Berlin, 24-26 Ottobre 2008: „Reproductive Health and Responsibilities“
11:15Society’s Responsibilities for Reproductive HealthChair:
- Mirella Parachini, IT
- Sybill Schulz, DE
Access to safe legal abortion in developing countries
Anibal Faundes (Brazil)
Maternal Mortality is almost 100 times higher in some developing countries than in the developed world and unsafe abortion is one of the main contributors to maternal death in developing countries where abortion is not legal. Maternal Mortality due to unsafe abortion depends on the rate of induced abortion, the proportion of induced abortion that are unsafe and the severity of the risk. There are no major differences in induced abortion rate between developed and developing countries, except that the largest rates are observed in Eastern Europe and the lowest in western Europe. The large difference is in the rate of unsafe abortion, which is around 30 per 1000 women in fertile age or over in developing countries and negligible in Western Europe and North America. Even greater is the difference in the risk of dying as a consequence of unsafe abortion. While one out of every 130 women with induced abortion die in Eastern Africa and one out of every 120 in Western Africa, the risk of dying after an induce abortion is practically nil in developing countries.
The main determinants of unsafe abortion, apart of the rates of unplanned, unwanted pregnancies, are the legal situation of abortion in each country and the the access to safe abortion in the full extent of the law. While more than 90% of abortions are legal and safe in developed countries, less than 50% are legal in the less developed world. Moreover, even women who fulfill the requirement of restrictive laws do not have access to abortion due to administrative, professional economical and health system barriers. The lack of access to safe abortion and its social and health consequences for women in developing countries is one of the most unfair imbalances between rich and poor countries. The society in general cannot remain indifferent to the suffering of so many women and as physicians, it is our responsibility to fight against this injustice. FIGO is assuming its part through the Initiative for the Prevention of Unsafe Abortion, currently including 54 countries with high induced abortion and unsafe abortion rate.
Society’s responsibility to provide a legal setting
Christian Fiala (Austria)
Gynmed Clinic, Vienna, Austria
For most women, the diagnosis of an unwanted pregnancy is unexpected. Women are therefore unprepared for either carrying the pregnancy to term or having an abortion. They need a great deal of information within a very short space of time. If they decide to terminate the pregnancy, they must have fast access to medical facilities.
This presentation analyses legal requirements and regulations in European countries to see how far they support women in finding a solution.
Societies react differently to the needs of women, but the past was largely dominated by a rigid paternalism, coupled with the belief that pregnant women could not responsibly make decisions regarding their own pregnancy. Society therefore “had” to intervene in order to ensure that the “right” decision was made. People who were not directly involved with these unwanted pregnancies dominated the public debate and decided on the relevant laws. Not surprisingly, they operated on wrong assumptions or basic misunderstandings of how a pregnant woman should be treated and cared for.
Huge progress has been made in the last few decades to overcome this approach and respect women and their needs, including the legalisation of contraception and abortion. However, there are still many remnants of the old thinking, such as obligatory waiting (“cool off”) periods of an arbitrary number of days or mandatory ‘counselling’, even though counselling is voluntary by definition.
There is no evidence that these restrictions are of any benefit. They do, however, cause delays in the provision of treatment and have negative effects on the physical and psychological health of those affected. Examples and comparisons of European countries are given in the presentation.
What happens if society opts out?
Vicki Saporta (United States)
National Abortion Federation (NAF), United States
Abortion has been legal in the United States since the Supreme Court decided Roe v. Wade in 1973. However, during the last thirty-five years, abortion opponents have launched legal, legislative, and judicial challenges that have resulted in more restrictions and obstacles being placed in the way of women seeking abortion care. The most onerous of these restrictions is the lack of public funding for abortion care. In the United States where abortion is legal and safe, access continues to be a challenge especially for low-income women.
In the United States, low-income individuals rely on the government for basic and long-term health care. Medicaid is the joint federal-state program that finances health care for 55 million low-income people. In 2006, 37% of women of reproductive age in families with incomes below the Federal Poverty Line were enrolled in Medicaid, according to the Guttmacher Institute.
When abortion was legalized in 1973, Medicaid covered abortion care without restriction. In 1976, Congress passed a provision to limit federal funding for abortion care. Current law requires coverage of abortion only in cases of rape, incest, and life endangerment; however, it can be very challenging for a woman to actually obtain a publicly-funded abortion even in these limited circumstances. The Guttmacher Institute has found that 20-35% of Medicaid-eligible women who would choose abortion carry their pregnancies to term when public funds are not available.
