countries where it seems abortion services are available as they are still not available for those women who are in the most vulnerable social economic situations.
To improve the journey through medical abortion for women we have to improve it for all women.

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      Improving women´s journey through abortion in Portugal

      Lisa Vicente
      Directorate of General of Health, Lisbon, Portugal

      Abortion, according to the Portuguese penal code, is considered a crime against intrauterine life. Over the years Portuguese law has incorporated reasons that preclude the illicit use of abortion.
      Serious maternal illness, foetal malformation and rape constitute grounds for termination of pregnancy. These motives are accepted for 32 years in Portuguese health care.
      It was just in 2007, after a national referendum, that the practice of abortion at women´s request up to10 weeks gestation was recognised. Since then it has been performed within the National Health Service (NHS) or in officially recognised, private clinics.
      The implementation of abortion services was made possible within the NHS through a national network, along with the availability of mifepristone and misoprostol, the publication of national guidelines and the creation of a national online registry, mandatory for all health care units.
      Nowadays 67% of all the abortions are performed in the NHS, where 95-97% of interventions are medical abortions.  In private units the majority of the interventions are still performed using the surgical method (98%).
      It is unknown what was the absolute number of illegal abortions before 2007, although 20 000 was the estimated number. We only have data on the complications caused by these abortions because women came to health services looking for treatment. Serious complications included deaths, uterine perforations and sepsis. Many women travelled abroad to seek a safe abortion – a number never known.
      National reports show a significant decrease in the number and seriousness of complications caused by illegal abortions since 2008. With legal abortions complications remain low but in 2010 there was one fatal case of Clostridium Sordellii associated with medical abortion.

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      Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends

      Gilda Sedgh

      Guttmacher Institute, New York, USA

      Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We estimated subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014 and abortion rates in subgroups of women. Estimates were made using abortion data compiled from government agencies, nationally representative studies and a Bayesian hierarchical time series model. We estimated that, on average, 56 million (90% UI 52·4 to 70·0) abortions took place each year in 2010- 2014, for an annual abortion rate of 35 (90% UI 33 to 44) per 1000 women aged 15-44 years. Estimates of abortion trends globally and across subregions will be presented. We also used the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion.

  • 11:00-
  • 11:30-
    Barriers and restrictions
    • Kristina Gemzell-Danielsson, SE
    • Amália Pacheco, PT
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      The Global Abortion Policies Project: a WHO-United Nations Population Division initiative to strengthen transparency of laws and policies and accountability for women’s health and human rights

      Brooke Ronald Johnson1, Bela Ganatra1, Rajat Khosla1, Vinod Mishra2
      1World Health Organisation, Geneva, Switzerland, 2United Nations, New York, USA

      Prevention of unsafe abortion is a core component of the WHO Reproductive Health Strategy to accelerate progress towards the attainment of international development goals and targets. To facilitate policy work towards preventing unsafe abortions, the WHO Safe Abortion technical and policy guidance for health systems (2012) recommends that:

      • Laws and policies on abortion should protect women's health and their human rights; 
      • Regulatory, policy and programmematic barriers that hinder access to and timely provision of safe abortion care should be removed;
      • An enabling regulatory and policy environment is needed to ensure that every woman who is legally eligible has ready access to safe abortion care; and,
      • Policies should be geared to respecting, protecting and fulfilling the human rights of women, to achieving positive health outcomes for women, to providing good-quality contraceptive information and services, and to meeting the particular needs of poor women, adolescents, rape survivors and women living with HIV.

      The Global Abortion Policies Project is designed to further strengthen global efforts to eliminate unsafe abortion by producing an open-access, interactive database and repository of current abortion laws, policies, and national standards and guidelines for all countries in the world.  The Project aims to increase the transparency of abortion laws and policies and accountability for implementation and protection of women's health and human rights.  The database and repository will facilitate comparisons of national laws and policies with WHO guidelines and international human rights standards related to safe abortion.  
      The first of three presentations will provide details on the methodology used to retrieve official legal and policy documents, extract selected information for the database and conduct independent validation and country review.  Plans for updating the database/repository, producing a second edition of Abortion policies: a global review, and working with international human rights bodies and intergovernmental organisations will also be presented.

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      Regional analyses of abortion laws and policies in the context of international human rights standards

      Rajat Khosla1, Brooke Ronald Johnson1, Bela Ganatra1, Vinod Mishra2
      1WHO, Geneva, Switzerland, 2UN Population Division, New York, USA

      The Global Abortion Policies Project is designed to further strengthen global efforts to eliminate unsafe abortion by producing an open-access, interactive database and repository of current abortion laws, policies, and national standards and guidelines for all countries in the world.  The Project aims to increase the transparency of abortion laws and policies and accountability for implementation and protection of women’s health and human rights.  The database/repository will facilitate comparisons of national laws and policies with WHO guidelines and international human rights standards related to safe abortion.
      Within the context of this project this presentation will provide regional analyses of abortion laws and policies in the context of international human rights standards and highlight the areas of progress and gaps that remain.

  • 12:45-
    Lunch session 01 - Exelgyn sponsored session
    • David Baird, GB
    • Teresa Bombas, PT
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      Cervical priming before surgical abortion

      Aubert Agostini, Alexandra Ohannessian
      La Conception Hospital, Marseille, France

      Legal abortions are an international public health issue, with one in five pregnancies worldwide resulting in the decision to terminate. Accordingly, in 2008, 43.8 million elective abortions were performed, for a mean of 28 per 1000 women aged 15 to 44 years, with nearly 8.5 million complications. These complications can be life-threatening and are responsible for 13% of the annual international maternal mortality.
      Surgical abortion requires mechanical dilatation of the cervix. This cervical dilatation is the source of the principal complications of abortions including cervical laceration, uterine perforation with a risk of wounding adjoining organs, haemorrhage and, finally, the long term risks of cervical incompetence, late miscarriage and preterm delivery.On the other hand, when cervical dilatation is not adequate at the moment of aspiration, it can also cause other short-term complications: ongoing pregnancy and infection that can affect fertility. Cervical preparation has shown benefits in terms of cervical dilatation and reduction of intraoperative bleeding as well as a reduction in the incidence of complications. Misoprostol and mifepristone are the two substances recommended for cervical preparation during the first trimester.

