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Riportiamo la newsletter di Safe abortion women’s rights, network internazionale con sede in UK, con l’appello al ricorso alla telemedicina per l’aborto farmacologico in casa, documenti che ne provano la sicurezza e notizie da diversi paesi nel mondo.

TO: Women, Health Systems, Governments, UN Human Rights Bodies and WHO

We Need a Rational Policy for Safe Abortion in Every Country NOW!

Every day, in every country of the world, women have abortions. Each year, globally, there are 56 million abortions, or an average of 154,000 abortions every single day. Some 45% of those abortions are still unsafe in spite of 100 years of national and international campaigns for safe, legal abortions.

In almost every country, even where abortions are safe, access to abortion is restricted by antediluvian, punitive and medically unnecessary laws and regulations. The only way many women manage to have abortions at all is if they or an abortion care provider breaks the law in some minor or major way – 25 million times each year if we count only the unsafe abortions. The serious effect of the COVID-19 virus on all our lives has put this absurdity into sharp relief.  

Abortion clinics are being closed as part of the response to COVID-19, e.g. in Brazil and the USA. Medical abortion pills cause an abortion in a way that is very similar to a spontaneous miscarriage. They are 98% effective in ending a pregnancy when used correctly, both the combination of mifepristone and misoprostol, and misoprostol alone. Millions of women have used the pills safely, including in their own living spaces. Every country could and should move most abortions out of hospitals and clinics by ensuring women can get abortion pills and self-manage their abortions up to 10-12 weeks at home, with a number to call for advice and back-up care if needed. 

WE CALL ON:

UN Human Rights Bodies to:

  • declare that universal access to safe abortion for everyone who requests it is a human right, an essential part of Universal Health Coverage and an ongoing urgent public health priority.

The World Health Organization to make a public statement to be sent to all governments and Ministers of Health, stating that: 

  • abortion is an essential health service and all barriers to accessing safe abortions, especially to obtaining abortion pills and self-management of abortion, should be set aside;
  • medical abortion pills (mifepristone and misoprostol) are essential medicines and should be approved for use in all countries;
  • Ministers of Health should approve the use of telemedicine for provision of medical abortion pills, thus allowing many women to remain at home; to have direct access to abortion pills in pharmacies and by mail, and with information on how to use them. Providers could be pharmacists, nurses, midwives, GPs and abortion information hotlines – without needing an in-person visit.

Governments & Health Systems to: 

  • lift restrictions on ordering essential medicines from other countries;
  • facilitate pharmacy access to medical abortion pills by permitting direct ordering;
  • suspend customs regulations that create barriers for countries to import and export essential medicines and for pharmaceutical companies to be able to ship essential medicines abroad without regulatory delays, including abortion pills and contraceptives.

International Campaign members, health professionals & colleagues to:

  • advocate that your government takes the above essential actions;
  • work with and support national abortion information hotlines to provide women with accurate information and support for the self-management of abortion and where to obtain abortion pills;
  • initiate (and work with others to initiate) national abortion information hotlines in countries where they do not yet exist.
  • where it is safe to do so, share information with women and ask supportive journalists to write articles on how to self-manage abortions safely and effectively at home; and also share information on where to seek help for those who need a surgical abortion, especially abortions after 12 weeks of pregnancy. 

Everyone who is able to get pregnant to:

  • always use condoms and/or effective contraceptives to prevent unwanted pregnancy;
  • if you have no access to these methods, enjoy safer sex without penile-vaginal contact. There are many safe ways – use your imagination! Or give up sex for a bit – also known as social distancing!
  • if you think you are pregnant and don’t want to be, do not delayin seeking abortion pills to end the pregnancy. Used correctly, the pills are effective from the point when you first miss your period. Mifepristone is not yet available in many countries, but you can use misoprostol alone. It can be just as effective if you follow the instructions.

TELEMEDICINE FOR ABORTION: EVIDENCE OF SAFETY, EFFICACY AND SATISFACTION

Telemedicine for medical abortion: a systematic review

by M Endler, A Lavelanet, A Cleeve, B Ganatra, R Gomperts, K Gemzell‐Danielsson

BJOG: An International Journal of Obstetrics & GynaecologyMarch 2019;126(9)

Background: Telemedicine is increasingly being used to access abortion services.

Objective: To assess the success rate, safety, and acceptability for women and providers of medical abortion using telemedicine.

Search strategy: We searched PubMed, EMBASE, ClinicalTrials.gov, and Web of Science up until 10 November 2017.

Study criteria: We selected studies where telemedicine was used for comprehensive medical abortion services, i.e. assessment/counselling, treatment, and follow up, reporting on success rate (continuing pregnancy, complete abortion, and surgical evacuation), safety (rate of blood transfusion and hospitalisation) or acceptability (satisfaction, dissatisfaction, and recommendation of the service).

Data collection and analysis: Quantitative outcomes were summarised as a range of median rates. Qualitative data were summarised in a narrative synthesis.