When society opts out of providing women access to abortion care, the burden is shifted to the private sector. Since 2001, NAF has been operating a modest Patient Assistance Fund through our toll-free Hotline. With limited resources, we were only able to fund the most desperate cases and often had to turn away more women than we were able to help. However, through increased private sector funding, we are now able to subsidize the cost of abortion care for low-income women at or below 150% of the Federal Poverty Level. In order to be eligible for this funding, a woman must live in one of the 35 states or the District of Columbia where Medicaid does not cover abortion except in very limited circumstances, and obtain abortion care at a NAF member clinic. We have received hundreds of letters from women thanking us for helping them obtain abortion care that they otherwise would not have been able to afford.
Low-income women are four times as likely to experience an unplanned pregnancy as higher-income women, according to the Guttmacher Institute. It is incumbent upon us to continue to use the voices of these women to educate the public about the barriers low-income women face when accessing abortion care, and the necessity for public funding. When society opts out, the private sector becomes critical in helping women obtain the abortion care they need.
14:00Benefits and risks of abortionChair:
- Elisabeth Aubény, FR
- André Seidenberg, CH
Consequences of unwanted childbirth: Outcomes for women and unwanted children
Catherine Bonnet (France)
Unwanted childbirth is still a reality in developed countries on 2008. For centuries unwanted childbirths were part of any family life until the end of the XIX century when society began to manage the beginning of the contraception. On the second part of the XX century it was possible to say “a baby if I wish and when I wish”. In spite of legalized abortions, they are still women who discover from the second trimester until the birth pregnancy unplanned, babies unwished.
Clinical consequences of unwanted childbirth. Every birth is a personal history case but it may be interesting to describe several types of cases:
- The baby is well welcome, the healthcare are surprised.
- The baby is given up for adoption with a clear wish and without any external pressures
- The mother is unable to make a decision whether to keep or to give up the baby as the results of personal difficulties, the healthcare professionals are in distress.
- The mother would like to make a decision which is opposite to her family, partner.
- The mother expresses negative thoughts towards the baby and would like to keep it.
- The mother expresses a decision but is unable to make it because she is overwhelmed by external pressures: society, religion, politic.
- The mother has given up her newborn baby but changes her mind few hours later.
- The mother refuses to give her identity but the anonymous delivery does not still exist in the law.
- The baby has been killed or abandoned on a public place, the mother is brought to the maternity to deliver the placenta.
How to reduce the negative outcomes for both children and women?
- To detect denied, hidden, neglected pregnancies
- To offer a multidisciplinary support (social, psychological, juridical) as soon as they book their first appointment.
- To help women/adolescent to speak out the future of the newborn even if they unwanted to keep the baby.
- To support their decision-making and protect women/adolescent from external pressures.
- To plan a place where they will get a good welcome while they will deliver.
- To speak about the choice of anonymous birth if this is possible in the country.
- To train healthcare professionals and especially midwifes and nurses.
Outcomes for women based on psychological background
Sharon Cameron (Scotland)
University of Edinburgh, Scotland
It has been claimed that the decision to terminate an unwanted pregnancy can lead to mental health problems for women. However, childbirth can be a physically and emotionally demanding time for mothers and many studies have demonstrated an increase in depression and anxiety post-partum. There has been a lack of research on the long term mental health of women choosing an abortion. Of those studies which have been published, many have suffered from methodological problems or failed to account of possible confounding factors.
Recently, a systematic review of the literature relating to mental health of women following abortion, was conducted by the American Psychological Association. This concluded, based upon the available evidence, that among adult women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single first trimester abortion, than if they deliver that pregnancy.
Whilst there may not be a causal link between abortion and mental health problems, nevertheless some women do experience negative psychological responses including depression and anxiety. Risk factors that have been identified include ambivalence about the decision to have the abortion, whether the pregnancy was originally intended, lack of a supportive partner, a psychiatric history and membership of a cultural group that considers abortion to be wrong. Some of these risk factors are also predictive of mental health problems following childbirth.
Further, more robust and definitive research studies are required on mental health after both abortion and alternative reproductive outcomes such as childbirth or miscarriage
Physiological and reproductive outcomes
Michel Tournaire, Sophie Gaudu, Philippe Faucher (France)
Surgical abortion. The influence of surgical abortion on subsequent reproductive outcome, reported for several decades in the literature can be summarized with seven criteria.
- Fertility. Four studies did not find an increased infertility after surgical abortion and one retrospective study showed a slight increase.
- Uterus. Synechiae have been diagnosed by hysteroscopy in 17 to 30% of the cases after curetage and 7.7% after suction.
