"You can't do that 'round here": a case study of the introduction of medical abortion care at a University Medical Center

Mifepristone medical abortion was introduced in 2002 into the University of New Mexico Medical Center clinic system through a joint effort of the departments of Family Medicine and Obstetrics and Gynecology. A stepwise approach to the integration of medical abortion, manual vacuum uterine aspiration, and first trimester obstetric ultrasound was successful in overcoming a series of educational, political, economic and logistical challenges. The integration of medial abortion care into resident training in FM and Ob/Gyn may expand access to reproductive services in primary care settings.

Consultations concerning contraception and induced abortions among university students — trends in Finland 1986–2003

The Finnish Student Health Service (FSHS) provides primary health care services to university students in Finland. The material for this study was drawn from the statistics of the FSHS. From 1986 to 2003, the number of students increased by 50%, while physician consultations did not, indeed to the contrary. The numbers of family planning consultations fell from 358 to 217 per 1000 female students. The induced abortion rates among university students are very low compared with the population in general and decreased from 4 to 3 per 1000 female students. Students are responsible, and because they want to postpone pregnancy after studies, they use contraceptives effectively. The FSHS has succeeded in guaranteeing contraception services and in preventing unwanted pregnancies and minimizing the need for induced abortions among university students while at the same time decreasing physician consultations. This was possible by changing the distribution of tasks among physicians and nurses, and by adding telephone contacts instead of face-to-face consultations with physicians.

[Adolescent contraception. Current trends]

Despite easy availability of contraception, Germany is confronted with the problem of increasing rates of pregnancies and abortions in minors. Prescription of contraceptives that do not rely on compliance and are acceptable to adolescents is required in addition to improved counseling. For that purpose, adherence to the guidelines for the use of contraceptives in minors written by the consortium for legislation in medicine (AG Medizinrecht) is essential. Oral contraceptives are the most commonly prescribed form of birth control, advantages include reversibility as well as a good tolerance and safety profile. New developments are low-dose compounds, novel progestins, prevention of ovulation by pure gestagen pills and the long-term use of low-dose monophasic micro pills. Long-term contraceptives like subdermally implantable depot compounds or hormone-releasing pessaries in utero have been used on a regular basis and seem a convenient alternative for birth control for longer periods, also in adolescents. The easy-to-use intravaginal ring and the birth control patch have expanded the spectrum of hormone-releasing contraceptive systems. Studies show improved compliance and a possible reduction of unintentional pregnancies due to application errors. Amelioration of the range of highly effective birth control products different modes of application will hopefully lead to drop in the rate of unplanned pregnancies, especially in adolescents.

Kontrazeption des Mannes – Geeignet für Jugendliche?

Although effective contraceptive methods are available, the incidence of teenage pregnancies and consecutive pregnancy interruptions remains high in industrial nations, including Germany. There are several reasons for this high incidence. Apart from earlier sexual maturation, the absence of contraceptive use or the use of inefficient methods contributes mainly towards this increase. Existing contraceptive methods for men either show unsatisfying efficacy (coitus interruptus, use of condoms) or problems of reversibility (vasectomy), which limits their broader use. Of the different experimental approaches towards male contraception, the hormonal approach is closest to practical implementation. Androgens are an essential part of all experimental approaches to hormonal contraception in males; they cause suppression of spermatogenesis through gonadotropin suppression. Previous clinical trials have validated the concept of hormonal contraception in men. However, the application modalities and the ineffectiveness of all self-administered androgen preparations have been unacceptable for practical use. Therefore recent developments focus either on androgen implants or on injectable, long-acting testosterone esters in combination with progestins, which also suppress gonadotropin secretion. Over the last decades various combinations of androgen preparations with different progestins or GnRH antagonists have been tested in clinical trials. Of these, testosterone with either depot medroxyprogesterone acetate, norethisterone, desogestrel or etonogestrel have shown promising efficacy in phase II clinical trials. However, whether hormonal contraception might be given to adolescent males remains to be elucidated. This will have to be assessed once a hormonal contraceptive for men has reached the market. Special attention will need to be given to bone maturation as androgens at the prescribed doses might induce premature closure of the epiphyseal joints.

