INNOVATIONS: Mifepristone registered in Mexico. RESEARCH WITH IMPACT: IUD placement after medical abortion WHAT MATTERS TO YOU?

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1 Add to your address book to ensure delivery of Medical Abortion Matters. If someone forwarded you this and you'd like to sign up for future issues, visit November 2011 Innovations Research with impact What matters to you? Perspectives Featured organization Resource spotlight We want to hear from you! Contact us at medicalabortion to suggest an organization, resource or content to be featured in a future issue. Visit the Ipas Medical Abortion Portal medicalabortion THANKS TO THE MEDICAL ABORTION MATTERS ADVISORY PANEL: Traci Baird, MPH Director, Special Projects, Ipas Alfonso Carrera, MD Senior Medical Advisor, Ipas Mexico Talemoh Dah, MBBS, FWACS Africa Regional Clinical Advisor, Ipas Mary Fjerstad, NP, MHS Director of Medical Affairs and Pharmacovigilance, WomanCare Global Beverly Winikoff, MD, MPH President, Gynuity Health Projects Kate Worsley, MBBS, DFFP, MBA Associate Director, Medical Development Team, Marie Stopes International You're receiving this because you've expressed interest in medical abortion news, research and progress. Here are some highlights, but you can always find more at INNOVATIONS: Mifepristone registered in Mexico more on ipas.org Legalization of abortion in the Federal District of Mexico (Mexico City) has been a great achievement, but one important ingredient was missing: mifepristone. However, with Mexico's recent decision to register mifepristone, women will now benefit from the highly effective combination of mifepristone and misoprostol to end early pregnancy. RESEARCH WITH IMPACT: IUD placement after medical abortion more on ipas.org WHAT MATTERS TO YOU? How soon after medical abortion can an IUD be inserted? And are higher expulsion rates or increased risk of infection a concern for women who have an IUD inserted during the follow-up visit after a medical abortion? Two recent studies shed light on these questions. Is there a way to predict how much pain a woman will have with medical abortion? Pain experience is very individual so there is no way to predict how a particular woman will experience medical abortion. However, there are some predictors of pain with medical abortion that generally apply. Read more on ipas.org. PERSPECTIVES: An interview with James Trussell, PhD, Office of Population Research at Princeton University Question: Do you see any similarities or differences between contraceptive uptake over the years and medical abortion uptake more recently? Answer: As you well know, medical abortion is quite popular; when women have a choice, many of them

2 Susan Yanow, MSW Reproductive Health Consultant will choose medical abortion. In sharp contrast, the very best contraceptives that we have the intrauterine contraceptives and the implants are hardly used by anyone, so there's a real disconnect here. more on ipas.org FEATURED ORGANIZATION: Women's Global Network for Reproductive Rights (WGNRR) The Women's Global Network for Reproductive Rights (WGNRR), coordinated out of the Philippines, builds and strengthens movements for sexual and reproductive health, rights and justice around the world. WGNRR focuses specifically on access to safe and legal abortion, access to contraceptives, sexual rights and the special unmet demands of young people. Through Regional Members' Meetings, members share experiences and develop advocacy and policy strategies at national, regional and international levels, and WGNRR links members through an online database. Expanding on the success of Latin America's Day of Action for the Decriminalization of Abortion observed annually on September 28 WGNRR recently launched this day of action as a global campaign. To find out more about WGNRR's campaigns, meetings and resources, visit RESOURCE SPOTLIGHT: The Asia Safe Abortion Partnership's (ASAP) Country Profiles The Asia Safe Abortion Partnership (ASAP) aims to promote, protect and advance women's sexual and reproductive rights and health in Asia by reducing unsafe abortion and its complications and, where it is legal, by promoting access to comprehensive safe abortion services. A regional affiliate of the International Consortium for Medical Abortion (ICMA), ASAP engages in regional and international advocacy efforts and supports its members in areas including advocacy, capacity building, research, documentation, service delivery, and the promotion of safe abortion technologies. ASAP's comprehensive country profiles present laws, policies, method availability, public awareness, statistics and other abortion-related information for the 15 countries in the Asia/Pacific region where ASAP has members. Find these profiles and more about ASAP's work at Thank you for your interest in Ipas. View past issues of our other newsletters or sign up now. P.O. Box 5027, Chapel Hill, NC USA (voice) (toll-free in US) (fax) contact us privacy policy photo disclaimer 2011 Ipas. All Rights Reserved.