- Miscarriage. In five studies from 1986 to 1998 the incidence of miscarriage after surgical abortion was not significantly increased. In a large series published in 2000 the risk of miscarriage was increased if the interval between abortion and the following pregnancy was lower than three months.
- Ectopic pregnancy. In seven studies no association was found between past history of surgical abortion and ectopic pregnancy, but two studies found such an association.
- Placental abnormalities. In nine studies there was an inceased risk of placenta praevia (OR 1.7 in a metaanalysis) after curetage but not after suction. The frequency of placenta accreta was not higher in two studies.
- Prematurity. In a metaanalysis published in 2003 twelve studies found a higher riskof prematurity (OR 1.3 to 2). In seven studies the risk increased with the number of previous surgical abortions. Eight found an increased risk for severe prematurity (<32w). However in the two most recent studies there was no augmentation of prematurity.
- Preeclampsia. In a majority of studies the ratio of pre eclampsia after induced abortion was reduced but only with women conceiving again with the same partner.
Medical abortion. Despite the increasing proportion of abortion by means of medication, limited information is available regarding the effects of this procedure on subsequent pregnancies.
A recent (2008) metaanalysis including eight studies on reproductive outcome compared the influence of medical and surgical abortion. The incidence of miscarriage and post partum hemorrage was significantly lower for the pregnancy immediatly following a medical abortion. No other significant difference was found.
For the outcome of the future pregnancies, medical abortion may thus be safer than the surgical option.
Psychological impacts on men
Ann Lalos (Sweden)
Department of Obstetrics and Gynecology, Umeå University, Umeå, Sweden
In general, men involved in induced abortion constitute an invisible group and there is scarcely any knowledge about their reactions and reflections. Thus, to increase knowledge and understanding of the complexity of the abortion situation 75 Swedish men involved in abortion were studied.
Most men were found to live in stable relationships with a financially good position. A quarter had previously experienced an abortion. Wanting an abortion did not imply that the men experienced their standpoint as easily conceived. Contradictory feelings towards the pregnancy appeared among more than one third and more than half used both positive and painful words to describe their feelings in connection with the abortion. Nearly half of those who solely expressed positive initial feelings towards the pregnancy also stated that they wanted an abortion.
Twenty-six of the men participated in a follow-up study 4 and 12 months post-abortion. Nearly all of them were happy with the women’s decision to have an abortion at both follow-ups. They experienced the abortion as a relief and a responsible act. Simultaneously, abortion could also be experienced as a painful and ethically problematic act. Overall, most men had only positive experiences post-abortion, such as a feeling of maturity. However, it was also found that 1-year post-abortion, more than a third consistently did not use a reliable contraceptive method.
For deeper understanding of the complexity of the abortion situation it is of great importance that men’s ambivalence and experienced paradoxes also become visible. In the work to prevent induced abortions it is of fundamental importance that a gender perspective is incorporated.
16:00Workshop 1 Induced abortionChair:Workshop 2 Immigrant women
- Gabriele Halder, DE
- John Spencer, GB
Chair:Workshop 3 How to change restrictive laws
Experiences of health care professionals
André Seidenberg (Switzerland)
Not only by the general public but also by health professionals induced abortion is regarded as something special. Emotional, ethical, and psychological considerations were inevitable and a matter of course. We conducted a little survey on opinions and measures in the region of Zurich, Switzerland. Medical directors of gynaecological clinics take precautions for their staff, who is involved in induced abortion treatment.
Risk management in abortion care
Sam Rowlands (Great Britain)
University of Warwick, Coventry, United Kingdom
The aim of risk management is to identify potential risk and thereby reduce untoward events and the loss and harm that may result. An error in management of a client which leads to an adverse event can be termed an incident. An incident that is narrowly avoided can be termed a near miss. Near misses occur at higher frequency than actual incidents, yet with limited impact; they are rich learning material. Examples of incidents are: procedure performed on the wrong client, wrong procedure performed, inaccurate gestational assessment leading to commencement of inappropriate procedure, IUD inserted/not inserted after abortion in error, anti-D given/not given in error, client intercepted at clinic entrance by protestors.
It is necessary to create a no-blame culture in the workplace. Errors are the result of human failure, but there is often a systems component in the background. Self-reporting of errors (one’s own or other people’s) is encouraged. This should be done at the time of the incident by filling in a specially-designed form. During discussions about incidents, the anonymity of those who have reported incidents should be preserved. When harm has been done, it is good practice to give a detailed explanation of what went wrong and to say sorry to the client; this is not admitting legal liability. General ways of reducing risk include: designing procedures to counteract error and taking complaints seriously. Specific ways of reducing risk include: adequate consent procedures, routine ultrasound scanning, having a low threshold for transferring a client to hospital from a free-standing clinic if events deviate from the normal pathway, supplementary security measures (for instance access control system, panic buttons, police liaison).