The Incidence of Induced Abortion in the Philippines: Current Level and Recent Trends

CONTEXT

In the Philippines, abortion is legally restricted. Nevertheless, many women obtain abortions--often in unsafe conditions--to avoid unplanned births. In 1994, the estimated abortion rate was 25 per 1,000 women per year; no further research on abortion incidence has been conducted in the Philippines.

METHODS

Data from 1,658 hospitals were used to estimate abortion incidence in 2000 and to assess trends between 1994 and 2000, nationally and by region. An indirect estimation methodology was used to calculate the total number of women hospitalized for complications of induced abortion in 2000 (averaged data for 1999-2001), the total number of women having abortions and the rate of induced abortion.

RESULTS

In 2000, an estimated 78,900 women were hospitalized for postabortion care, 473,400 women had abortions and the abortion rate was 27 per 1,000 women aged 15-44 per year. The national abortion rate changed little between 1994 and 2000; however, large increases occurred in metropolitan Manila (from 41 to 52) and Visayas (from 11 to 17). The proportions of unplanned births and unintended pregnancies increased substantially in Manila, and the use of traditional contraceptive methods increased in Manila and Visayas.

CONCLUSION

The increase in the level of induced abortion seen in some areas may reflect the difficulties women experience in obtaining modern contraceptives as a result of social and political constraints that affect health care provision. Policies and programs regarding both postabortion care and contraceptive services need improvement.

Estimating Australia's abortion rates 1985–2003

AIM

To estimate national rates of induced abortion in Australia from 1985 to 2003, using Medicare claim statistics for private patients and hospital morbidity statistics for public patients.

DESIGN AND SETTING

Estimates were based on Australian and South Australian data collections relating to abortions. SA hospital morbidity statistics were compared with SA statutory notifications of abortions to estimate the accuracy of these collections. Medicare statistics on abortion procedures performed on private patients in South Australia were then compared with hospital morbidity statistics for private patients. National statistics on abortion derived from Medicare and hospital morbidity statistics were adjusted for inaccuracies found in these sources.

MAIN OUTCOME MEASURES

Numbers of induced abortions in Australia for each year from 1985 to 2003; abortion rates per 1000 women aged 15-44 years.

RESULTS

Abortion numbers based on Medicare claims by private patients overestimated by 18.7% the number of abortions derived from statutory notifications in South Australia during the period 1988-89 to 1999-00. Hospital morbidity data using principal diagnosis codes relating to medical abortion overestimated statutory notifications by 2.3% (mainly because of readmissions). National statistics were adjusted for these overestimations and for the estimated 14.1% of private patients who would not have submitted Medicare claims (based on surveys of private-clinic patients in New South Wales and Victoria). The estimated Australian abortion rate increased from 17.9 per 1000 women aged 15-44 in 1985 to a peak of 21.9/1000 in 1995, then declined to 19.7/1000 in 2003 (estimated number of abortions, 84,460).

CONCLUSION

There are no data currently available for deriving accurate numbers of induced abortions in Australia. Suggestions are made for collection of national statistics.

"Abortion? That's for women!" Narratives and experiences of commercial motorbike riders in south-western Uganda

Although constitutionally illegal, induced abortion is a vital reproductive health option in Uganda. This paper analyses men's narratives about meanings of, and experiences with, abortion. Men play significant roles in abortion as instigators, facilitators, collaborators, transporters, advisors, informers, supporters or punishment givers. Many participants were knowledgeable about abortion. Attitudes were ambivalent, with initial reactions of denial and relegation of abortion to women's private domains. Further exploration, however, revealed active support and involvement of men. Interpretations of abortion ranged from 'dependable saviour' to 'deceptive sin'. Though a private action, abortion is socially scripted and often collectively determined by wider social networks of kinsmen, the community, peers, law and religion. A disjuncture exists between dominant public health discourse and the reality of local men who interact with women and girls as wives, lovers, sex sellers, mothers, daughters and sisters. Interventions targeting men about abortion should include safe sex education, provide safe abortion services and create stronger social support mechanisms. Policy and law should incorporate local knowledge and practice.