3 Ipas IUD placement after medical abortion Español WHO WE ARE WHAT WE DO WHERE WE WORK Resources News Contact Us Jobs Sign Up for Newsletters IUD placement after medical abortion November 2, 2011 Because we now know that women can ovulate as early as eight days after mifepristone, 1 and perhaps even earlier, and because we know that some women resume intercourse soon after medical abortion, if women want long-term reversible contraception, time is critical. IUDs are as effective as sterilization but are reversible and forgettable once they re inserted, the woman doesn t have to remember to do anything to maintain contraceptive coverage. The questions for clinicians have been: How soon after medical abortion can the IUD be inserted? Is there a high expulsion rate if the IUD is inserted at the follow-up visit once the provider confirms the woman is no longer pregnant? Is there a higher risk of infection if the IUD is inserted at the follow-up visit versus delayed insertion? Two recent studies shed light on these questions and the answers are reassuring. In a prospective observational study, 118 women received either the levonorgestrel IUD or copper IUD at the follow-up visit seven to 10 days after mifepristone administration. 2 Women had IUD insertion as early as six days after mifepristone administration; the mean day of insertion was eight days following mifepristone at Boston Medical Center and nine days at the Utah Women s Clinic. At the conclusion of the three-month study, the expulsion rate was 4.1 percent. There was not a comparison group in the study that had delayed IUD placement. There were no reported infections, perforations or pregnancies of the women who received IUDs during the three-month study period. A recently published randomized clinical trial compared placement of the copper IUD at the one-week visit following medical abortion to delayed IUD placement four to six weeks later. 3 Among the 156 women in the study, there were no cases of serious infection, uterine perforation, hemorrhage, or anemia requiring IUD removal. There were no pregnancies except for four pregnancies in the group who were scheduled for delayed IUD insertion but did not return for insertion. How does the expulsion rate of IUDs placed one week after medical abortion compare to the expulsion rate of IUDs inserted immediately after vacuum aspiration? An additional study helps us understand this context. A randomized noninferiority trial of 575 women who had vacuum aspiration for first-trimester induced or spontaneous abortion compared IUD insertion immediately after the procedure versus insertion two to six weeks later. 4 The six-month expulsion rate was 5 percent with immediate insertion and 2.7 percent with delayed insertion. One important finding of the paper was that almost 29 percent of the women scheduled for delayed IUD did not actually follow up with IUD insertion despite financial incentives offered to women to return for IUD placement. Five of these women who did not receive an IUD became pregnant during the six-month follow-up. The important lessons to be gleaned from this research are: If clinics use the model of follow-up which includes a return visit to the clinic, IUDs can be placed at the medical abortion follow-up visit when the provider determines the woman is no longer pregnant and her bleeding is within normal range.

4 Ipas IUD placement after medical abortion IUD placement as early as one week after medical abortion achieves a low expulsion rate, similar to that of immediate IUD placement following vacuum aspiration. IUD placement as early as one week after medical abortion is safe and will not worsen pain or bleeding after medical abortion. 3 Delaying IUD insertion places the woman at risk for repeat pregnancy because a fairly high percentage of women scheduled for delayed placement do not return. References 1. Schreiber, Courtney A., Stephanie Sober, Sarah Ratcliffe, Mitchell D. Creinin Ovulation resumption after medical abortion with mifepristone and misoprostol. Contraception, 84(3): Betstadt, Sarah, David Turok, Nathalie Kapp, Kui-Tzu Feng, Lynn Borgatta Intrauterine device insertion after medical abortion. Contraception, 83(6): Shimoni, Noa a, Anne Davis, Maria Elena Ramos, Linette Rosario, Carolyn Westhoff Timing of copper intrauterine device insertion after medical abortion. Obstetrics and Gynecology,118(3): Bednarek, Paula H., Mitchell D. Creinin, Matthew F. Reeves, Carrie Cwiak, Eve Espey, Jeffrey T. Jensen for the Post-Aspiration IUD Randomization (PAIR) Study Trial Group. Immediate versus delayed IUD insertion after uterine aspiration New England Journal of Medicine, 364(23): Gillett PG, Lee NH, Yuzpe AA, Cerskus I A comparison of the efficacy and acceptability of the Copper- 7 intrauterine device following immediate or delayed insertion after first-trimester therapeutic abortion. Fertility and Sterility, 34(2): * This article is published as part of the newsletter Medical Abortion Matters, November For more information, contact media@ipas.org PO Box 5027, Chapel Hill, NC USA (voice) (toll-free in US) (fax) contact us privacy policy photo disclaimer Ipas. All rights reserved.