Should gynaecologists be obliged to perform abortions?
Marc Bygdeman (Sweden)
Department of Woman and Child Health, Division for Obstetrics and Gynecology, Karolinska Hospital, S171 76, Stockholm, Sweden
In 1999 the U.N. General Assembly agreed that “where abortion is not against the law, health systems should ensure that such abortion is safe and accessible”. The woman has the right to be treated with respect, empathy and understanding of there difficult situation. However, some health care providers may find that providing care would present for them a personal moral problem – a problem of conscience. Respect for conscience is important but the effect when exercised by physicians and/or other health care personal is to fustrate or negate patients’ legal right of access to abortion. To force gynecologists to perform abortion may therefore not be in the best interest of the woman. It should, however, be stated that conscientious refusal is only valid for performing the abortion. All health care providers, independent of their attitude to abortion, must provide the woman with accurate and unbiased information about their legal rights, the procedure and have the duty to refer the woman in a timely manner to other providers willing to perform abortion. Conscientious refusal to perform abortion is a personal matter and should not be applied to health-care institutions. As in some European countries medical care should be organized so that a woman can obtain an abortion at anytime and to ensure the availability of an adequate number of providers so that women are able to exercise their right to abortion.
- Olga Loeber, NL
- Giovanna Scasselatti, IT
Chair:Workshop 4 Emergency contraception
- Sabine Müller, DE (all speeches)
Abortion in women after female genital mutilation (FGM)
Sabine Müller (Germany)
Estimated 150 million women underwent the procedure of FGM, 8-10% of them are infibulated. The movie will show a defibulation, so an abortion may be performed.
Classfication of FGM (according to FIGO):
- "small sunna", removal of the preputial skin
- Excision of the clitoris
- Excision of the small lips ( with ot without clitorectomie)
An area-based study in central Italy
Sara Farchi, A. Polo, D. Di Lallo (Italy)
Introduction. Italy recently dealt with a consistent migration flow. In Lazio region (main city Rome), a 45% of increase of fertile immigrant women was observed between years 2003 and 2007. This issue represents a challenge for health services because migrant women have more difficulties in access to care.
This study describes characteristics of migrant women making induced legal abortions.
Materials and methods. Data were extracted by the mandatory legal induced abortion file containing for each induced abortion performed in Lazio region information on reproductive history, socio-demographic characteristics, gestational age of the woman asking for the interruption. Other information regards the urgency for the abortion, the institution that certificated the interruption, and its characteristics.
Descriptive analyses and a multivariate logistic models were performed to estimate the risk of multiple induced abortion and the risk of late interruption (at 11-12 weeks of gestation) among migrant women in contrast to Italian ones, including only legal induced abortions performed within 90 days of gestation. Potential confounders included in the models were: woman age, education, marital status and parity.
Results. In 2007, in Lazio region 14242 abortions within 90 days have been performed. An increasing trend in foreign women induced abortions was observed in recent years: in 2007, the 42.6% of the interruptions were asked by a foreign woman, while in 1987 they represented the 5.4%. At the same time, a induced abortion decreased among Italian women. The 77% of the foreign women were born in non industrialised countries (Romania, Peru and Ukraine). 70% of the migrant women were aged 20-34 years, while Italian ones tended older. A larger proportion of multiple induced abortions and late interruptions were observed among foreign women than Italians. Multivariate logistic models showed that women from non industrialised country had 2,5 times the risk of multiple abortion than the Italians (OR=2.49; 95% CI 95%: 2.29-2.71), while no difference between Italians and women coming from industrialised countries was observed. Moreover, women from non industrialised countries had higher risk of late interruptions than Italians (OR=1.62; CI 95%: 1.49-1.76).
Conclusion. This descriptive study highlights the need of preventive interventions aimed at improving the quality of reproductive care for these women.
Immigrant women and contraception: Meeting the challenges
Cornelia Helfferich (Germany)
Evangelische Fachhochschule Freiburg, Bugginger Strasse 38, 79114 Freiburg i. Br., Germany
Migration to Germany is often a linked to the family history of migrant women: as marriage migration of young women or migration together with husband, children (and parents). Thus migration implies different realities and different needs for family planning.