Induced abortion in Nigeria: findings from focus group discussion

Abortion is carried out daily in Nigeria despite the restrictive abortion law. This study was carried out to obtain information on societal attitude to the issues of family planning, unwanted pregnancy, abortion, adoption of children and laws relating to them. Focus group discussions were held in south-western Nigeria among 11 sub-groups. Participants felt that there was high prevalence of unwanted pregnancy and abortion particularly among youths. They had high level awareness of contraceptives and ascribed its low use to negative side effects, high cost and provider bias. Christians favoured planning of pregnancies while the Muslims did not. Majority of the respondents had negative perception of induced abortion. Some of them supported abortion if the education of the young girl would be disrupted, if paternity of pregnancy is in dispute, or if it would save the family from shame. Participants supported the enactment of laws that would make adoption of unwanted children easier.

Factors associated with adolescent abortion in a rural area of Bangladesh

This study examines levels and trends in abortion among adolescent girls in 1982-98 and identifies groups of adolescents who are at high risk for having an abortion. The study used data sets collected in Matlab in Bangladesh where the Center for Health and Population Research at ICDDR,B, has maintained a demographic surveillance system, since 1966. Both bivariate and multivariate techniques of analysis were employed. We also used qualitative information derived from in-depth interviews with adolescents. The incidence of abortion was 35 times higher for unmarried than for married adolescents. Abortion ratios were also higher for adolescents who were <18 years old and for those with more than primary education. A little less than half of the abortions were induced by biomedical health workers (by means of menstrual regulation) which means that traditional providers fulfilled an important function in this rural area. The findings suggest that high-quality abortion services provided to adolescents in the framework of comprehensive reproductive health services will help to lower abortions in general and of unsafe abortions provided by traditional providers in particular.

Influence of prenatal diagnosis and pregnancy termination of fetuses with birth defects on the perinatal mortality rate in Victoria, Australia

Historical data show that in Victoria birth defects have accounted for approximately 25% of all perinatal deaths. Terminations of pregnancies (TOPs) for birth defects occurring at > or =20 weeks gestation are included in the population-based perinatal data collection. These are classified as stillbirths or neonatal deaths. Some would have survived the perinatal period if no termination had taken place, and as a result they have the effect of increasing the perinatal mortality rate (PMR). Conversely, TOPs <20 weeks gestation, of fetuses with lethal birth defects that would have resulted in a perinatal death, are not included in the statistics and therefore reduce the PMR. The aim of this study was to examine the effect on the PMR of TOPs following the prenatal detection of birth defects, taking into account the severity or 'lethality' of the birth defects. Data on live births, stillbirths, neonatal deaths and TOPs carried out because of a birth defect were collected from the Victorian Birth Defects Register (BDR) for 1989-2000. Birth defects were categorised into three groups, according to the estimated likelihood of a baby with that condition dying in the perinatal period: a 'lethal' birth defect was one where there was >50% likelihood of death, 'possibly lethal' 15-50% and 'non-lethal' less than 15%. Based on these 'lethality' groups and associated assumptions about average survival rates beyond the neonatal period, the PMR was recalculated. TOPs for 'non-lethal' birth defects at > or =20 weeks gestation increased the PMR by 3.8%. TOPs for 'lethal' birth defects <20 weeks decreased the PMR by 14.4%. The net effect on the overall PMR from TOPs for birth defects was a 10.6% decrease.

[Prognosis of the reproduction health care in the Czech Republic until 2010: II. Planned parenthood]

OBJECTIVE

To prepare a prognosis of development of contraception, artificial termination of pregnancy and asisted reproductive technologies until 2010, based on the trend in their indicators in the previous years.

DESIGN

A retrospective epidemiological study to be used as a basis for the prognosis

SETTING

Mother and Child Care Institute, Prague - Podolí

METHODS

For outlining the probable trend in the use of various types of contraceptives (IUD) as well as for artificial termination of pregnancy, evaluated according to their internationally recognised indicators, the extrapolation of the trends in these criteria prevalent in the period 1995-2002 was used.