5 Ipas Mifepristone registered in Mexico Español WHO WE ARE WHAT WE DO WHERE WE WORK Resources News Contact Us Jobs Sign Up for Newsletters Mifepristone registered in Mexico November 2, 2011 Legalization of abortion in the Federal District of Mexico (Mexico City) has been a great achievement, but one important ingredient was missing: mifepristone. However, with Mexico s recent decision to register mifepristone, women will now benefit from the highly effective combination of mifepristone and misoprostol to end early pregnancy. Abortion during the first trimester was decriminalized in the Federal District in April 2007, and within 24 hours the Secretaría de Salud del Distrito Federal (SSDF) was providing abortion care. Women with no health insurance who reside in the Federal District could and still do receive abortions at no cost to them, while women living outside the Federal District pay on a sliding scale. Demand was overwhelming; women arrived in the middle of the night and slept on the sidewalk to be sure they would receive services when the clinic was open. Early on, procedures were almost always done with dilation and curettage (D&C), but with continual training, manual vacuum aspiration (MVA) has now almost entirely replaced D&C. However, because there weren t enough doctors or space to offer MVA to all women, those women who were nine weeks pregnant or less and who lived within the Federal District were given medical abortion. Women more than nine weeks pregnant or who lived beyond the Federal District received MVA. While mifepristone was not registered or available in Mexico, misoprostol was widely available. Therefore, the medical abortion regimen used since 2007 has been sequential doses of misoprostol 800 mcg taken by the buccal route. Now mifepristone is registered in Mexico. It will soon be available to physicians in private offices and clinics who are registered to administer it, and it will also be stocked in pharmacies to be dispensed as a Class 3 prescription (similar to prescriptions for narcotics that require a physician s prescription). Mifepristone has also been added to the Essential Drug List in the Federal District so the public hospitals and clinics will be able to work on procurement. Outside of the Federal District, states in Mexico have laws that restrict induced abortion to limited circumstances, such as rape, risk of death or if the health of the woman is in great danger. However, there may be some indications within those laws for mifepristone/misoprostol use; how mifepristone and misoprostol are used in some states may evolve. In addition, Gynuity Health Projects and SSDF recently completed a joint study using mifepristone 200 mg combined with misoprostol 800 mcg by the buccal route. One thousand women were recruited for the study and the results were significant: The high success rate of this regimen was virtually identical to the success rates of mifepristone and misoprostol medical abortion published elsewhere, explained Dr. Patricio Sanheuza, SSDF s coordinator of reproductive health. Sanheuza described the study as well as the status of mifepristone and plans to integrate it in the public sector at a meeting organized by SSDF and Gynuity Health Projects in July in Mexico City. The many organizations and individuals that worked tirelessly to make mifepristone available in Mexico are now hopeful that the results of this joint study, combined with on-going advocacy efforts, will continue to expand women s access to this highly effective medical abortion drug. * This story is published as part of the newsletter Medical Abortion Matters, November 2011.

6 Ipas Mifepristone registered in Mexico For more information, contact PO Box 5027, Chapel Hill, NC USA (voice) (toll-free in US) (fax) contact us privacy policy photo disclaimer Ipas. All rights reserved.

