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Introduction Our objective was to compare outcomes of medication abortions using telemedicine or clinic visits. Other studies have found telemedicine abortions to be safe and effective, but no one has reported a comparison of direct-to-patient abortions and we also wanted to compare the un-scheduled communication with the two groups. Method This was a case-controlled chart review study comparing all the telemedicine medication abortions in one clinic to a control group matched for date seen. Basic demographics, outcomes and unscheduled visits or communications with staff and physicians were recorded. Results During the two years, we saw 4340 people requesting abortion, of whom 182 were seen only by telemedicine. We reviewed all their charts and a group of 199 in-clinic patients, matched for date seen. The ages and gestational ages were similar, but the telemedicine group lived much farther from the clinic (mean 5.5 h vs. 0.7 h, p Conclusions Providing medical abortions by telemedicine is safe, effective and feasible. Unscheduled communication with physicians was similar but unscheduled communication with clinic staff was more frequent.

Objective: The objective was to compare the practical aspects of providing medication abortions through telemedicine and in-person clinic visits so that clinics can use this information when planning to add this service. Study design: We conducted a comparative retrospective chart review comparing telemedicine medication abortions to a control group matched for date seen. We extracted and compared demographics, use of dating ultrasound, outcomes and unscheduled visits or communications with staff and physicians. Results: During the study period, we provided 4340 medication abortions, of which 182 (4.2%) were provided through by telemedicine; 199 patients met the criteria to be in the control group. The mean age was 28.7 years for telemedicine patients and 28.1 years for in-person patients (p = .38). The mean gestational ages were also similar, 48.2 days for telemedicine patients and 46.5 days for in-person patients (p = .03). Only 33 (18.1%) of telemedicine patients had dating ultrasounds compared to 199 (100%) of in-clinic patients (p 0.5). Unscheduled communications with office assistants were greater in the telemedicine patients than the in-person patients (84/182, 46.2% vs. 43/199, 21.6% in-person, p

Background Some licensing authorities require fasting before abortions under intravenous sedation to avoid aspiration of gastric contents. This study was conducted to estimate the incidence of anesthesia-related complications in women undergoing abortions without preprocedure fasting. Study Design This is a retrospective cohort chart review of patients having abortions with both fentanyl and midazolam at two urban free-standing abortion clinics with routine policy of advising women to eat a light meal before the procedure. Results There were no reports of anesthesia-related complications in the 47,748 charts reviewed from 1998 to 2010. Applying Hanley's formula for rare events that have not occurred, the upper 95% confidence interval for the true incidence of anesthesia-related complications for women having abortion under low-dose procedural sedation without fasting was estimated to be 0.00006%. Conclusions This large retrospective cohort chart review identified no complications related to low-dose procedural sedation in over 47,000 consecutive nonfasting patients having abortions through 18 weeks' gestation. Eliminating the requirement to fast would decrease unnecessary stress and unpleasant symptoms without increase in the anesthesia-related complications for women having abortions.

Objective: The objective of this study was to compare Rh alloimmunization rates in two countries (Canada and the Netherlands) with completely different policies regarding abortion-related use of anti-D immunoglobulin to ultimately determine any benefit in use. In the Netherlands, the policy is to offer anti-D immunoglobulin to Rh-negative women having spontaneous abortions over 10 weeks 0 days gestation and induced abortions over 7 weeks 0 days. In Canada, it is recommended to offer all Rh-negative women having induced or spontaneous abortions anti-D immunoglobulin. Methods: We used public databases to obtain the population data, the number of births, the abortion rates (the percentage of women having induced abortions in one year) and the Rh-negativity rates (percentage of Rh negative women) in Canada and the Netherlands. Both countries do routine prenatal blood screening and we obtained the rates of clinically significant antibodies from public databases. Results: In nearly 2 million blood samples from pregnant women in both Canada and the Netherlands, the prevalence of clinically significant antibodies was statistically lower in the Netherlands: 4.21 (95% CI: 4.12 to 4.30) and 4.03 (95% CI: 3.93 to 4.12) per 1000, respectively. Canada and the Netherlands had small differences in rates of abortion (1.9 per 100 vs 1.2 per 100) and of Rh negativity (13.0% vs 14.5%). Conclusion: Despite different anti-D Ig treatment policies, we found a similar prevalence of clinically significant perinatal antibodies among women in Canada and the Netherlands. Implications: Our findings suggest that The Dutch policy of not treating Rh-negative women having spontaneous abortions under 10 weeks’ or induced abortions under 7 weeks’ gestation can be safely adopted by other countries. Keywords: Abortion, induced, Pregnancy trimester, first, Rho(D) immune globulin, Rh isoimmunization, Erythroblastosis, fetal

The objective of this study was to estimate the menstrual cycle day of conception in women presenting for abortion.This was a retrospective chart survey in two urban free-standing abortion clinics.There were 913 charts reviewed of women presenting for an abortion at less than 63 days' gestation as determined by endovaginal ultrasound who were "sure" of the date of their last normal menstrual period. The estimated mean cycle day of conception determined by sonographically estimating length of gestation was 14.6. There were 26 (26.3%) of 99 women using cyclic hormonal contraception who conceived before 10 days after the onset of withdrawal bleeding compared to 100 (14.7%) of 679 who conceived before 10 days after the onset of their last menstrual period who were using all other forms of contraception, including "none" (p=.005). No other differences in the proportions conceiving early in the cycle were observed with respect to age, ethnicity or obesity.These data suggest that there is a sizeable subset of women who ovulate earlier after onset of withdrawal bleeding when using 21/7 hormonal contraceptives than after onset of menses when not using hormonal contraception. It is possible that women using hormonal contraceptives may have a higher risk of pregnancy if they ovulate sooner after the onset of bleeding.