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      Comprehensive pain management in early medical abortion – A follow up

      Christian Fiala
      Gynmed Clinic, Vienna, Austria

      Introduction: Medical abortion is increasingly used. But most women will experience some pain that requires intervention, while satisfaction with medical abortion may be limited by differences between women’s expectations of pain and their actual symptoms. Pain is still a neglected issue in many settings and even studies. So far, no evidence-based comprehensive pain management protocol has been published. Therefore, a group of experts has developed recommendations based on the following principles: avoidance of pain, non-pharmacological strategies and medical pain treatment.
      Background: Pain usually starts following administration of misoprostol. It is caused by contractions, with a peak around expulsion decreasing thereafter. Several associations between various factors and pain can be found. However, the predictive value of these factors is insufficient to define pain management for an individual woman.
      Avoidance of pain and non-pharmacological strategies are a cornerstone, including:
      ·      Facilitating access so that women can have the abortion at an early gestational age
      ·      Giving detailed information to women on what to expect during the procedure
      ·      Using the lowest effective dose of misoprostol
      ·      Taking misoprostol at home in a relaxing environment with a support person present
      Medical pain treatment: Treatment for pain in first trimester MToP should be systematic and women should have easy access to additional stepwise pain treatment. The limited data do not show prophylactic treatment to be superior compared with curative administration. However, experts’ recommendation is to give prophylactic analgesia using NSAIDs like ibuprofen. Pain treatment should be given stepwise using
      ·      1st line,: ibuprofen 400 to 800 mg
      ·      Use of Paracetamol alone is not recommended.
      ·      In addition, 2nd line analgesia for break through pain should be offered and be accessible easily and without delay, consisting of opioids like codeine, dihydrocodeine, or morphine.

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      A tailored pregnancy test offers new possibilities to women for follow-up after medical abortion

      Kristina Gemzell Danielsson
      Karolinska Institutet, Stockholm, Sweden

      One reason for limited access to medical abortion is that women are required to make multiple visits to the clinic. The purpose of a follow-up visit after medical abortion has been to ensure that pregnancy has successfully terminated, to detect complications and to start contraceptives. However, in case of complications women should not wait until a routine follow-up visit and, importantly, to help women start contraception after the abortion contraceptive counselling and provision should be done at the first visit to the abortion clinic and should not be postponed to the follow-up. Hence the main purpose of a routine follow-up visit after medical abortion is to detect an on-going pregnancy. Most service delivery guidelines recommend that women return at 2-3 weeks for a follow-up visit. However, an increasing number of women choose not to return for follow-up after their medical abortion.
      Recently, studies have assessed alternative methods of follow-up after medical abortion, such as using a low-sensitivity urine pregnancy test, semi-quantitative urine pregnancy test or a high sensitivity pregnancy test followed by a telephone follow-up or through text message or online. A few studies have also investigated women’s experiences and perceptions of self-assessment and safety and effectiveness of self-assessment in low resource settings, including women who reside in rural areas, have low literacy levels and limited access to telephone and transport facilities.
      Overall there is no increased risk of complications in women who self-assessed their treatment outcome compared with women who attend clinical follow-up. Self-assessment of treatment success after early medical abortion has a resource-saving potential. Women need to be counselled about the risk of continuing pregnancy and any strategy for self-assessment will need to be carefully assessed for test and user performance before introduction.
      A simple, reliable test for self assessment allows a one-stop clinic for medical abortion.

    Lunch session 02 - IPPF - Barriers to Safe abortion: A global perspective
    Lunch session 03 - Positive developments
    • Eduardo Lopez Arregui, ES
    • Duarte Vilar, PT
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      Resistance in the US

      Vicki Laporta
      National Abortion Federation, Washington, DC, USA

      In the last several years anti-choice legislators have made restricting abortion access a priority in the United States. We have seen a record number of anti-abortion restrictions being introduced and passed at state and federal levels. These restrictions have made it increasingly difficult for women to access the care that they need and have even forced clinics to close.
      In the last year, we have also endured a smear campaign using highly-edited, misleading videos to target and demonise abortion providers. This anti-abortion campaign has led to increased investigations against providers and a dramatic increase in hate speech and internet harassment, death threats, attempted murder and murder targeting providers.
      We have been active in fighting back against these attacks, particularly in the courts. NAF immediately sued the individuals and organisations behind the illegal undercover videos in order to protect the safety and security of our members. Earlier this year the Supreme Court heard arguments in Whole Woman's Health v. Hellerstedt - a challenge to Texas abortion restrictions designed to close more than half of the clinics in that state. The outcome of this case could have implications for abortion restrictions throughout the United States.

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      Timid progress in Africa and Latin America

      Anibal Faúndes
      State University of Campinas, Sao Paulo, Brazil

      In 2008, when the FIGO Initiative on Prevention of Unsafe Abortion started, twelve countries from Sub Saharan Africa participated and only South Africa and Ethiopia officially offered safe abortion services, although in every country abortion is permitted at least in some circumstances. In 2016, out of the same twelve countries only Tanzania, Cameroon and Gabon do not include the expansion of safe abortion services within the limits of the law in their plan of action. This progress, which may appear as quite impressive, it is still timid because it is still limited to a few larger, usually University, Hospitals. The potential for rapid expansion has not yet occurred with the exception of Ethiopia. The situation in Latin America is even worse. Only Cuba, out of the 17 countries participating in the FIGO Initiative, had liberal abortion law and access to safe legal abortion that is universal. Brazil was the other country where legal abortion after rape was being offered, although limited to a few larger hospitals. Five of these 17 countries have totally restrictive legislations, and abortion is not permitted in any circumstance. Uruguay changed its legislation to a liberal stance and access to safe legal abortion is close to universal. Several other countries are now offering access to safe legal abortion within the limits of the law: for example Brazil, Argentina, Bolivia, Peru and Colombia and the process is in continuous expansion. In addition, proposals for slightly more liberal legislations are being discussed in the five countries where abortion is currently not permitted in any circumstances.