7 Ipas Pain management during medical abortion Español WHO WE ARE WHAT WE DO WHERE WE WORK Resources News Contact Us Jobs Sign Up for Newsletters Pain management during medical abortion September 1, 2011 Q: Is there a way to predict how much pain a woman will have with medical abortion? Cramping is expected with medical abortion since uterine contractions are needed to expel the pregnancy, and most women will experience lower abdominal pain or cramping during a medical abortion. 1 Pain experience is very individual so there Figure 1 is no way to predict how a particular woman will experience medical abortion. However, there are some predictors of pain with medical abortion that generally apply. Older age, having given birth before, and a higher number of previous births are associated with reduced pain during medical abortion. Young age, nulliparity and higher gestational age are associated with increased pain. 2, 3 Women with painful periods may also experience increased pain with medical abortion independent of other factors such as age or reproductive history. 3 Q: How can we counsel women about pain they can expect during a medical abortion? All women should be counseled about the pain they might feel from medical abortion, keeping in mind factors that might put them at higher or lower risk of experiencing pain. Accurately describing the sensations a woman might feel during a medical abortion is important, as good counseling can alleviate fear and anxiety that may make pain worse. 4 A useful counseling tool to use with women presenting for medical abortion is the bell curve (see Figure 1). Show the woman the drawing and tell her that although a few women don t notice pain and some women experience intense pain, the majority of women fall somewhere in the middle. That is, most women will experience lower abdominal pain and cramping which may be similar to or somewhat worse than their menstrual period. 3 Q: What can women use to treat pain during a medical abortion? The best regimen for pain control has not been established. 5 Nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen are more effective than acetaminophen when taken once cramping starts and do not reduce the effectiveness of medical abortion. 6 Narcotic analgesics are another option for pain control, although the optimal drug, dose and timing is not known. All women who are having a medical abortion should be provided with pain medications or a prescription and should be advised to start the medications either with misoprostol or once cramping starts. 7 One common strategy is to give NSAIDS and narcotic analgesics and advise the woman to begin with NSAIDS once cramping starts and alternate the two medications if she continues to experience pain. Other pain management strategies that may help women undergoing medical abortion are thorough counseling, a supportive environment and applying a heating pad or hot water bottle to the lower abdomen. Music and guided imagery are effective for pain management in surgical abortion and may be helpful for medical abortion as well. 8 References

8 Ipas Pain management during medical abortion 1. Honkanen H, Piaggio G, Hertzen H, et al WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. BJOG, 111(7): Hamoda H, Ashok PW, Flett GM, Templeton A Analgesia requirements and predictors of analgesia use for women undergoing medical abortion up to 22 weeks of gestation. BJOG, 111(9): Suhonen S, Tikka M, Kivinen S, Kauppila T Pain during medical abortion: Predicting factors from gynecologic history and medical staff evaluation of severity. Contraception, 83(4): Kruse B, Poppema S, Creinin MD, Paul M Management of side effects and complications in medical abortion. American Journal of Obstetrics and Gynecology, 183(2 Suppl): S Jackson E, Kapp N Pain control in first-trimester and second-trimester medical termination of pregnancy: A systematic review. Contraception, 83(2): Livshits A, Machtinger R, David LB, Spira M, Moshe-Zahav A, Seidman DS Ibuprofen and paracetamol for pain relief during medical abortion: A double-blind randomized controlled study. Fertility and Sterility, 91(5): Ipas Medical abortion study guide. Chapel Hill: North Carolina: Ipas. 8. Renner RM, Jensen JT, Nichols MD, Edelman A Pain control in first trimester surgical abortion. Cochrane Database Syst Rev.,(2): CD * This article is published as part of the newsletter Medical Abortion Matters, November For more information, contact media@ipas.org PO Box 5027, Chapel Hill, NC USA (voice) (toll-free in US) (fax) contact us privacy policy photo disclaimer Ipas. All rights reserved.