The requirement that every woman desiring medical abortion must come in person to a clinical facility to obtain the drugs is a substantial barrier for many women. To eliminate this requirement in the United States, two key components of the standard initial visit would need to be restructured. First, alternatives to ultrasound and pelvic exam would need to be identified for ensuring that gestational age is within the limit for safe and effective treatment. This is probably feasible: for example, data from a large study suggest that in selected patients menstrual history is highly sensitive for this purpose. Second, the Food and Drug Administration would need to remove the medically unwarranted restriction on distribution of mifepristone. These two changes could allow provision of the service by a broader range of providers in nontraditional venues or even by telemedicine. Such options could have profound benefits in reducing cost and expanding access to abortion.

Objective To compare the efficacy, adverse effects and acceptability of the three most common misoprostol regimens used with mifepristone for medical abortion. Design Randomised nonblinded trial. Setting Three clinics associated with major research universities in Canada; two in major urban areas and one in a periurban area. Population Women of reproductive age. Methods Consenting women presenting for abortion services with gestations less than 56 days and who met inclusion criteria were given 200 mg mifepristone orally and then randomised into three misoprostol study groups: (group I) 400 micrograms of oral misoprostol, (group II) 600 micrograms of oral misoprostol, and (group III) 800 micrograms of vaginal misoprostol. Misoprostol was self-administered at home 24–48 hours following mifepristone, and participants were instructed to take a second similar misoprostol dose at 24 hours after the initial dose if bleeding was less than a normal menstrual period. Main outcome measures Successful abortion without surgery was 94.1%, with no significant differences across the three study groups (94.7% in group I, 93.4% in group II, and 94.3% in group III; P= 0.975). Results Efficacy and adverse effects did not differ significantly across the three study groups. Pain increased significantly across the study and the gestational age groups and was associated with lower acceptability. Conclusions There appears to be a range of safe and effective options for early medical abortion with mifepristone including a choice between oral and vaginal administration of misoprostol.

Objective The primary objective of this study was to determine if buccal misoprostol was as effective as vaginal misoprostol in medical abortions. The secondary objectives were to compare side effects and acceptability. Methods This was a randomized controlled trial of 600 μg misoprostol by the buccal or vaginal routes used 3 to 6 days after 50 mg/m2 methotrexate. The participants were women presenting for abortion at 49 days or less gestation. The outcome measures were the number of women who had aborted by Day 8, side effects and acceptability. Results Day 8 completion rate was 53.5% for the buccal route and 67.5% for the vaginal route (p = 0.012). Side effects were similar in the two groups except that there was more burning with the buccal route. Overall acceptability and route acceptability were similar in the two groups. Conclusions When used after methotrexate for early abortion, the vaginal route for misoprostol is more effective and preferred to the buccal route.

Objectives: 1) To describe and compare knowledge and attitudes about contraception and abortion of women in Canada, US, UK, France and Australia. 2) To assess usefulness and validity of online panels to conduct this type of research. Method: We used Survey Monkey Audience to obtain a sample of women aged 18-44 to administer a survey about knowledge and attitude to contraception and abortion. We assessed the representativeness of our samples by comparing the demographics and attitudes to relevant data in each country. Results: 1117 surveys were completed in January 2013: 233 in Canada, 223 in the US, 230 in the UK, 221 in France and 210 in Australia. The majority of women incorrectly believed abortion and contraception were more risky than births. About half (47.1%) of the participants were classified as pro-choice because they indicated that women should be allowed to have an abortion for any reason in the first 3 months: 38.7% in Canada, 37.1% in USA, 42.0% in UK, 68.7% in France and 53.6% in Australia (p

OBJECTIVE: To compare the effectiveness, side effects, and acceptability of medical abortions induced by methotrexate and misoprostol with abortions induced by mifepristone and misoprostol. METHODS: This was a multicenter, randomized, nonblinded, controlled trial comparing 50 mg/m2 of methotrexate followed 4–6 days later by 800 μg of vaginal misoprostol with 600 mg of oral mifepristone followed 36–48 hours by 400 μg of oral misoprostol. RESULTS: There were 518 women in the methotrexate group and 524 women in the mifepristone group. In the methotrexate group, 21 women required suction curretage, two for continuing pregnancy, eight because of physician request (usually for excessive bleeding), and 11 because of patient request. In the mifepristone group, 22 women needed surgical termination, 17 because of physician request, and five because of patient request. By day 8, only 386 (74.5%) in the methotrexate group had completed the abortion compared with 474 (90.5%) in the mifepristone group, and the mean number of days from beginning to completion was 7.1 for methotrexate and 3.3 for mifepristone (P ≤ .001). There were no differences in complications, and side effects were similar. Acceptance was slightly higher with mifepristone (88.0%) than with methotrexate (83.2%). CONCLUSION: Abortions induced with mifepristone completed faster than those induced with methotrexate, but the overall success rates, side effects, and complications were similar. Acceptance rates were slightly higher with mifepristone than methotrexate (P = .03).