In a study on behalf of the Federal Centre for Health Education, 300 immigrant women (20 to 44 years) from Turkey and Eastern European Countries were included. The results show that patterns of use of contraception are similar to those in the country of origin, but there is the problem of access to information and methods in Germany. Both immigrant groups have a high rate of abortion. Turkish immigrant women tend to limit family size by abortion, but a substantial proportion of abortions are carried out after marriage (which is linked to migration) to postpone the birth of the first child. For women from Easteuropean countries, especially for late repatriates, migration is linked to postponing birth (of the first child or further children) in the period after migration, mostly due to involvement in further education, by using contraception or abortion.
- Marta Okelly, ES (all speeches)
Problems in abortion care for immigrants in Spain
Marta Okelly (Spain)
In the last few years, Spain has become a receptor country for an increasing number of people coming from other countries. About half of these people are women who have their own way of dealing with their sexual and reproductive health and after emigrating from their nations, they have to get used to new conditions and situations.
The Association of Clinics Authorized to perform TOPs (ACAI in Spanish) has conducted an investigation aimed to get more knowledge about this group of immigrants in Spain. The surveys carried out on almost 1000 women show important data about their sexual and reproductive health, such as:
- Number of abortions among female immigrants according to their nationalities.
- Relationship between TOPs and their immigration status (legal or illegal).
- Reasons for TOPs (income levels, family structure, etc).
- Access to the public health system.
- Sexual and reproductive habits among female immigrants in our country: use of contraceptive methods, reasons of their failure, the most common methods used, knowledge of emergency contraception.
- Repeated TOPs.
- Difference and similarities about the sexual and reproductive behaviour among nationalities and even among different regions in a same country.
- Joyce Arthur, CA
- Maria Francès- Kircz, NL
Different strategies to legalize abortion: Successes and lessons from Colombia
Monica Roa (Colombia)
Sexual and reproductive rights have slowly been recognized as founded on mainstream human rights. There is no question regarding the recognition and legitimacy of these rights on paper; however, we have found that those in charge of applying rights to real life cases base reasoning and decisions on biases and prejudices when interpreting and applying the law. These intermediaries are the decision-makers at courts and tribunals (mostly judges). Our goal is to make gender equality an irrefutable measure by which law must be interpreted, applied and enforced.
Based on this premise, in April 2005, Women's Link Worldwide launched a bold and innovative challenge to the Constitutional Court of Colombia, asking the judges to liberalize the country's abortion law, which outlawed the procedure under all circumstances.
On May 10, 2006 the Constitutional Court issued a historic decision. The Court ruled that abortion should not be considered a crime under three circumstances:
- when the life or health (physical and mental) of the woman is in danger,
- when pregnancy is a result of rape or incest,
- when grave fetal malformations make life outside the uterus unviable.
The Women's Link's case was the first to challenge Colombia's abortion law using international human rights arguments. The Colombian Constitution explicitly states that international human rights treaties ratified by Congress take precedence over national laws. Not only is the decision historic for women’s rights but also the language utilized by the Court is groundbreaking in the acknowledgement of women’s reproductive rights and the implementation of international human rights standards in a national context.
The case of Colombia reactivated a regional debate which has shown a particular trend: "Whether you win or lose in parliament, the very next day, someone will go bring a challenge in court," she said, highlighting how the abortion battle has decamped from the political to legal arena”.
A 12 minute video with details on the different strategies developed in the case of Colombia will be shown by the presenter.
Different strategies to legalize abortion: Successes and lessons from Mexico
María Luisa Sánchez Fuentes (Mexico)
On April 24, 2007, abortion became legal on demand up to 12 weeks of gestation in Mexico City. Women for the very first time were considered full citizens with fundamental rights that must be recognized and protected by the Mexican constitution. What were the key factors that explain this historic change, in spite of the power and belligerence of the Catholic Church hierarchy in Mexico and the Latin American region? What strategies were vital to seize the political opportunity? What has changed after a year of legal abortion services? What are the most important social changes and what challenges lie ahead?
Different strategies to legalize abortion: Successes and lessons from Portugal
Duarte Vilar (Portugal)
A short history of the politics on abortion in Portugal before 2007 will be presented, stressing the importance of the political instance in producing and maintaining restrictive laws and in denying access to legal abortion services, and explaining the main reasons and actors that were involved in this process.
Some of the main moral and political debates occurred in the context of the 2007 Referendum will be presented.
The new legislation issued from the referendum process and the pro choice victory in 2007 will be presented an analysed on its limits and also in its positive and innovative aspects.
An overview on 15 months of legal abortion in Portugal will be done, presenting the gains on women’s health and also the main current constrains to the right to legal abortion.