RESULTS

The prognosis of increase in the number of female users of hormonal contraception at the expense of IUD as well as the decrease in the number of women solving their problem with unwanted pregnancy by artificial termination of pregnancy (ATP), based on the said extrapolation of their indicators with a prospect until 2010, is probably overly optimistic. Due to probable changes in the political, social and economic circumstances as well as in the women's attitudes, it is expected that this trend will slow down. This is why it is expected that the number of female users of hormonal contraception will increase merely to 500 and that the women using IUD will decrease to 50 per 1,000 fertile women. Also, as concerns the number of ATPs, it is expected that it will decrease merely just below 10 for every 1,000 fertile women and to 20 for every 100 births. Even if the trends of all these indicators slow down, it can be expected that they will reach the average levels reported in the countries of Western Europe. As for the trend in asisted reproductive technologies (ART), whose share in the total number of births will rise, the main emphasis will be put on consistent nationwide registration, amendments to legislation and research mainly in the area of psycho-neurological development of these children, as recommended by the WHO.

CONCLUSION

The expected rate of growth of the number of female users of effective contraception and the expected rate of decline of the number of ATPs, corresponding to the trend of the recent years, will probably decrease by 2010 but the average levels reported by the countries of Western Europe will still be reached. According to the recommendation of the WHO, the trend in some forms of ART will require research in the field of psycho-neurological development of the children from these pregnancies until they reach adulthood as well as some amendments to legislation.

Prenatal diagnosis, pregnancy terminations and prevalence of Down syndrome in Atlanta

BACKGROUND

The impact of prenatal diagnosis on the live birth prevalence of Down syndrome (trisomy 21) has been described. This study examines the prevalence of Down syndrome before (1990-1993) and after inclusion of prenatally diagnosed cases (1994-1999) in a population-based registry of birth defects in metropolitan Atlanta.

METHODS

We identified infants and spontaneous fetal deaths with Down syndrome (n = 387), and pregnancies electively terminated after a prenatal diagnosis of Down syndrome (n = 139) from 1990 to 1999 among residents of metropolitan Atlanta from a population-based registry of birth defects, the Metropolitan Atlanta Congenital Defects Program (MACDP). Only diagnoses of full trisomy 21 were included. Denominator information on live births was derived from State of Georgia birth certificate data. We compared the prevalence of Down syndrome by calendar period (1990-1993, 1994-1999), maternal age (<35 years, 35+ years), and race/ethnicity (White, Black, other), using chi-square and Fisher's exact tests.

RESULTS

During the period when case ascertainment was based only on hospitals (1990-1993), the prevalence of Down syndrome was 8.4 per 10,000 live births when pregnancy terminations were excluded and 8.8 per 10,000 when terminations were included. When case ascertainment also included perinatal offices (1994-1999), the prevalence of Down syndrome was 10.1 per 10,000 when terminations were excluded and 15.3 when terminations were included. During 1990-1993, the prevalence of Down syndrome was 24.7 per 10,000 among offspring to women 35+ years of age compared to 6.8 per 10,000 among offspring to women <35 years of age (rate ratio [RR] = 3.65, 95% confidence interval [CI] = 2.53-5.28). During 1994-1999, the prevalence of Down syndrome was 55.3 per 10,000 among offspring to women 35+ years compared to 8.5 per 10,000 among offspring to women <35 years (RR = 6.55, 95% CI = 5.36-7.99). There was no statistically significant variation in the prevalence of Down syndrome by race/ethnicity within maternal age and period of birth strata. During 1994-1999, the proportion of cases that were electively terminated was greater for women 35+ years compared to women <35 years (RR = 5.10, 95% CI = 3.14-8.28), and lower for Blacks compared to Whites among women 35+ years of age (RR = 0.33, 95% CI = 0.16-0.66).

CONCLUSIONS

In recent years, perinatal offices have become an important source of cases of Down syndrome for MACDP, contributing at least 34% of cases among pregnancies in women 35+ years of age. Variation in the prevalence of Down syndrome by race/ethnicity, before or after inclusion of cases ascertained from perinatal offices, was not statistically significant. Among Down syndrome pregnancies in mothers 35+ years we found a lower proportion of elective termination among Black women compared to White women. We suggest that future reports on the prevalence of Down syndrome by race/ethnicity take into account possible variations in the frequency of prenatal diagnosis or elective termination by race/ethnicity.