  • 12:45-
  • 14:00-
    Concurrent session 01: Free communication
    • Françoise Dedrie, BE
    • Anabela Araujo Pedrosa, PT
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      A randomised controlled trial of immediate initiation of contraception by levonorgestrel-releasing intrauterine system (LNG-IUS) after medical abortion - one year continuation rates

      Riina Korjamo1 ,2, Maarit Mentula1, Oskari Heikinheimo1 ,2
      1Helsinki University Hospital/ Obsterics and Gynecology, Helsinki, Finland, 2University of Helsinki, Helsinki, Finland

      Objectives: Immediate insertion of intrauterine device at the time of the surgical abortion results into higher uptake of effective contraception and prevent unintended pregnancies. We performed a randomised controlled trial comparing immediate (≤3 days) vs. delayed (within 2-4 weeks) insertion of the LNG-IUS after medical abortion.
      Method: Women ≥18 years requesting medical abortion and desiring LNG-IUS contraception were eligible to enter the trial, which was conducted at Helsinki University Hospital between Jan 30nd 2013 and Dec 31st 2014. Trial has registered to, NCT01755715. The primary outcome was the LNG-IUS use at 1 year after abortion. Secondary outcomes were expulsions, further pregnancies and abortions.
      Results: Altogether 267 women were randomised to immediate (134) and delayed (133) insertion groups, of which 264 (133 and 131, respectively) were analysed. LNG-IUS was inserted in 127 (95.5%) women in the immediate and 111 (84.7%) women in the delayed insertion groups (OR3.81, 95%CI 1.48-9.83, p=0.004). The verified numbers of women continuing the LNG-IUS use at 1 year were 83 (62.4%) and 52 (39.7%), respectively (OR2.52, 95%CI 1.54-4.14, p=0.001). In the best case scenario (the use of LNG-IUS verified or LNG-IUS inserted) 113 (85.0%) women in the immediate, and 88 (67.2%) women in the delayed insertion group continued LNG-IUS use at 1 year (OR2.76, 95%CI 1.52-5.03, p=0.001). Numbers of total expulsions were 3 (2.3%) vs. 3 (2.3%) (OR0.98, 95%CI 0.20-4.97, p=1.00), partial expulsions 26 (19.5%) vs. 9 (6.9%) (OR3.29 95%CI 1.48-7.34, p=0.003), new pregnancies 6 (4.5%) vs. 16 (12.2%) (OR0.34 95%CI 0.13-0.90,p=0.027) and further abortions 4 (3.0%) vs. 5 (3.8%) (OR0.78 95%CI 0.21-2.98, p=0.75), respectively.
      Conclusions: Immediate insertion of the LNG-IUS after medical abortion resulted in a higher uptake and continuation rates of intrauterine contraception compared to delayed insertion, despite higher partial expulsion rates of LNG-IUS. Immediate insertion of the LNG-IUS decreased the 1-year pregnancy rates but did not affect the rate of further abortions.

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      The impact of a liberalisation law on legally induced abortion hospitalisations

      Manuel Gonçalves-Pinho2 ,3, João V.Santos2 ,3, Antónia Costa1 ,4, Altamiro Costa-Pereira2 ,3, Alberto Freitas2
      1Obstetrics and Gynecology Department, Hospital São João, Porto, Portugal, 2Department of Health Information and Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, 3Centre for Health Technology and Services Research (CINTESIS), Porto, Portugal, 4Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Porto, Portugal

      Objectives: Legally induced abortion (LIA) for maternal option without /maternal pathology (MOLIA) was liberalised in Portugal in 2007. The aim of this paper was to study the impact of the liberalisation of abortion by maternal request on total LIA-related hospitalisation trends.
      Method: We considered hospitalisations of legally induced abortion (ICD-9-CM codes 635.x) with discharges from 2000 to 2014. Data was obtained from a Portuguese administrative database, which contains all registered public hospitalisations in mainland Portugal. Hospitalisations per abortion were calculated by dividing the number of LIA hospitalisation by the number of LIA. Mean ages, number of hospitalisations per age group, complications, admission type and length of stay were also analysed.
      Results: Hospitalisations rose during the study period. Since the liberalisation law was passed there was a significant decrease in the number of hospitalisations per abortion: from 1.07 in 2000 to 0.11 in 2014 (p < 0.001).  Furthermore, the mean age remained stable since liberalisation (30.8 years before 2007 and 40.0 after). Abortion-related hospitalisations are more frequent in women aged 25-39. A significant decrease from the emergency to the scheduled type of admission occurred from 2000 to 2014 (from 83.5% to 56.7% of emergency admissions) (p < 0.001). Complications remained stable and delayed or excessive haemorrhage was the most frequent (4.6%) (p = 0.07).
      Conclusions: Since the liberalisation, hospitalisations per abortion have decreased, reflecting the major impact that the liberalisation of MOLIA had on abortions trends nationwide. LIA-related hospitalisations are more frequent in women aged between 25-39 years old. This study shows the impact that MOLIA liberalisation law can bring to abortion and to hospitalisation trends.