Different strategies to legalize abortion: Successes and lessons from Switzerland
Anne-Marie Rey (Switzerland)
Situation in Switzerland before start of pro choice campaign in 1971. Penal Code of 1942: abortion allowed for health reasons only, to be certified by a second doctor. By 1971, 6 out of 25 cantons applied the law quite liberally and accepted mental and social health reasons for legal abortion, most of the other cantons stayed rather or very restrictive. Hence:
- abortion tourism from conservative to liberal cantons or to other countries,
- 20.000 illegal abortions estimated per year, with concomitant complications and death cases,
- some 100 women condemned each year for illegal abortion.
30 years of campaigning. June 1971 launch of a radical initiative for a constitutional amendment aiming at the repeal of abortion legislation. Its primary purpose was to break the taboo and raise public and parliamentary debate.
1975: launch of a second „reasonable“ initiative (abortion on request within the first 12 weeks of pregnancy), which was narrowly rejected on the ballot in 1977, by 51.7% of the votes.
1978: referendum and vote on a very unsatisfactory compromise law, rejected by a 2/3 majority.
1985: an initiative by the antis to write the right to life from conception into the constitution was rejected by 69% of the votes.
1993: a parliamentary bill proposed legalization of abortion on request in the first few months of pregnancy.
In March 2001 Parliament finally approved a corresponding amendment to the Penal Code. Conservatives immediately asked for a referendum.
June 2002: 72% of voters approve the new legislation. On the same ballot, an anti-initiative asking for a total abortion ban is defeated by a 82% majority.
- Gradual liberalization of abortion in practice over a period of 30 years (1971-2001).
- Reimbursement of the costs of abortion by health insurance (1981).
- Obligation for the cantons to create family planning counselling centers (1981).
- Abortion on request in the first 12 weeks of pregnancy (2002), no compulsory counselling except by the doctor himself, no „cooling off period“, no parental consent necessary for minors. Explicit mention of severe mental distress as a legally accepted reason for later abortions, without compulsory second medical opinion. Cantons have to designate clinics and doctors authorized to perform abortions.
Particularly successful strategies used.
- Personal contacts with the media, giving them regular and factual information,
- networking, building alliances with women’s, youth, political and professional organizations, mobilizing and briefing them,
- lobbying of parliamentarians, intensive personal contacts with some of them,
- formulating legislative texts and amendments for members of parliamentary committees,
- pragmatism, readiness to compromise, using moderate language and adapting our arguments to the changing situation.
Other reasons for our success.
- Decreasing influence of religion,
- changing role of women in society,
- growing open-mindedness in matters concerning individual lifestyles and sexuality.
In conclusion. Strategies must adapt to the situation, to political and religious forces present in a country and to the strength of pro choice mobilisation. Our experience: every time a broad public debate arose, some progress resulted. But: the battle for women’s right to decide whether and when to become a mother is hard and long. It needs dedication and perseverance. But in the end, I think, we have the better arguments.
- Elisabeth Aubény, FR
- Silvio Viale, IT
Experiences with prescription-only access
Ines Thonke (Germany)
Pro Familia Bundesverband, Germany
In contrast to many European countries, the “morning after pill” is as we know only available on prescription in Germany. pro familia’s National Association has established in a survey among counceling offices that prescription-only availability is the main but not the only obstacle that girls and women are confronted with when they need the “morning after pill”. The information gained from practical experience could prove to be useful in objective discussions and sharing experience as to how to improve the provision of safe post-coital contraception to women in Germany.
New data show that about 12 % of women in the age of 20 to 44 have used emergency contraception at least once in their life. The observed frequency of application shows differences in age and marital status, in urban and rural areas and is also depending on educational background.
Our survey shows that the need to see a doctor to obtain a prescription leads to different obstacles.
At weekends and overnight medical care is provided by medical walk-in centres and hospital outpatient clinics.
Hospital provision. A refusal of EC was by no means the exception. This practice is evident among catholic hospitals. A further reason which is cited is that the hospital cannot issue this type of prescription for reasons of cost and as a third reason that duty doctors refuse on moral grounds or justify their refusal by claiming that it is not an emergency. Women who need the “morning after pill” also find that they are charged for gynaecological investigations, pregnancy tests and ultra-sound scans. Additionally girls and women are burdened by the fact that they have to present their private worries several times in the clinic and in some cases they have to endure very lengthy waiting times (up to 3 hours)
Walk-in centre provision. Our survey shows that similar problems are experienced at medical walk-in centres. For girls under the age of 16, often parental agreement is required.