Trends in postabortal mortality and morbidity in Ibadan, Nigeria

Illegally induced abortion at the University College Hospital, Ibadan increased steadily over a 10-year period (1980-1989) despite increasing availability of family planning services. Abortion was the commonest cause of death in the gynecology service during the period of the study and constituted 36.6% of fatalities. The majority of patients (76.2%) did not accept contraceptives. Almost one-third of the illegal terminations were performed by physicians. Although the percentage of deaths decreased, the contribution of physicians to these fatalities increased, and accounted for 6/9 (66.7%) of fatalities in 1989. This circumstance probably signifies a defect in physician training and ability to perform abortion aftercare. Physicians should be trained in abortion care and laws changed in conjunction with greater drive to improve contraceptive utilization and reduce the incidence of unsafely induced abortion.

Autopsy after termination of pregnancy for fetal anomaly: retrospective cohort study

OBJECTIVE

To study trends in termination of pregnancy for fetal anomaly over 10 years and to assess the contribution of autopsy to the final diagnosis and counselling after termination.

DESIGN

Retrospective study with cases from a congenital anomaly register and a defined unselected population.

DATA SOURCES

Pregnancies resulting in termination for fetal anomaly identified from the Oxford congenital anomaly register. Details about the prenatal diagnosis and autopsy findings were retrieved from case notes.

RESULTS

Of the 57 258 deliveries, 309 (0.5%) were terminated because of prenatally diagnosed abnormality. There were 129/29 086 (0.4%) terminations for fetal anomaly carried out in 1991-5 and 180/28 172 (0.6%) in 1996-2000. The percentage of fetuses that underwent autopsy fell from 84% to 67%. Autopsy was performed in 132 cases identified by ultrasound scan, with no evidence for abnormal karyotype. In 95 (72%) the autopsy confirmed the suspected diagnosis and did not add important further information, two cases were not classified, and in 35 (27%) the autopsy added information that led to a refinement of the risk of recurrence (reduced in 17, increased in 18); in 11 of these 18 cases it was increased to a one in four risk.

CONCLUSIONS

Though there has been an increase in the rate of terminations of pregnancy for fetal anomaly, there has been a decline in the autopsy rate. When a prenatal diagnosis was based on the results of a scan only, the addition of information from an autopsy by a specialist paediatric pathologist provided important information that changed the estimated risk of recurrence in 27% of cases and in 8% this was to a higher (one in four) risk.

[Analysis of abortion trends in the Zenica-Doboj Canton]

Authors present results of statistical analysis of data of abortions, in period since 1980 up to date. The frequency and trend of the abortions in the entitled canton of Federation of Bosnia and Herzegovina, in the period 1980-1989 and 1996-2001. It was found that the percentage of abortions had been yearly growing, from 66 cases per 100 deliveries in the year 1980, 88 cases in the year 1985, to 97 cases in the year 1989. Comparing to Zenica-Doboj Canton, in the regions of Doboj, Tuzla, Sarajevo, the number of abortions in the mentioned period was remarkably higher varying from 127 to 178 cases per 100 deliveries. It is worthy to notify that in the period 1996-2001 the participation of young women in the abortions with the percentage of 2.5% in the year 1996, had been rather indicative showing the tendency of growing during the rest years of the investigated period. The women of the age group between 25 and 39 were the main candidates for artificial abortions, the ladies within 30-34 years of age being most predominant. It is also remarkable that in the last four years the elderly ladies (elder than 49 years of age) showed the tendency of artificial abortions, up to 0.49 cases per hundred deliveries.

An audit of the management of induced abortion in England and Wales

OBJECTIVES

To assess the quality of care provided to women undergoing induced abortion.

METHODS

The design was a single round audit questionnaire aimed at the providers of abortion services throughout England and Wales (NHS hospitals, clinics under NHS, agency agreements and private units. The levels of care were assessed against agreed audit criteria.