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      Pain management for up to 9 weeks medical abortion – An international survey among providers

      Christian Fiala1 ,8, Sharon Cameron2, Teresa Bombas3, Mirella Parachini4, Aubert Agostini5, Roberto Lertxundi6, Laurence Saya7, Kristina Gemzell-Danielsson8
      1Gynmed Clinic, Vienna, Austria, 2Chalmers Centre, NHS Lothian, Edinburgh, UK, 3Obstetric Service A, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 4San Filippo Neri Hospital, Rome, Italy, 5Obstetric and Gynecology Department, La Conception hospital, Marseille, France, 6Clinica Euskalduna, Bilbao, Spain, 7Altius Pharma CS, Paris, France, 8Department of Women’s and Children’s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden

      Introduction: There is no consensus about pain management for medical abortion (MToP) and evidence based guidelines give different recommendations. A survey among providers was done to analyse regimens being used in clinical routine.
      Methods: A questionnaire on details of pain management for first trimester MToP was developed by a group of experts. Health care providers all over the world offering MToP were invited to complete it through a FIAPAC dedicated website.
      Results: 283 health care professionals from all regions of the world completed the questionnaire: Europe 59%, North America 21%, Asia 8%, Australia and New Zealand 6%, Africa 4%, Latin America 2%. Most respondents (n= 267, 94%) reported analgesic prescription/provision for all women, either prophylactic for 82% (n=233) or upon request for 12% (n=34). WHO Step I analgesics (NSAIDs, paracetamol) were the most often used in both cases. A total of 16 (6%) respondents indicated that they never provided analgesics (or prescriptions for them). Only 24 providers (10%) started pain treatment after mifepristone. Female providers of abortion care were significantly more likely to prescribe systematic analgesia for patients than male providers (85% vs 74%, p<0.04). Most practitioners did not adapt the analgesic treatment to gestational age or according to place of intake of misoprostol (home or at the clinic/hospital). The majority of respondents (69%, n=195) did not conduct formal assessments of women’s pain.
      Conclusion: There is widespread variation in the assessment and management of pain during MToP, reflecting the lack of evidence based guidelines. This is a clear indication for improvement of using available and effective pain treatment to avoid unnecessary pain by women.

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      Safety and effectiveness of medical abortion outside the formal healthcare setting: do women seek timely care for potential complications?

      Abigail Aiken1 ,2, Rebecca Gomperts3, James Trussell1
      1Princeton University, Princeton, NJ, USA, 2University of Texas at Austin, Austin, TX, USA, 3Women on Web, Amsterdam, The Netherlands

      Objectives: Medical abortion provided outside the formal healthcare setting is an important option for women in countries where abortion is illegal or highly restricted. Yet very little is known about its safety and effectiveness. We address this important knowledge gap using high-quality data from a setting where women commonly rely on this pathway to abortion.
      Methods: We examine outcomes and complications among 1,234 women in Northern Ireland (representing 79% follow-up) who conducted medical abortion through Women on Web between March 30th 2009 and December 31st 2012. Women used a regimen of 200mg oral mifepristone and 1200mcg buccal misoprostol (with additional misoprostol provided if required).
      Results: At the time of consultation, 77% reported gestational age under seven weeks, and 23% between seven and nine weeks. Abortions typically occurred between five and 21 days later (women were strongly discouraged from performing abortion after 12 weeks gestation). Virtually all women (99.0%) were able to end their pregnancies and 95.1% were able to do so without surgical intervention. Three women (0.2%) required a blood/blood product transfusion and 23 (1.9%) were given antibiotics. Nine percent of women reported bleeding lasting more than two hours soaking more than two maxi pads per hour; fever >39C or purulent discharge; or pain persisting several days postabortion. Among women reporting these possible symptoms of serious complications, 97% sought timely medical care (the other 3% suffered no harm). Among women not reporting a potentially serious complication none received treatment for one.
      Conclusions: Despite a variety of gestational ages (including some beyond nine weeks) and the likely possibility that some providers performed surgical intervention and prescribed antibiotics unnecessarily, findings show that medical abortion provided outside the formal healthcare setting is highly effective and safe. Crucially, women are able to self-identify potentially serious complications and seek appropriate and timely medical assistance.

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      Disparities in access to first trimester legal abortion in the public sector in Mexico City: Who presents past the gestational age limit?

      Blair G. Darney1 ,2, Biani Saavedra-Avendano1, Patricio Sanhueza4, Raffaela Schiavon3
      1National Institute of Public Health, Cuernavaca, Morelos, Mexico, 2Oregon Health & Science University, Portland, OR, USA, 3International Pregnancy Advisory Services, Mexico City, Mexico, 4Mexico City Ministry of Health, Mexico City, Mexico

      Objective: First trimester abortion was decriminalised in Mexico City in 2007; laws in Mexico’s other 31 states remain restrictive. Women who present for care past 12 weeks are not able to receive services. The objective of this study was to identify factors associated with presenting for public abortion services past the gestational limit.
      Methods: We conducted a retrospective cohort study using clinical data from the public abortion programme in 2011 and 2012. Our primary outcome was receipt of abortion services. We compared characteristics of women who did not receive abortion services with those who received either medical or aspiration abortion. We used multivariable logistic regression to identify associations between client characteristics and our primary outcome, controlling for socio-demographic and clinical confounders.  
      Results: Our sample included 22,945 women, 73.1% of whom had a medical, and 18.3% an aspiration abortion; 8.6% of the sample (n=1935) did not receive abortion services due to presenting past the gestational age limit. Adolescents (aged <18) made up 14.2% of the total sample and 32.7% of women came from outside Mexico City. In multivariable analyses women who travelled from the nearby State of Mexico (aOR=0.89; 95%CI=0.79–0.98) or from another state (aOR=0.83; 95%CI=0.67-0.99) both had lower odds of receiving services, compared with women living in Mexico City. Adolescents had lower odds of receiving services compared with adults (aOR=0.67; 95%CI=0.58-0.77). Women with basic educational levels (aOR=0.71 and 0.72 for primary and secondary versus high school or higher), or who had not experienced a previous pregnancy (aOR=0.79; 95%CI=0.69-0.90) had lower odds of receiving services.
      Conclusions: Factors associated with delay in seeking abortion services in Mexico City’s public abortion programme include distance travelled, younger age, nulliparity and low education level. Our results can be used to support efforts to promote earlier recognition of pregnancy and timely assistance to access services.