Objective: Our aim was to find out whether intravenous fentanyl was effective in reducing the pain of first-trimester abortion. Study Design: This randomized controlled trial included 825 women attending a nonhospital abortion facility. Some women chose standard care. Women who did not choose standard care were randomly assigned to receive either 50 to 100 μg of fentanyl, a placebo, or no intervention. With SAS software and a mixed effects analysis of variance model with covariates, we compared mean pain scores of the fentanyl and placebo groups to detect a difference of at least 1 point on an 11-point pain scale. Results: The mean pain score of the fentanyl group was 1.0 point less than that of the placebo group (95% confidence interval, 3.7-4.3) and 0.9 point less than that of the observational group (95% confidence interval, 4.7-5.1). This pain reduction was statistically significant, but the women who were studied wanted a 2-point reduction from fentanyl. Conclusion: Fentanyl, when compared with the placebo, reduced abortion pain by 1.0 point on an 11-point scale. This reduction was of questionable clinical significance and was less than desired by the women included in the study. (Am J Obstet Gynecol 2001;185:103-7.)

This was a prospective cohort questionnaire study to compare the loss of ability to work in 62 women having medical and 69 having surgical abortions. Outcomes included the number of days lost from work outside the home and inside the home before and after the abortion appointment. The mean total loss from work inside the home was 10.1 days for the surgical group and 5.3 days for the medical group (P

Background The objectives of this study were to assess perceptions of women viewing the products of conception after abortion and to assess the feasibility of offering this choice. Study Design Women presenting for abortion at two abortion clinics were given a questionnaire asking if they wished to view the products of conception. A second questionnaire was given to women who had viewed products of conception about their perceptions. Clinic staff members were interviewed after completion of the study. Results The study revealed that 152/508 (28.7%) of women having abortions chose to view the products of conception and 98/122 (83.1%) found that viewing did not make it harder emotionally. Older women and those who had children were less likely to want to view products of conception (p=.037) and more likely to find it harder if they did (p=.05). All 11 clinic staff members interviewed were positive about offering this service. Conclusions It is feasible to offer women having abortions the choice to view the products of conception and for most, viewing does not make it emotionally harder for them.

Objective: This study was undertaken to compare oral to injected methotrexate with respect to effectiveness, side effects, and acceptability. Study Design: One hundred women in an urban primary care practice were randomly assigned in phase 1 to receive 50 mg/m 2 methotrexate by either the oral or the injected route. In phase 2 another 87 women were allowed to choose between the oral and injected routes. In both phases and in all groups the methotrexate was followed 5 to 7 days later by misoprostol administered vaginally by the patient. The main outcome was the success rate (the number whose pregnancies aborted without surgery); other outcomes included side effects and acceptability. Results: There were no differences in rates of success, side effects, or acceptability between groups receiving oral and injected methotrexate. Among the women in phase 2 the oral form was chosen by 57.5%. Conclusion: This study indicates that for medical abortions induced with methotrexate and misoprostol it is possible to offer both the oral and injected routes of methotrexate without sacrificing efficacy and that about half of the women offered a choice will choose the oral route. (Am J Obstet Gynecol 1999;181:149-52.)

The purpose of this study was to compare tamoxifen to methotrexate, with respect to effectiveness, when followed by misoprostol to induce abortion. In the first phase, 198 women presenting for medical abortion at7 weeks gestation were randomized to receive either 40 mg of tamoxifen, followed 2 to 3 days later by 800 micrograms of misoprostol self-administered vaginally or 50 mg/m2 of methotrexate, followed 5 to 7 days later by the same dose of misoprostol. In the second phase, 200 women were randomized to receive 20 mg tamoxifen twice daily for 4 days, followed by 800 micrograms misoprostol or the same regimen of methotrexate and misoprostol as in phase 1. The main outcome measure was success rate determined by the number of women who aborted without surgery. In phase 1, the success rate was higher in the methotrexate group (93.0%) compared to the tamoxifen group (85.7%) (p = 0.045). In the tamoxifen group, nine of 98 women had incomplete abortions with symptoms requiring a surgical aspiration, compared to one of 100 women in the methotrexate group. In phase 2, the success rates were 90.9% in the methotrexate group compared to 84.7% in the tamoxifen group (p = 0.20). The side effects were less in the tamoxifen group in phase 1 but not in phase 2. When tamoxifen is given as a single dose, it is less effective than methotrexate but when it is given 20 mg twice daily for 4 days, there is no significant difference. Tamoxifen does not appear to have any benefits over methotrexate.This study aims to compare the effectiveness of tamoxifen with that of methotrexate when each is used in combination with misoprostol for abortion. In the 1st phase of the study, 198 medical abortion cases at 7 weeks gestation were randomized to receive either 40 mg of tamoxifen followed by 800 mcg of misoprostol after 2-3 days or 50 mg/sq. m of methotrexate followed by the same dose of misoprostol after 5-7 days. In the 2nd phase, 20 mg tamoxifen twice daily for 4 days was administered to 200 women, followed by 800 mcg misoprostol or the same methotrexate and misoprostol regimen as in phase 1. The number of women who experienced abortion without surgery was determined to measure the success rate. The success rate in phase 1 was higher in the methotrexate group (93.0%) than in the tamoxifen group (85.7%) (p = 0.045). About 9 in 98 women in the tamoxifen group and 1 in 100 women in the methotrexate group had incomplete abortions, indicating surgical aspirations. In the 2nd phase, the success rates were 90.9% in the methotrexate group and 84.7% in the tamoxifen group (p = 0.20). There were fewer side effects in the tamoxifen group during the 1st phase but not in the 2nd phase. Tamoxifen was seen to be less effective than methotrexate if given in a single dose. There was no significant difference when tamoxifen was given in 20 mg doses twice daily for 4 days. There were no advantages observed in tamoxifen over methotrexate.