RESULTS

Responses were received from 240 (74%) of the 324 units providing abortion care in England and Wales. These units undertook 80% of the 176,000 termination procedures. Generally standards of care were appropriate, but there were clear areas for improvement including choice of method, infection screening, and delays in referral. A number of unnecessary investigations were still evident, including cross-matching, while lower doses and alternative drug regimens might reduce costs. Only half of the units audited procedures and complications.

CONCLUSIONS

This audit was carried out prior to the publication of the RCOG evidence-based guideline and a further round of audit to assess the impact of the guideline should now be considered.

Knowledge, attitude and practice of private medical practitioners in Calabar towards post-abortion care

This study examined the knowledge, attitude and practice of private medical practitioners in Calabar on abortion, post-abortion case and post-abortion family planning. Forty eight private practitioners who were proprietors of private clinics in the city were interviewed using a structured questionnaire. The results showed that 22.9% of the doctors routinely terminate unwanted pregnancies when requested to do so by women, while 83.3% of them treat women who experience complications of unsafe abortion. The major reasons given by some of the doctors for not terminating unwanted pregnancies were religious, moral and ethical considerations rather than respect for the Nigerian abortion law. Only 18.2% of the doctors use standard procedures such as manual vacuum aspiration (MVA) for the management of patients with abortion and abortion complications. A good number of them did not routinely practice integrated post-abortion family planning and STDs management. There is need for a comprehensive programme of retraining of private medical practitioners in Calabar on the principles and practices of safe abortion, post-abortion care and family planning. These aspects of reproductive health need to be integrated into the medical training curricula in Nigeria. It is believed that this approach would help reduce the present high rate of abortion-related morbidity and mortality in Nigeria.

Morbidity and mortality from bowel injury secondary to induced abortion

Eight patients managed for bowel injury following induced abortion were studied for the pattern of morbidity and mortality. The patients were aged 18-39 years. Three of them were married, five were single. Two of the cases were detected at the time of termination of pregnancy. The interval from termination of pregnancy to presentation in hospital was two days to two weeks in the other six patients. Injury was in the ileum in three, jejunum in two and the sigmoid colon in three. Twenty surgical interventions were performed for primary treatment and management of complications. Major complications were abdominal wound dehiscence (5), faecal fistula (2) and postoperative diarrhoea (1). The duration of hospitalisation at the first admission ranged from seven to 163 days. The excessive morbidity is attributed to delay in presentation; most patients been seen after 72 hours. Primary repair of colonic injury is discouraged. No death was recorded. Literature is reviewed on the condition in West Africa and suggestion made on means of reducing morbidity from induced abortion.

Seasonality of births and abortions in New South Wales, Australia

BACKGROUND

Complex seasonal variations in abortions and seasonal trends have been reported worldwide, but there are no data from Australia.

MATERIAL/METHODS

Hospital morbidity and birth data were modelled using time series and regression techniques to describe seasonal changes in births and abortions (1989-99) in NSW, Australia. Data were also analysed to determine demographic predictors of abortions.

RESULTS

A higher proportion of births in NSW were recorded in March and September-October. Irrespective of the nuptiality the lowest seasonal indices were recorded in February and November. For married women aged 20-49 years, voluntary abortions were significantly higher in February (t=0.04) and significantly lower in April (t<0.001) and June (t=0.03) and non-voluntary abortions were significantly higher in February (t=0.002) and March (t=0.006). There was seasonality in voluntary abortions (F=4.3, p<0.001) and no seasonality in non-voluntary abortions (F=2.4, p=0.01) for never married women aged 20-49 years. As similar to married women, voluntary abortions among never married women were significantly higher in February (t<0.001) and significantly low in April (t=0.009). The lowest number of abortions were in April. Non-voluntary abortions occurred mostly in March for married women. The average number of voluntary abortions were significantly higher for never married women than for married women.

CONCLUSIONS

There was a significant seasonality of births and abortions in NSW, Australia, with a peak of conceptions in December/January. Abortions were lowest in April and non-voluntary abortions were peaked in March. These data suggest that the human reproductive behaviour has a close relationship with environmental factors.