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      Seeking clandestine abortion safely: Unwanted pregnancy and medical abortion among young women in Dar es Salaam

      Ingrid H. Solheim1 ,2, Catherine Kalabuka3, Karen-Marie Moland1 ,2, Andrea B. Pembe4, Astrid Blystad1 ,2
      1Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway, 2Centre for International Health, University of Bergen, Bergen, Norway, 3CSK Research Solutions, Dar es Salaam, Tanzania, 4Muhimbili University of Health and Associated Sciences, Dar es Salaam, Tanzania

      Objective: The aim of this project was to enhance knowledge about the challenges faced by young women with unwanted pregnancies living in an urban, low-income settings where abortion is criminalised but assumed to be performed clandestinely with increasing off-label use of the recently registered drug misoprostol.
      Methods: The study was explorative, involving the use of in-depth interviews with women ≤ 25 years having performed medical abortion (n = 15), postabortion care providers (n = 16) and pharmacy workers (n = 10) and informative interviews with different stakeholders (n = 15). Focus group discussions (FGDs) were performed with women from low-income areas and students ≤ 25 years (n of FGDs = 10).
      Results: To induce abortion is viewed as a common practice by young women in Dar es Salaam. While hospitals are often considered the safest providers of abortion, misoprostol is viewed by many as the best method. Misoprostol is perceived to be more accessible, simple to use, private, cheap and less dangerous compared to surgical hospital procedures. Many health workers experience fewer and more manageable complications among their postabortion care patients related to misoprostol use for abortion. However, girls often view the procedure as a ‘matter of chancing'.  Low drug doses are typically used, and there is little follow-up and lack of information from vendors concerning potential complications. Finally, even though ‘miso' is commonly known among young women, traditional methods are still the cheapest and therefore the only option for some.
      Conclusion: In Dar es Salaam misoprostol can be accessed clandestinely for pregnancy termination through drug stores or health facilities offering different levels of safety and costs. For many young women this is the preferred abortion method but use, and especially safe use, is limited to those who can afford it.

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      Efficacy of very early medical abortion

      Isabella Bizjak1, Christian Fiala2, Helena Kopp Kallner1, Ingrid Sääv1, Kristina Gemzell-Danielsson1
      1WHO CCR, Department of Women´s and Children´s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Stockholm, Sweden, 2GynMed Clinic, Vienna, Austria

      Background: In countries which have introduced medical abortion an increasing number of women present very early for their abortion. However due to limited data and fear of an adverse effect on a possible ectopic pregnancy many health care providers are reluctant to initiate the abortion treatment before an intrauterine pregnancy can be visualised and therefore tend to delay the treatment. This study was conducted to assess the effectiveness and safety of medical abortion in women with very early pregnancy (VEMA) and no confirmed intrauterine gestation (IUG).
      Methods: Register based multicentree cohort study comparing women undergoing very early medical abortion (gestations ≤49 days) with or without a confirmed intrauterine pregnancy (i.e. yolk sac or foetal structure) at the initiation of the abortion treatment. 435 women without confirmed IUG were identified and compared with 870 controls with confirmed IUG, matched with regard to age, parity and date of initiation of abortion treatment.
      Results: Women with no confirmed IUG were not more likely to experience VEMA failure (i.e. ongoing pregnancy or incomplete abortion) than those with gestations ≤49 days and confirmed IUG.  Ectopic pregnancies (n=3) were diagnosed and treated without any serious adverse events.
      Conclusion: VEMA failure is not more likely in women with very early pregnancy and no confirmed IUG on ultrasound than those with gestations ≤49 days and confirmed IUG. Hence our findings support that VEMA is both effective and safe for terminating pregnancies in women with no confirmed IUG. Women should, therefore, not be subject to unnecessary delay but should be offered medical abortion accordingly.

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      Contraception needs and induced abortion in China: two cross-sectional studies

      Wei-Hong Zhang1 ,2, Shangchun Wu3, Marleen Temmerman1 ,4
      1International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium, 2Research Labouratory for Human Reproduction, Faculty of Medicine, Université Libre de Bruxelles (ULB), Brussels, Belgium, 3The national Research Institute for Family Planning (NRIFP), China, Beijing, China, 4The department of Obstetrics and Gynecology, Women’s health Centre of Excellent East-Africa, the Faculty of Health Science, Aga Khan University, Nairobi, Kenya

      Objective: In China, the official estimated annual number of induced abortions ranges from 7 million to 13 million in recent years. Chinese family planning (FP) services, with a major concern on birth control among married couples, have been a political priority for more than thirty years prior to the two child policy implemented recently.  Abortion is commonly used to end unintended pregnancy. This study aimed to describe the characteristics of abortion seekers in two, time periods of studies in China.
      Methods: Two cross-sectional surveys were conducted in 2005 and 2013 respectively and similar methods were used for collecting data.  A questionnaire was completed by abortion service providers for all women seeking abortion within 12 weeks of pregnancy during a period of two months. The information included self-reported demographic & economic characteristics, history of induced abortion and practices regarding contraception. Twenty-four hospitals from 3 cities in 2005 and 295 hospitals from 30 provinces in 2013 participated in the studies, respectively.
      Results: Total numbers of participants consisting of 7291 in 2005 and 79,174 in 2013 were included in the analysis.  A higher proportion of subsequent induced abortions were reported in 2013 (65%) than in 2005 (35%).  The main reason of current unintended pregnancy was non-use of any contraception (65.1%) in 2005 and failure of contraception (50.3%) in 2013. Condoms were the most used contraceptive method among married and unmarried women in both periods of studies, but the proportions of consistent and correct utilisation of condoms were low in both time periods. 
      Conclusion: The large numbers of induced abortions are primarily due to contraceptive failure or no use of contraception. Postabortion FP services are often lacking in hospital settings where the majority of induced abortions were performed. Integrating postabortion family planning into the existing health system is urgently needed and is an opportunity and a challenge in China.