This was a dual-cohort study performed to determine if, by using methotrexate alone, abortions could be induced with fewer side effects, without sacrificing effectiveness and patient satisfaction. The subjects were 358 consecutive patients who requested elective medical termination of pregnancy at7 weeks gestation. Women were given information and allowed to choose between methotrexate alone (50 mg/m2 intramuscularly) or methotrexate followed 4 days later by 800 micrograms misoprostol vaginally. The two groups were compared with respect to the number of surgical aspirations required, the number of days until the abortion was completed, side effects, and the number of women who would choose the same method again. The surgery rate for methotrexate was 17.2%, whereas for the combination it was 10.9%. The mean numbers of days until the abortion were complete was 23 and 12, respectively. Side effects, mean pain scores, total days of bleeding, and satisfaction rates were not significantly different in the two groups. The high failure rate with methotreaxate alone suggests that it should not be offered despite the high level of satisfaction.A dual-cohort study was conducted to determine whether abortion induced by methotrexate alone produces fewer side effects than a misoprostol-methotrexate regimen without sacrificing efficacy. 358 consecutive Canadian abortion seekers with pregnancies of 7 weeks' gestation or less were given the choice of a regimen of 50 mg/sq. m of intramuscular methotrexate or methotrexate followed 4 days later by 800 mcg of vaginal misoprostol. 101 women chose the former and 257 opted for the latter regimen. Women tended to choose the methotrexate-only regimen to avoid misoprostol-related side effects; selection of the combination was motivated by a desire for a rapid pregnancy termination. 82 women (82.8%) in the methotrexate-only group and 228 (89.1%) in the combination group aborted successfully. The failure rate in both groups was significantly higher when the procedure was performed at 6 or more weeks of gestation. It took a mean of 23.1 days from injection to complete abortion in the methotrexate-only group compared with 11.7 days in the methotrexate-misoprostol group. More than half the women had medication-related side effects, primarily nausea, vomiting, and diarrhea, with no significant differences between groups. The mean number of days of bleeding was 9.0 in the methotrexate-only group and 10.1 in the combination group. The mean worst pain score (on an 11-point scale) was 6.4 in the former and 6.1 in the latter group. 91.8% of women in the methotrexate-only group and 90.7% of those in the misoprostol-methotrexate group who successfully aborted stated they would chose the same method again. Given the high failure rate, methotrexate alone should not be offered routinely to abortion seekers. Its use should be reserved for women with very early pregnancies who have relative contraindications for misoprostol.

Misinformation about the risks and sequelae of abortion is widespread. The purpose of this study was to examine whether women having an abortion who believe that there should be restrictions to abortion (i.e., that some other women should not be allowed to have an abortion) also believe this misinformation about the health risks associated with abortion.We carried out a cross-sectional survey of women presenting consecutively for an abortion at an urban abortion clinic in Vancouver, British Columbia, between February and September 2012.Of 1008 women presenting for abortion, 978 completed questionnaires (97% response rate), and 333 of these (34%) favoured abortion restrictions. More women who favoured restrictions believed that the health risk of an abortion was the same as or greater than the health risk of childbirth (84.2% vs. 65.6%, P0.001), that abortion caused mental health problems (39.1% vs. 28.3%, P0.001), and that abortion caused infertility (41.7% vs. 21.9%, P0.001). Using multivariate logistic regression analyses, believing that abortion should not be restricted was found to be a significantly correlated with correct answers about health risks, mental health problems, and infertility.Misinformed beliefs about the risks of abortion are common among women having an abortion. Women presenting for abortion who favoured restrictions to abortion have more misperceptions about abortion risks than women who favour no restrictions.

In this double-blind study, 104 women were randomized to receive 1 mg lorazepam or placebo prior to a first-trimester abortion. In addition, 262 women were allowed to choose whether or not to take the lorazepam. The outcome measures were 11-point verbal pain scales of pain during the abortion and anxiety measured before premedication and during the abortion. The mean anxiety and pain scores did not differ significantly in the lorazepam and placebo groups of the randomized trial. In the observational group, the women who took lorazepam had their mean anxiety score drop from 5.5 to 4.7 while in those who did not take it, the score rose from 3.8 to 4.9. This study indicates that giving oral benzodiazepines preoperatively is neither helping nor hurting our patients but the placebo effect can be helpful to make our patients more comfortable.