9 Ipas Perspectives: An interview with James Trussell, PhD, Office of Population Research at Princeton University Español WHO WE ARE WHAT WE DO WHERE WE WORK Perspectives: An interview with James Trussell, PhD, Office of Population Research at Princeton University Resources News Contact Us Jobs Sign Up for Newsletters November 2, 2011 Dr. Trussell is a senior fellow at the Guttmacher Institute, a member of the National Medical Committee of Planned Parenthood Federation of America, and a member of the board of directors of the NARAL Pro-Choice America Foundation and the Society of Family Planning. He serves on the editorial advisory committees of Contraception and Contraceptive Technology Update, and he is the author or coauthor of more than 300 scientific publications, primarily in the areas of reproductive health and demographic methodology. He tells Medical Abortion Matters about his views on contraceptive and medical abortion uptake and the barriers facing both. Do you see any similarities or differences between contraceptive uptake over the years and medical abortion uptake more recently? Dr. James Trussell As you well know, medical abortion is quite popular; when photo courtesy of Dr. James Trussell women have a choice, many of them will choose medical abortion. In sharp contrast, the very best contraceptives that we have the intrauterine contraceptives and the implants are hardly used by anyone, so there s a real disconnect here. We have a very high rate of unintended pregnancy in the United States, the rate of unintended pregnancy has changed hardly at all and the proportion of pregnancies that are unintended has changed hardly at all in 30 years, and it s not going to change unless there s more uptake of the long-acting, reversible methods [of contraception]. Does this suggest that women are more comfortable taking a pill than using methods of contraception they perceive to be more invasive and over which they seemingly have less control? I don t think we precisely know the answer to why women [in the United States] don t use [IUDs and implants]. There certainly are misperceptions about them. Do you think a reason that women have been so receptive to medical abortion is that it s presented in a very positive way? I think that certainly is the case. But my guess would be many more women know about medical abortion than know about IUDs or implants. What do you see as some obstacles to medical abortion uptake? Certainly we know that cost is an issue. Even women who have medical insurance don t by and large use it to pay for their abortions because they re afraid that their employer will somehow find out about it. Distance is a barrier for many women. More than a third of the women in the United States live in a county with no abortion provider at all. I think one of the real barriers is that it is not mainstreamed. Your garden-variety gynecologist is not going to provide it.

10 Ipas Perspectives: An interview with James Trussell, PhD, Office of Population Research at Princeton University You ve listed several barriers to medical abortion uptake in the United States. Do you think these same barriers exist in other countries? Certainly one of the challenges in the United Kingdom is getting new doctors to be able to do abortions. So teaching is a real problem now in the U.K., whereas in the United States at least [we currently have a strong private fellowship program in family planning that] has made a huge difference; it s had exactly the intended effect. Is another barrier to uptake the over-medicalization of medical abortion? That s not as much the case in the United States, but it certainly is in the United Kingdom where, for example, women aren t allowed to take misoprostol at home, so they have to go back [to the clinic]. And you can only [provide medical abortion] in the U.K. in hospitals and licensed clinics, so a regular OB-GYN couldn t even [offer the service] outside of a hospital or a licensed clinic. I would say in the United States it s not over-medicalized, but it s certainly over-regulated because of all the restrictions abortion opponents are adding on. Would it be better to have medical abortion available over the counter to women everywhere? I think it would be absolutely terrific. I don t think it will happen, but it certainly would be [a positive step]. What s much more interesting to me because it is happening is this push to use misoprostol to stop post-partum hemorrhage, which kills so many women worldwide. But then once [misoprostol] is out there, it can be used for medical abortion. If you could do one thing to reverse the cycle of high fertility rates, unplanned pregnancy, and maternal and infant mortality, what would it be? Much greater funding for family planning and universal availability of misoprostol to prevent post-partum hemorrhage. In addition to your research, you also maintain an emergency contraception website (not-2-late.com). What audience does it reach and how has it evolved? It s English, Spanish, French and Arabic. When we first put it up in 1994, it was just to show that it could be done. I think probably we were the first reproductive health website anywhere. We set up a hotline as well, but over time of course the website completely dominated the hotline with many times as many users. * This article is published as part of the newsletter Medical Abortion Matters, November For more information, contact media@ipas.org PO Box 5027, Chapel Hill, NC USA (voice) (toll-free in US) (fax) contact us privacy policy photo disclaimer Ipas. All rights reserved.