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      Stigma associated with abortion is influencing choice to provide or sidestep abortion services

      Asifa Khanum1, Syed Kamal Shah1, Nadeem Mahmood1, syed Mustafa Ali2
      1Rahnuma FPAP, Lahore, Pakistan, 2Individual Consultant, Lahore, Pakistan

      There is little evidence available on the manifestation of abortion stigma in Pakistan. There is marginalisation of abortion services within medical settings through its negligible inclusion in curriculum, knowledge about abortion law in Pakistan, perceptions about abortion and religion, socio-cultural disapproval, etc. These factors all contribute in the decision of healthcare providers to provide or sidestep abortion services. A research study was designed to understand the expression of stigma associated with abortion by service providers providing abortion services and those not providing these services.
      Methods: A mixed method exploratory study was designed to understand perspectives of both types of service providers. Due to restrictive abortion law and taboos that are stigmatising abortion services and its providers, data was collected from 40 providers providing abortion services and 40 non-providers of these services from reference facilities in 4 districts of Pakistan. Basic descriptive analysis was carried out using SPSS.
      Results: It is evident from analytical findings that the knowledge base of service providers on abortion law in Pakistan, perceptions about its religious permissibility, internalisation of negative community perceptions about abortion service providers and stigmatisation of women seeking abortion services are pertinent attributes influencing provider choice of extending abortion services or not.
      Conclusion: In an effort to de-stigmatise abortion, immediate measures are required at various levels such as: integration/institutionalisation of essential contraceptive services including safe abortion services, formal/informal education and knowledge about abortion laws as explained by Shariat Court of Pakistan, Value Clarification and Attitudes Transformation (VCAT) workshops for providers, and behaviour change communications and education strategies for sensitising communities.

    Concurrent session 02: Catholics for choice. I walk the line: when abortion is a crime
    • Jon O´Brien, US
    Concurrent session 03: FIAPAC masterclass
    • Joaquim Neves, PT
    • Mirella Parachini, IT
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      Abortion in women with cardiac disease

      Oskari Heikinheimo
      Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland

      The presentation will cover:
      Presentation of cardiac conditions and their treatment in which continuation of pregnancy predisposes the woman to high-risk of cardiac or obstetric complications. These include conditions such as history of cardiomyopathy (especially with comprised cardiac function), pulmonary hypertension and/or conditions in which cardiac disease or its treatment requires anticoagulation or treatment with teratogenic medication(s);
      Management of abortion (either medical or surgical) in women with cardiac disease, especially as concerns management of haemodynamics, and current recommendations concerning anticoagulation and possible antibiotic prophylaxis;
      Recommendations concerning multidisciplinary treatment of women with underlying cardiac disease faced with unwanted pregnancy and situations where continuation of pregnancy is considered contraindicated.

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      Abortion in women with haematological disease

      Alison Edelman
      Oregon Health & Science University, Portland, Oregon, USA

      Controversy exists regarding the management of haematological diseases in women undergoing abortion. However, the overall risk of either haemorrhage or thrombosis is extremely rare in women undergoing abortion; as such, little change is likely to be necessary in the management of these women other than increased vigilance. Consideration of clinical setting, availability of emergency resources and gestational age may influence clinical management but will vary with the type and severity of the disorder and its risk of "bleeding" or "clotting".  Anecdotally clinicians prefer aspiration or surgical abortion over medical in women at risk for bleeding because of the ability to control and monitor bleeding directly.  As pregnancy exponentially increases the risk of thrombosis, a woman's choice to end the pregnancy returns her risk back to baseline. Measures to prevent bleeding and clotting and the evidence behind them will also be included. Finally, one of the most important aspects of the care for women with haematological diseases is the prevention of and planning for the next pregnancy as well as the non-contraceptive benefits that can be obtained from the use of a contraceptive method for these women.  The current literature will be discussed as well as a brief review of the common haematological disorders likely to be encountered and a practical approach to the clinical management of these patients.

    Concurrent session 04: European Society for Contraception and Reproductive Health: Improving abortion care and postabortion contraception
    • Eduardo Lopez Arregui, ES
    • Ingrid Sääv , SE
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      Improving access to abortion care

      Sam Rowlands
      Bournemouth University, Bournemouth, UK

      The following ways of overcoming barriers to access to abortion will be presented: Elabouration by Health ministries as to precisely what the abortion law allows; Exemptions or reimbursement in jurisdictions in which women have to pay for abortions; Drafting by professional societies of country-specific abortion guidelines or dissemination of international guidelines for the benefit of health care professionals; Advocacy by clinicians for improved clinical standards in abortion care; Wide dissemination of information about abortion services to allow choice for women; Availability of medical and surgical methods of abortion at all legal gestations; More first trimester procedures offered within a primary care setting; The option of making appointments via a centralised booking system; Delivery of services as close to women’s homes as possible; Special arrangements for women who live far away from cities or towns; Seamless care pathways for the whole of a woman’s journey; Greater participation in all elements of abortion procedures by staff other than doctors; Tightly regulated and monitored conscientious objection; Information and postabortion care provision by clinicians in jurisdictions in which self-administered abortion is prevalent.