Pharmacy provision. Sometimes women face even more problems in obtaining the medication. Not all pharmacies have the “morning after pill” in stock or their stocks are minimal. In rural areas and with no car, this can quickly result in a lengthy delay before it can be taken.
General problems from everyday practice. Girls and women tell about the high cost which is an obstacle for them and also of their fear of gynaecologists and the difficulty of booking an appointment at short notice.
Conclusion and the need for action. Problems in provision are still being reported in various parts of the country. The shortfall in provision described above represent obstacles which still delay and prevent the "morning after pill" from being taken. The information in medical training and development about the current standard of quality and provision for hormonal emergency provision must be considered a central task in the current options for action. In order to tackle moral and ethical concerns, it is important to provide clearer information about the current findings on effectiveness as EC is still cited in the context of abortion and/or equated with it. Many of the other obstacles mentioned here can be overcome with in-depth training and development of doctors and clear rules for charging in hospitals. Instead of blaming couples for contraceptive use failure they should be encouraged to act responsible when asking for EC.
Is there a reduction in abortion rates?
Sharon Cameron (Scotland)
University of Edinburgh, Scotland
Emergency Contraception (EC) can prevent pregnancy. Effectiveness of EC has been based upon estimates of the risk of pregnancy depending on the timing of unprotected intercourse within the menstrual cycle. Research demonstrated that the main barriers to use of EC were lack of knowledge of EC and difficulty in obtaining EC.
It was anticipated therefore that increasing the availability of EC would lead to a reduction in unintended pregnancies, reflected in lower abortion rates. In some countries, EC is available without prescription at pharmacies. In the UK and France, cross sectional surveys have shown that this has led to more women obtaining EC from the pharmacy rather than other sources.
However, increased use of EC has not been associated with a reduction in abortion rates in UK or Sweden. This may be because abortion is linked to other social, economic and political factors.
A Cochrane database systematic review of RCT’s that examined effects of advance provision of EC (women supplied with EC to have rapid access in case of need) compared to standard access, showed increased use of EC but no difference in unintended pregnancy rates. In those cycles resulting in pregnancy where women with EC did not use it, this was mostly due to a misperception that they were not at risk of pregnancy.
Encouraging use of more effective methods of contraception before or during sex may be a more effective strategy to prevent unintended pregnancies than use of EC.
Methods – What’s new?
Linan Cheng (China)
Background. Emergency contraception is using a drug or copper intrauterine device (Cu-IUD) to prevent pregnancy shortly after unprotected intercourse. Several interventions are available for emergency contraception. Information on the comparative efficacy, safety and convenience of these methods is crucial for reproductive health care providers and the women they serve.
Objectives. To determine which emergency contraceptive method following unprotected intercourse is the most effective, safe and convenient to prevent pregnancy.
Selection criteria. Randomised controlled trials and controlled clinical trials including women attending services for emergency contraception following a single act of unprotected intercourse were eligible.
Data collection & analysis. Data on outcomes and trial characteristics were extracted in duplicate and independently by two reviewers. Quality assessment was also done by two reviewers independently. Meta-analysis results are expressed as relative risk (RR) using a fixed-effects model with 95% confidence interval (CI). In the presence of statistically significant heterogeneity a random-effect model was applied.
Main results. Eighty trials with 43,743 women were included. Most trials were conducted in China (70/81). There were more pregnancies with levonorgestrel compared to mid-dose (25-50 mg) (15 trials, RR: 2.01; 95% CI: 1.27 to 3.17) or low-dose mifepristone (<25 mg) (9 trials, RR: 1.43; 95% CI: 1.02 to 2.01). Low-dose mifepristone was less effective than mid-dose (20 trials, RR:0.67; 95% CI: 0.49 to 0.92), but this effect was no longer statistically significant when only high quality trials were considered (6 trials, RR: 0.75; 95% CI: 0.50 to 1.10). Single dose levonorgestrel (1.5 mg) administration seemed to have similar effectiveness as the standard 12 hours apart split-dose (0.75 mg twice) (2 trials, 3830 women; RR: 0.77, 95% CI: 0.45 to 1.30). Levonorgestrel was more effective than the Yuzpe regimen in preventing pregnancy (2 trials, RR: 0.51; 95% CI: 0.31 to 0.83). CDB-2914 (a second-generation progesterone receptor modulator) may be as effective as levonorgestrel (1 trial, 1549 women; RR:1.89; 95% CI: 0.75 to 4.64) but the confidence interval is wide and the result compatible with higher or lower effectiveness. Delay in the onset of subsequent menses was the main unwanted effect of mifepristone and seemed to be dose-related.