[1] Committee on Obstetric Practice. ACOG committee opinion. Exercise during pregnancy and the postpartum period. Number 267, January 2002. American College of Obstetricians and Gynecologists. Int J Gynecol Obstet 2002;77(1):79–81. [2] Royal College of Obstetricians and Gynecologists. Exercise in Pregnancy (RCOG Statement 4). www.rcog.org.uk. http://www.rcog.org.uk/womens-health/clinicalguidance/exercise-pregnancy. Published 2006. [3] Macera CA, Ham SA, Yore MM, Jones DA, Ainsworth BE, Kimsey CD, et al. Prevalence of physical activity in the United States: Behavioral Risk Factor Surveillance System, 2001. Prev Chronic Dis 2005;2(2):A17. [4] WardM,McGee H, Morgan K, Van Lente E, Layte R, BarryM, et al. SLAN 2007. Survey of Lifestyle, Attitudes and Nutrition in Ireland. ‘One Island—One Lifestyle?’ Health and lifestyles in the Republic of Ireland and Northern Ireland: Comparing the population surveys SLAN 2007 and NIHSWS 2005. www.drugsandalcohol.ie. http:// www.drugsandalcohol.ie/12449/1/slan_oneisland.pdf. Published 2009. [5] American College of Obstetricians and Gynecologists (ACOG). Exercise During Pregnancy and the Postpartum Period. Technical Bulletin #8. Washington, DC, USA: American College of Obstetricians and Gynecologists; 1985. [6] Bell RJ, Palma SM, Lumley JM. The effect of vigorous exercise during pregnancy on birth-weight. Aust N Z J Obstet Gynecol 1995;35(1):46–51. [7] Goodwin A, Astbury J, McMeeken J. Body image and psychological well-being in pregnancy. A comparison of exercisers and non-exercisers. Aust N Z J Obstet Gynecol 2000;40(4):442–7. [8] Cali AM, Caprio S. Obesity in children and adolescents. J Clin Endocrinol Metab 2008;93(11 Suppl 1):S31–6.

To gain a better understanding of women's perceptions and experiences of viewing the ultrasound (US) before an abortion.This mixed-methods study included questionnaires and interviews. Women presenting for medical and surgical abortion at two urban abortion clinics completed questionnaires asking if they wished to view the US image and those women who had done so answered questions about their perceptions. A randomly selected ten women were interviewed six weeks later about their perceptions. The interviews were audio-taped, transcribed and analysed for salient themes.The 350 participants had a mean age of 27.6 years, 0.68 births, and were at a mean of 49.1 days gestation at the time of the procedure. Most women (254/350, 72.6%) chose to view the US and 179/219 (86.3%) found it a positive experience. Older women and those who had children were less likely to want to view the US image (p = 0.001). All ten interviewees recommended that this choice be offered to every woman and recommended more communication between care providers and patients at the time of the US. None of the women changed her mind about having the abortion after having seen the US.Offering the choice to view the ultrasound is both feasible and beneficial to women having abortions. Our findings support those of the only other study published on the subject.

Objective Whether Canadian physicians can refuse to refer women for abortion and whether private clinics can charge for abortions are matters of controversy. We sought to identify barriers to access for women seeking therapeutic abortion and to have them identify what they considered to be most important about access to abortion services. Methods Women presenting for abortion over a two-month period at two free-standing abortion clinics, one publicly funded and the other private, were invited to participate in the study. Phase I of the study involved administration of a questionnaire seeking information about demographics, perceived barriers to access to abortion, and what the women wanted from abortion services. Phase II involved semi-structured interviews of a convenience sample of women to record their responses to questions about access. Responses from Phase I questionnaires were compared between the two clinics, and qualitative analysis was performed on the interview responses. Results Of 423 eligible women, 402 completed questionnaires, and of 45 women approached, 39 completed interviews satisfactorily. Women received information about abortion services from their physicians (60.0%), the Internet (14.8%), a telephone directory (7.8%), friends or family (5.3%), or other sources (12.3%). Many had negative experiences in gaining access. The most important issue regarding access was the long wait time; the second most important issue was difficulty in making appointments. In the private clinic, 85% of the women said they were willing to pay for shorter wait times, compared with 43.5% in the public clinic. Conclusion Physicians who failed to refer patients for abortion or provide information about obtaining an abortion caused distress and impeded access for a significant minority of women requesting an abortion. Management of abortion services should be prioritized to reflect what women want: particularly decreased wait times for abortion and greater ease and convenience in booking appointments. Since many women are willing to pay for services in order to have an abortion within one week, this option should be considered by policy makers.

Background: The purpose of this study was to determine whether East Asian women had more side effects and a higher discontinuation rate than Caucasian women when choosing to use hormonal contraceptives. Study Design: This was an observational cohort study of usual care using questionnaires for 2 months after being given hormonal contraceptives following an abortion in Vancouver, Canada. Results: In the first month, 73 (64.4%) of the 110 East Asian and 86 (80.4%) of the 107 Caucasian women took any of the sample provided (p=.020). In the second month, 52 (47.3%) of the East Asian and 62 (57%) of the Caucasian women used the prescription to buy and take their hormonal contraception (p=.12). Total side effects were similar, but there was more nausea in the East Asian women (23.3% vs. 8.1%) (p=.03) and more acne in the Caucasian women (8.2% vs. 20.9%) (p=.05). Conclusions: There may be both physiological and cultural differences leading East Asian women to use less hormonal contraception.