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      Intrauterine contraception after medical abortion

      Ingrid Sääv1 ,2, Kristina Gemzell Danielsson1
      1Karolinska Institutet, Stockholm, Sweden, 2Norrtälje Hospital, Norrtälje, Sweden

      Background: Today a large proportion of early abortions are medical terminations, in accordance with the woman's choice. Intrauterine contraceptives (IUC) provide highly effective, reversible, long-acting contraception but the effects of timing of IUC insertion after medical abortion are not well known. Routine insertion after the first menstruation means an obvious risk of a new pregnancy.
      Methods: Women undergoing early medical abortion with mifepristone and misoprostol up to 63 days gestation and opting for IUC were randomised to early insertion (day 5-9 after mifepristone) or delayed (routine) insertion (at 3-4 weeks after mifepristone). The primary outcome was the rate of IUC expulsion six months after IUC insertion. Secondary outcomes were rate of insertion, use at 6 and 12 months, and adverse events.
      Results: A total of 129 women were randomised and 116 women had a successful IUC insertion. There was no difference in expulsion rate between the groups (p=0.65) with 6 expulsions in the early insertion group (9.7%) compared to 4 in the late insertion group (7.4%). Significantly more women returned for insertion in the intervention group (p=0.03) and more women (41%) had unprotected intercourse prior to insertion in the delayed group (p=0.015). Adverse events were rare in both groups.
      At the follow ups no differences could be found in regard to bleeding patterns, menstrual pain or compliance with the IUC.
      Conclusions: Early insertion of IUC after medical abortion is safe and well tolerated with no increased incidence for expulsions or complications. Women are more likely to return for the IUC insertion if scheduled early after the abortion and less likely to have had an unprotected intercourse prior to insertion. Early insertion should be offered as a routine for women undergoing first trimester medical abortion.
      Key words: IUC, medical abortion, insertion, intrauterine contraception

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      Quickstarting implants after medical abortion

      Helena Kopp Kallner
      Karolinska Institutet, Stockholm, Sweden

      Given the choice, the majority of women in the first trimester choose medical rather than surgical abortion. In Europe, and globally, a significant proportion of women having an abortion have had one or more previous abortions. Long acting reversible contraception reduces subsequent abortions in women. In studies, women resumed sexual intercourse quickly and are thus at risk for unintended pregnancy if effective contraception is not provided. Immediate postabortion initiation of long acting reversible contraception is therefore desirable and recommended by guidelines.
      Implants are the only long acting contraception which can be provided at the same time as the initial abortion medication. However, theoretically treatment with a progestin could affect the binding of mifepristone to the progesterone receptor.
      Several pilot studies have reported implant insertion at the time of mifepristone in medical abortion. In addition, there is one randomised study performed in Mexico and the United States and one randomised study performed in Sweden and Scotland. Women were randomised to implant insertion at the time of mifepristone ingestion or at follow up. These studies show that implant insertion at the time of the mifepristone is safe and acceptable for women. In addition, the efficacy of the medical abortion is not affected. In the study from Mexico and the United States insertion rates differed between countries and no difference could be shown in unintended pregnancy at the 6 month follow up. The study from Sweden and Scotland had similar insertion rates to women recruited in the United States. There was a significant difference in unintended pregnancy at the 6 month follow up between the immediate and delayed insertion group.
      Thus, immediate insertion of implants is safe and acceptable and may prevent subsequent abortions as early as 6 months postabortion.

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      Avoiding unwanted pregnancies in Zagreb

      Vesna Stepanic, Vlastimir Kukura
      Clinical Hospital Merkur, Zagreb, Croatia

      An unwanted pregnancy is associated with an increased risk of serious problems for the mother and baby.
      According to the Croatian National Institute of Public Health, in 2014, there were 3,020 legal terminations of unwanted pregnancies in Croatia - less than in previous years. It is unclear whether the reason for the decrease is that the abortion rate is actually decreasing or because of inappropriate data collection.
      Contraception and termination of unwanted pregnancies are closely related. Reproductive health education should emphasise the necessity of contraception use if there is no chance to cope with an unwanted pregnancy, no matter what reasons a woman might have for such a decision.
      Improved education and counselling about responsible sexual behaviour is considered to be the optimal method of decreasing the number of unwanted pregnancy terminations.
      To this end, the first symposium on “Avoiding Unwanted Pregnancies” with assistance and a grant from the European Society of Contraception and Reproductive Health, was held in Zagreb in May 2015.
      The Symposium was dedicated to addressing the global public health problem of unwanted pregnancies by convening experts involved with this issue to engage in lively discussion, develop conclusions and propose guidelines for further action in terms of counselling and education about responsible sexual behaviour.
      In conclusion, the necessity of counselling and education about responsible sexual behaviour was emphasised, as well as the necessity of having further discussion about the institution of conscientious objection and about changes in laws regarding pregnancy termination.
      The organiser warmly hopes that the importance of the Symposium will be recognised by national authorities. However, this issue is also a political problem and no matter how much the professionals want to do there are limits that are established by the government and social constraints.

    Concurrent session 05: European Consortium for Emergency Contraception
    • Elisabeth Aubény, FR
    • Cristina Puig, ES
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      Quick starting after emergency contraception (EC

      Sharon Cameron
      NHS Lothian, Edinburgh, UK

      Meta-analyses have shown that women who have further episodes of unprotected sex in the same cycle after taking oral EC have a two- to three-fold higher risk of pregnancy than women who do not. This raises the importance of quick starting a regular method of contraception immediately after EC is used. Guidelines advise that when quick starting a hormonal method after taking levonorgestrel for EC, that women use barrier methods/ abstinence for the standard numbers of days until contraceptive effectiveness of the method if achieved (e.g. 7 days for combined hormonal methods, 2 days for progestogen only pills- POP). Since Ulipristal acetate (UPA) is a progesterone receptor modulator, quick-starting a hormonal method after UPA could in theory alter the effectiveness of hormonal contraception by competition at the receptor site or vice versa. Two RCTS have addressed this. One examined the effect of UPA followed by COC on ovarian quiescence and suggested that UPA does not affect the contraceptive efficacy of COC. This study was not designed to examine a potential impact of COC on UPA. The other study examined UPA followed by POP (desogestrel) and also suggested that UPA does affect the contraceptive action of POP. However, this study indicated that commencing a POP 24hrs after UPA can prevent the ability of UPA to delay ovulation. In view of this, women who wish to commence hormonal contraception after UPA for EC are advised not to quick start. Interim guidance from the Faculty of Sexual and Reproductive Healthcare UK, advise that women wait at least 5 days after UPA before commencing hormonal contraception.