Reviewers' conclusions. Mifepristone middle dose (25-50 mg) was superior to other hormonal regimens. Mifepristone low dose (<25 mg) could be more effective than levonorgestrel 0.75 mg (two doses) but this was not conclusive. Levonorgestrel proved more effective than the Yuzpe regimen. The copper IUD was another effective emergency contraceptive that can provide ongoing contraception.
Mode of action: No evidence for effect post-fertilization
Kristina Gemzell (Sweden)
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden
Recently post-coital treatment with levonorgestrel (LNG) and the antiprogestin mifepristone has emerged as the most effective hormonal methods available for emergency contraception. LNG in a single dose of 1.5mg has become the recommended emergency contraceptive pill. However the mechanism(s) of action of these methods when used for emergency contraception in humans remains a matter of concern.
We therefore evaluated the effect of LNG in doses effective for emergency contraception, on ovulation as well as tubal and endometrial development. Treatment with 1.5 mg LNG in the late follicular phase inhibited the LH surge in all subjects. No effect on endometrial development could be found either following preovulatory or postovulatory LNG treatment.
LNG was shown to have no effect on endometrial progesterone receptor concentration and other suggested markers of endometrial receptivity remained essentially unchanged. The effect of mifepristone and levonorgestrel was further studies in an in vitro implantation model. Taken together our data suggest that emergency contraception with a single dose of 1.5 mg of levonorgestrel acts mainly to inhibit or delay ovulation but does not prevent fertilization or implantation. Increased knowledge on mechanism of action could hopefully increase the acceptability and thus availability of these methods, to offer women a chance to prevent an unwanted pregnancy and thus reduce the numbers of induced abortions.
Second trimester abortionChair:
- Marc Bygdeman, SE
- Blanka Kothe, DE
Consequences of the laws for women and political challenges in Europe
Marge Berer (Great Britain)
London, United Kingdom
There will always be some women who seek abortion after 12 weeks of pregnancy and in fewer cases at 20-24 weeks and even later, with the numbers diminishing rapidly at later gestations. Late abortions, the women who have them and the providers who do them are especially stigmatised. The number of providers willing to carry out abortions drops rapidly after 12–16 weeks of pregnancy and even more beyond 20 weeks. Many abortion laws do not permit second trimester abortion at all, except perhaps to save the life of the woman. Those that do distinguish second trimester abortion usually have more restricted grounds and/or bureaucratic approval processes.
Abortion “tourism” is a long-standing reality in Europe. The illegality of abortion after 12 weeks is less of a public health problem because women can travel for abortions, and the problems for women are hidden. In countries where abortion is legally restricted, morbidity and mortality are greater from complications of second trimester abortion than first trimester. The reasons are due not just to pregnancy being more advanced but due to greater risks from self-medication, the conditions in which the abortion is performed, lack of access to training in best practice for providers, less safe methods used and lack of access to timely, skilled follow-up care in case of complications. Moreover, deaths from second trimester abortions may be hidden in mortality statistics.
Women seeking late abortion are often in a precarious position personally (e.g. very young). Fetal indications are mostly not identified until 20–22 weeks. Where abortion for fetal indications is legal, many of the barriers women otherwise face don’t occur. Indeed, abortion may be encouraged. Where it is not legal, women may be forced to continue pregnancies and deliver even though the baby will certainly die soon after birth.
Medical methods: Advantages and disadvantages
Kristina Gemzell (Sweden)
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden
Delayed diagnosis of fetal anomalies, logistic and financial difficulties in obtaining abortion services, and failure to recognize an undesired pregnancy in the first trimester all contribute to the continuing need for late abortions. Second trimester abortion constitutes 10–15% of all induced abortions worldwide but is responsible for two-thirds of all major abortion-related complications. During the last decade, medical methods for second trimester induced abortion have shown a considerable development and have become safe and more accessible.
Today, in most cases, safe and efficient medical abortion services can be offered or improved by minor changes in existing health care facilities. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of second trimester pregnancy. In some places medical abortion has become the recommended method for second trimester abortion leading to increased access. In countries where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective, although a higher total dose is needed and efficacy is lower than for the combined regimen. Therefore, whenever possible the combined regimen should be used. Efforts should be done to reduce unnecessary surgical evacuation of the uterus after expulsion of the fetus and future studies should focus on improving pain management. More studies are also needed to explore the safety of medical abortion regimens in women with a previous caesarean section or uterine scar. Advantages and possible disadvantages with medically induced abortion in the second trimester will be discussed.