⁎ Corresponding author. 1013-750 West Broadway, Vancouver, BC, Canada. Tel.: +1 604 709 5611; fax: +1 604 873 8304. E-mail address: ewiebe@interchange.ubc.ca (E. Wiebe). following methotrexate must be used. A review of studies using regimens of methotrexate followed by misoprostol or misoprostol alone found that failure rates were lower with the combined regimens [1]. The major disadvantage of methotrexate compared with mifepristone regimens is the slower speed of action. [2]. A study of misoprostol-only regimens found that the highest success rates were obtained using 800 μg misoprostol within 24 h [3]. The present study was a retrospective sequential cohort comparison trial of abortions induced in women with a pregnancy of 49 days of gestation or less, documented by endovaginal ultrasound. All women were treated similarly, with 50 mg/m2 methotrexate (Novopharm, Toronto, Canada) followed 1–5 days later by vaginal misoprostol (Apotex, Weston, Canada). Four groups of different doses of misoprostol were established: Group 1 with 800 μg once; Group 2 with 600 μg 3 times 24 h apart; Group 3 with 600 μg 3 times in 24 h (4–12 h apart); and Group 4 with 800 μg 3 times in 24 h seroprevalence. It is hoped that further expansion of TOP services in South Africa will effect a sustained reduction in maternal deaths related to septic abortion. References

Objective To review published reports of first-trimester medical abortion regimens that do not include mifepristone. Methods Reports listed in Pubmed and Medline on prospective and controlled trials of the efficacy of misoprostol, alone or associated with methotrexate, for first-trimester abortion were analyzed if they included more than 100 participants and were published since 1990. Results The efficacy of regimens using misoprostol alone ranged from 84% to 96%, and when misoprostol was used with methotrexate the efficacy ranged from 70% to 97%. Efficacy rates were influenced by follow-up interval. Treatment for infection, bleeding, and incomplete abortion were infrequent with both methods (0.3%–5%). Conclusion Alone or in combination with methotrexate, misoprostol is an efficacious alternative to mifepristone for the medical termination of pregnancy.

Objective : To examine attitudes of women presenting for elective abortions. Method : Women presenting for elective abortion induced with medication at an urban free-standing abortion clinic were given semistructured interviews about their attitudes to abortion. Results : Of the 60 women interviewed, 26 voiced antiohoice attitudes. These interviews were transcribed and analyzed for themes. The women with antichoice attitudes were similar to the women with prochoice attitudes in age, education, and religion but were less likely to be white (61.8% of prochoice women identified themselves as white, compared with 30.8% of antichoice women, P=0.02). The antichoice women felt most strongly that other women should not be allowed to have an abortion if they gave as their reason, "want no more children," "not married," or "cannot afford." The most common themes were that one needed "enough" reasons to have an abortion and that women should take better precautions to prevent conception. Conclusion : It is important for abortion clinic staff to realize that many women coming to an abortion clinic have antichoice views. These views may affect a woman's ability to recover emotionally after the procedure and will therefore have implications for the kind of supportive care women need both before and after the abortion.

Telemedicine has been used to provide abortion in severalways. The website Women onWeb [1] uses e-mail support to facilitate the provision of medical abortion to women in situations in which safe abortion is not available [2]. Some US clinics offermedical abortions in which the patients see a counselor in the clinic but see the doctor via videoconferencing [3]. Routine ultrasound is usually used to date the pregnancy and determine abortion success in North America but serial quantitative human chorionic gonadotropin (hCG) values can also be used [4]. Because mifepristone is not available in Canada, the usual regimen is methotrexate (50 mg/m intramuscularly or orally) followed by misoprostol (800 μg vaginally) repeated twice 4–12 hours later. This regimen has a similar success rate to that of mifepristone plus misoprostol [5]. We conducted a retrospective chart review of women who underwent medical abortion via telemedicine between May 1, 2012, and May 1, 2013, at Willow Women’s Clinic, Vancouver, Canada. The study was approved by the Research Ethics Board at the University of British Columbia, Vancouver, Canada. To be eligible for a telemedicine abortion at the study clinic, women must live in British Columbia (where the clinic physicians are licensed); have access to a laboratory for timely serum quantitative hCG estimations; and be able to travel to the clinic or to another community facility for surgical completion, if necessary. They see a physician and counselor via Skype (Microsoft Skype Division, Luxembourg City, Luxembourg) videoconferencing for screening, information, and consent. Thewomen go to a local laboratory for hCG tests at initial screening, on the day of the medication, and 1 week later (3 tests). If their hCG level is above 5000mIU/mL, an ultrasound is arranged. Rhesus-negative women are offered anti-D; this is arranged through a local facility. Themedications are couriered or a prescription is faxed to a local pharmacy. Women have a follow-up videoconferencing appointment to discuss their blood test results and any reactions to the medications. If their hCG level has fallen by 80% in 1 week, women are informed that the abortion is complete and that they require no further follow-up. If additional medication, surgery, or further blood tests are required, they are arranged by the clinic. Between May 2012 and May 2013, 11 women underwent medical abortion via telemedicine at the study clinic (Table 1). One woman experienced spontaneous abortionwith nomedication, 1woman required surgical completion, and 1 woman was lost to follow-up; the other women experienced uneventful medical abortion. During the study period, a further 29 women were seen in-clinic for their first visit and ultrasound, with scheduled videoconferencing for follow-up; in addition, 1858 women made regular in-clinic visits. The main innovation with regard to this program is that we see patients in their own homes using their own technology (a computer or smart phone), yet provide the same physician and counseling services as we do in the clinic. This method of providing abortion via telemedicine is feasible in the present setting and may improve access to abortion.