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      IUD for EC

      David Turok
      University of Utah, Salt Lake City, Utah, USA

      Widespread availability of oral emergency contraception (EC) has failed to have a public health effect on reducing unintended pregnancies. The EC visit presents an opportunity to initiate a highly effective method of contraception in a population at high risk of unintended pregnancy at a time when they actively seeking to avoid pregnancy. The copper IUD is the most effective method of EC and continues to provide contraception as effective as sterilisation for up to 12 years; it should be offered as the first line method of EC wherever possible. Clinic-based EC visits should include access to the copper IUD as optimal care and should ideally include access to all highly effective methods of contraception. At the conclusion of this programme, participants will be able to:

      • Provide women with user specific recommendations for the most effective methods of EC
      • Optimise strategies for the use of the copper IUD as EC and initiating highly effective methods of contraception
      • Identify opportunities to initiate highly effective contraception with EC
  • 15:30-
  • 16:00-
    Information & availability
    • Andreja Štolfa Gruntar, SI
    • Alberto Stolzenburg, ES
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      The Turnaway Study: Women’s experiences five years after receiving versus being denied a wanted abortion

      Diana Foster
      University of California, San Francisco, Oakland, CA, USA

      The Turnaway Study is a longitudinal study of nearly 1,000 women who sought abortions from thirty abortion facilities across the United States between 2008 and 2010. We followed women just above and just below facility gestational limits to examine what happens to women when they have abortions and when they are denied, wanted, abortions. Findings from this study have been used to inform U.S. Supreme Court cases and Senate Committee hearings. It has produced data for 25 scientific papers on multiple aspects of women's experiences with unwanted pregnancy such as reasons for choosing abortion, experiences finding and receiving an abortion and emotional responses to abortion and childbirth. We have completed five years of data collection. In this panel the principal investigator will share results on women's physical health, mental health, emotions, relationships, socioeconomic wellbeing, subsequent pregnancies and the wellbeing of their children. We find no mental health harms from either abortion or birth following abortion denial but significant economic hardships among women denied, wanted, abortions compared to women who receive an abortion. We also find negative consequences for women's existing children and new child if they are forced to carry a pregnancy to term.

      Women are thoughtful, even prescient, in the reasons they give for wanting to terminate a pregnancy. Their concerns around economic security, relationships with the man involved and ability to care for existing children are born out in the experiences of women denied a wanted abortion. Understanding the real consequences to women's lives of abortion and unwanted childbearing is essential to informing policy and providing reproductive health care. These data also help us to identify groups of women who may need additional support after abortion and to support policies to improve abortion access and mitigate the harms of being denied a wanted abortion.

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      Expanding providers and task sharing

      Helena Kopp Kallner
      Karolinska Institutet, Stockholm, Sweden

      In many countries the access to medical doctors in abortion care is limited either by a general shortage of medical doctors or by the unwillingness of medical doctors to be involved in abortion care. Specially trained, midlevel providers can often perform services generally performed by physicians. In abortion care the evidence in support of midlevel provision of surgical and medical abortion and postabortion care is increasing.
      In some countries midlevel providers perform primary vacuum aspiration for surgical abortion and in low resource settings midlevel providers supply medication and information and thereby perform medical abortions. Medical abortion provided by midlevel providers in a low resource setting has been evaluated in a large randomised trial in Nepal and was found to be safe and effective.
      In high resource settings abortion is usually provided after an ultrasound provided by a trained physician. However, access to appointments for ultrasound may, in fact, increase the waiting time to have an abortion. In a large randomised trial it has been shown that trained midlevel providers can perform early medical abortion including the ultrasound as part of standard care as effectively and safely as physicians.
      Women in countries where abortion is illegal often self induce abortions surgically or medically. Denied health care due to complications contributes to maternal morbidity and mortality. Midlevel providers who supply postabortion care including manual vacuum aspiration for incomplete abortion have been shown to be safe and effective. In a large randomised trial it has been shown that trained, midlevel providers can perform postabortion care as effectively and safely as physicians in rural as well as in urban settings in Africa.

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      Challenging stigma and the undesirable: late presentation and multiple abortions

      Lisa McDaid
      University of Glasgow, Glasgow, Scotland, UK

      ‘Repeat' and ‘late' abortion are often framed as problematic, and there is continuing concern from a policy and provision perspective about the proportion of women presenting for ‘repeat' and ‘late' abortions. This presentation draws on findings from two studies of women in Scotland to demonstrate how and why such framings should be challenged.
      In 2013, we completed an audit of 281 women presenting for abortion at ≥ 16 weeks gestation in Scotland and conducted qualitative interviews with 23 of these. Women presenting later were young and a significant proportion were from more deprived areas. Our qualitative analysis suggested that reasons for later presentation were complex, varied and highly context-specific, with the majority having not expected to become pregnant. Factors which necessitated later abortion were often unforeseen and thus not easily amenable to intervention.
      In 2015, we collected questionnaires from 1662 women presenting for abortion and completed qualitative interviews with 23 women identified as having undergone a previous abortion in the preceding two years. 34% reported a previous abortion, while just under half of these reported two or more in the previous two years. Age, education, deprivation and experience of domestic abuse were associated with having had more than one abortion. Our qualitative data suggested more commonalties than divergences between experiences of women who have undergone more than one abortion and those who have not.
      The presentation will address how a disproportionate focus on ‘repeat' and ‘late' abortion' exacerbates stigmatisation and distracts from a more productive focus on improving abortion provision, when in fact it appears women in this position are no different from all women seeking abortion. I will conclude by discussing how efforts could be better spent focusing on how to improve the experiences of women seeking abortion and working to challenge prevailing, negative, social attitudes to abortion.

  • 18:00-
  • 20:00-