Objective: To examine the differences in anxiety levels and attitudes towards abortion between women having an early medical abortion and women having a surgical (manual vacuum aspiration) abortion. Methods: Women who presented for an early medical abortion or a surgical abortion at an urban, free-standing abortion clinic were invited to participate in this study. Fifty-nine women having a medical abortion and 43 women having a surgical abortion answered questionnaires before their scheduled abortion, and again 2 to 4 weeks after the abortion. Thirty women were interviewed about their answers. Results: Anxiety levels were similar in both groups before the abortion procedure. Anti-choice views about abortion were seen in 60.5% of women having a medical abortion and in 37.3% of women having a surgical abortion ( P = .027). Women who were pro-choice had a mean anxiety score of 5.0 (range, 0–10) before and 2.7 after the abortion, whereas women who were anti-choice had a mean anxiety score of 5.2 before and 4.4 after the abortion ( P = .005). Conclusion: It is important for providers of abortion care to understand that women undergoing a medical abortion may be more ambivalent about abortion than women undergoing a surgical abortion, and women who are anti-choice but having an abortion may have unresolved anxiety after the procedure.

Objective The purpose of this study is to monitor the content, timing of and response to telephone calls from medical and surgical abortion patients in order to improve the counseling and nursing care and allay patient's concerns. Methods There were 43 calls from a possible 626 surgical patients and 100 calls from a possible 671 medical patients. Calls were considered preventable in 67% of the medical patients and 46.5% of the surgical patients. Women who were having their first abortion were more likely to place preventable calls. Conclusions Calls could be reduced by explaining variations in normal bleeding and how to use analgesics and providing this information in diagrammatic form on an information sheet.

Objective To gain a better understanding of ethnic Chinese women's perceptions and experiences of using barrier and rhythm methods of contraception in order to improve contraceptive counseling at abortion clinics. Design Qualitative descriptive study. Setting Urban abortion clinic. Participants Forty ethnic Chinese women presenting for abortion. Method Data were collected in semi-structured interviews by one interviewer who is fluent in English, Mandarin and Cantonese. Transcribed interviews were systematically analyzed to identify salient themes. Main findings All of the women interviewed had used condoms (none with spermicide), 20 had used rhythm and 17 withdrawal, usually a combination of two or three of these methods. Many women noted that these methods are under male control and talked about the difficulty negotiating their use with partners. The majority of women using rhythm were unable to correctly identify “safe periods.”

This article discusses a study that aimed to determine the rate characteristics and experience of women who reported that they had used anal sex as a method of contraception. The questionnaire survey was conducted of women presenting for an abortion at an urban abortion clinic in Canada and contained questions about womens usage and experiences of natural family planning methods including anal sex. Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

The purpose of this study was to identify barriers to the use of oral contraceptives by ethnic Chinese women presenting for abortion. Using a qualitative descriptive study design, 40 ethnic Chinese women presenting for abortion were recruited. Data were collected in semi-structured interviews by one interviewer who is fluent in English, Mandarin, and Cantonese. Transcribed interviews were systematically analyzed to identify salient themes. The attitudes toward oral contraceptives were mostly negative. The most common fears were about weight gain, permanent infertility, and being considered "bad" (promiscuous). These mostly negative attitudes toward oral contraceptives appear to be barriers to their use.

Objective To determine the risks of short term adverse events in adolescent and older women undergoing medical abortion. Design Population based retrospective cohort study. Setting Finnish abortion register 2000-6. Participants All women (n=27 030) undergoing medical abortion during 2000-6, with only the first induced abortion analysed for each woman. Main outcome measures Incidence of adverse events (haemorrhage, infection, incomplete abortion, surgical evacuation, psychiatric morbidity, injury, thromboembolic disease, and death) among adolescent (

Objectives: In patients having medical abortions with methotrexate and misoprostol: (1) to determine if giving ibuprofen or acetaminophen plus codeine with misoprostol (prior to onset of pain) prevented severe pain; and (2) to determine if there were predictors of medical abortion pain. Methods: A group of 281 women randomized to receive placebo, ibuprofen or acetaminophen with codeine. This was taken at home with the misoprostol 4–6 days after the methotrexate. Results: There were no significant differences between the three groups with respect to age, gestational age, parity, anxiety, depression, worst period pain score, and ethnicity. There was no significant difference with respect to rates of severe pain scores. The mean pain score for the entire group was 6.2 on a scale of 0 to 10. Severe pain (scores of 9 or 10) were reported by 23.4% of women and in this group, the mean maternal age was lower (P=0.05), parity was lower (P=0.01), worst period pain scores were higher (P=0.001), anxiety scores were higher (P=0.05) and satisfaction was lower (P=0.01). Conclusions: The pain experienced in medical abortion causes significant distress and more research is needed to reduce it.

Most induced abortions in North America are performed under local anesthesia but many clinics provide supplementary medication in an effort to improve pain control. This study investigated the efficacy of conscious sedation (use of intravenous tranquilizers intravenous narcotics or inhaled nitrous oxide) in pain control through a comparison of patient experiences at randomly selected member clinics of the National Abortion Federation in the US and Canada. A total of 304 women were enrolled at 7 clinics offering conscious sedation and another 336 abortion patients were enrolled at 7 clinics that did not offer such sedation. Abortion patients were asked to rate their pain 5-30 minutes after the procedure on a scale of 0-10. The mean pain score was 4.41 at clinics offering conscious sedation and 5.32 at the remaining clinics. Women who actually received conscious sedation had a mean pain score of 4.00 compared with 5.27 among women not requesting or receiving such sedation (p = 0.001). Further investigation is needed to determine whether the risks side effects and discomfort associated with conscious sedation are outweighed by the approximately 1 point reduction in pain score.

Misoprostol a stable and inexpensive prostaglandin has been shown to be effective in preparing the cervix for induced abortion. However in 3 studies in which 200-400 mcg of misoprostol was inserted vaginally 30-60 minutes 6 hours and 12 hours respectively prior to induced abortion cervical dilatation was enhanced but many women experienced pain and bleeding before the procedure. The present study investigated whether vaginal insertion of 750 mcg of misoprostol 2 hours prior to induced abortion would prepare the cervix effectively with fewer side effects than were recorded in previous studies. Study participants were randomly assigned to receive either misoprostol (n = 46) or placebo (n = 47). Mean maternal age (26 years) gestational age (8 weeks) and parity (0.66 and 0.85) were the same or similar in both groups. The Pratt dilator first met resistance at 19.6 among controls and 21.4 among cases. The time taken to dilate was 63.9 seconds among controls and 54.6 seconds with misoprostol. The mean pain score on a 0-10 scale was 4.73 in the placebo group and 4.69 with misoprostol. There were no side effects in either group. These results indicate that misoprostol used vaginally 2 hours before abortion induction is not an effective way of preparing the cervix.

In an urban clinic providing abortions, it was noted that many women presenting for abortion were anemic. The U.S. National Health and Nutrition Examination Survey III established prevalence of anemia, defined as a hemoglobin lower than 120 g/ L, at 5.1% of the non-pregnant women in the population [1]. There are observational studies that associate anemia diagnosed prior to midpregnancy with increased risk of pre-term delivery, low birth weight, and fetal mortality [2,3]. A metaanalysis of trials of iron supplementation in pregnancy showed no detectable effect on any substantive functional measures of either maternal or fetal outcome [4]. The purpose of this study was to determine the prevalence of anemia in this population, identify

Seven hundred fifty-six women had abortions induced with methotrexate and misoprostol. Various protocols were compared. In Group 1, phase 1, after receiving 50 mg/m 2 methotrexate IM, 289 women were randomized to receive either 750 or 500 μg of vaginal misoprostol. In Group 1, phase 2, 84 women who had failed to abort after one dose of misoprostol were randomized to receive either vaginal or oral routes for the second dose of misoprostol given on Day 8. In Group 2, a cohort of 226 women who received 60 mg/m 2 methotrexate were compared to the 289 women who received 50 mg/m 2 in Group 1. There were no differences in rates of effectiveness in the various trial groups. Side effects were greater with 60 mg/m 2 of methotrexate. In Group 3, a cohort of 241 women received the misoprostol in three vaginal doses 8 hr apart starting on Day 5, and were compared to the 289 women in Group 1 receiving one vaginal dose. In women whose medical abortion failed, fetuses were found to have limb abnormalities. In the total group of 756 women, 88.8% aborted successfully without surgical aspiration, with only minor side effects, and the acceptance rate was high. This study indicates that medical abortions induced with methotrexate and misoprostol are safe and effective, but more research is needed to find a more effective protocol.

The objective of this study was to determine whether it is possible to reduce the concentration of lidocaine without increasing the pain experienced by women undergoing abortion under local anesthesia. According to an informal survey at the National Abortion Federation meeting in April 1995, the most common dose of local anesthetic used for abortion was 20 ml l.O”/ lidocaine. The manufacturer’s maximum recommended dose of lidocaine is 4.5 mglkg so this dose of 200 mg is close to the toxic dose, especially for small women. Therapeutic abortions are very safe but anesthetic reactions are the most common cause of abortionrelated death [1,2]. If it is possible to reduce the concentration of lidocaine without increasing the amount of pain experienced, the dose could be reduced below that known to cause toxic reactions.

Objective: To reduce the pain experienced during abortion. Methods: A four-phase study was conducted at a free-standing abortion clinic. Phase 1: a double-blind, randomized, placebo-controlled trial of 600 mg ibuprofen given preoperatively was carried out in 193 women. Pain during the procedure and 30 min postoperatively was compared. Phase 2: a double-blind, randomized trial compared 1% lidocaine, buffered 1% lidocaine and 0.25% bupivacaine in terms of the pain of the injection and the pain of the procedure in 200 women. Phase 3: waiting times of 0, 3 and 10–20 min between the end of the injection and the beginning of the procedure were compared in terms of pain during the procedure in 139 women. Phase 4: local anesthetic was injected into one side of the cervix slowly and one side quickly and the pain of the injections was compared in 87 women. Results: Phase 1:ibuprofen reduced pain scores more than placebo with the improvement being greatest for the postoperative period. Phase 2: buffered lidocaine was significantly less painful to inject than plain lidocaine or bupivacaine. Phase 3: waiting between the injection and the procedure did not improve pain control. Phase 4: slower injections were found to be less painful than fast injections. Conclusions: Several methods were found to improve pain control during abortions.