Main results: Rates relevant to success rate, safety, and acceptability outcomes for women ≤10 weeks’ gestation (GW) ranged from 0 to 1.9% for continuing pregnancy, 93.8 to 96.4% for complete abortion, 0.9 to 19.3% for surgical evacuation, 0 to 0.7% for blood transfusion, 0.07 to 2.8% for hospitalisation, 64 to 100% for satisfaction, 0.2 to 2.3% for dissatisfaction, and 90 to 98% for recommendation of the service. Rates in studies also including women >10 GW ranged from 1.3 to 2.3% for continuing pregnancy, 8.5 to 20.9% for surgical evacuation, and 90 to 100% for satisfaction. Qualitative studies on acceptability showed no negative impacts for women or providers.

Conclusion: Based on a synthesis of mainly self‐reported data, medical abortion through telemedicine seems to be highly acceptable to women and providers, success rate and safety outcomes are similar to those reported in literature for in‐person abortion care, and surgical evacuation rates are higher.

Tweetable summary by the authors: 

A systematic review of medical abortion through telemedicine shows outcome rates similar to in‐person care. #SelfManagedAbortion

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Women may appreciate reading this article by a UK abortion provider that says much the same things in a readable style: 

Self-managed abortions should be universally available, by Sam Rowlands, Secretary of the British Society of Abortion Care Providers, The Conversation, 24 March 2020

Importantly, this article tells us that two often routine procedures can safely be omitted with early abortions for the majority of women: ultrasound scans and blood tests. It also reports that all mail services between countries have been disrupted by a near total lack of international flights. Creative ways of communicating with local pharmacies or prescribers will therefore be needed.  

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Here’s an article about how pharmacy workers can provide correct information about using abortion pills after simple training:

Pharmacy workers in Nepal can provide the correct information about using mifepristone and misoprostol to women seeking medication to induce abortion

by Anand Tamang, Mahesh Puri, Kalyan Lama, Prabhakar Shrestha

Reproductive Health Matters Feb 2015;22(44)

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Contraception Journal: Special Issue, 2018 

You can also find a range of research and discussion articles here on training pharmacy workers to provide abortion pills, the experience of clandestine home use, efforts to have the pills approved, a discussion of whether pills will replace surgical methods, the efficacy of abortion pills at 6 weeks, and much more from Chile, Argentina, Madagascar, Benin and Burkina Faso, Nepal, Bangladesh, Kyrgyzstan, South Africa and the Burma-Thai border. 

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INFORMATION ON HOW TO USE ABORTION PILLS AND SELF-MANAGE ABORTION

Cheeks, Tongues and When to Swallow

It’s all about how you do it…use abortion pills, that is.

by Women Help Women, 29 January 2020

You’ve decided you want to have a self-managed abortion, you have the abortion pills on hand, and you’ve done everything you can to make sure you’re safe and comfortable. Now what? That depends on whether you have both mifepristone and misoprostol or misoprostol alone.

Someone who has both mifepristone and misoprostol will take one pill of mifepristone and four pills of misoprostol. They will start by swallowing the one pill of mifepristone with a glass of water. After waiting 24 hours, the person will tuck the four pills of misoprostol between their cheek and lower gum – two on the left side of their mouth and two on the right. They’ll let the misoprostol dissolve for 30 full minutes without eating or drinking anything, then swallow whatever is left. After that, they can eat or drink again.

Someone who has misoprostol alone will take a total of 12 pills of misoprostol. They will start by tucking four pills under their tongue and let them dissolve for 30 full minutes, and then swallow whatever is left. After three hours, they will put four more pills under their tongue, let them dissolve, and swallow what’s left after 30 minutes. Then they will wait another three hours. Finally, they will put four more pills under their tongue to dissolve for 30 minutes and swallow the rest. The person should not eat or drink while the pills are dissolving, but they can eat and drink normally between doses.

After swallowing what’s left of the dissolved misoprostol, the person can eat and drink normally again. In fact, it’s important to stay hydrated throughout the abortion.

If you have other questions about abortion with pills, from how to handle any nausea you might have during your self-managed abortion to whether a doctor can tell that you’ve used abortion pills, we’ve got your back. You can get accurate, up-to-date information at AbortionPillInfo.org and on the Euki reproductive health app, now available for both iOS or Android.

Addenda

1. Ensuring complete abortion: In using misoprostol alone, if you think the abortion has not been complete, you can take at least one additional dose every three hours. In almost all cases, the abortion will be complete after a total of five doses. 

2. Abortion can be painful, often compared to a very painful period. Before you start you can take a painkiller such as ibuprofen and repeat as needed. 

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STATEMENT by DR TEDROS ADHANOM GHEBREYESUS, WHO DIRECTOR-GENERAL, 2018

 “Ebola taught us several painful but valuable lessons. The most important is this: that a fragile health system in one country can potentially expose the world to a global health catastrophe. When surveillance systems are inadequate, or health workers do not show up to work because they have not been paid in months; or medicines are in short supply; or infection prevention and control is lacking, disaster is just around the corner.” Dr Tedros stressed that the key to creating a pandemic free world is to acknowledge that Universal Health Coverage and Health Security are two sides of the same coin and to invest in strengthening the fabrics of Health Systems everywhere.

QUOTED IN: Hidden Pockets, by Nishitha Aysha Ashraf, 24 March 2020

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REPORTS FROM COUNTRIES

INDIA

Common Health, the Coalition for Reproductive Health and Safe Abortion, believe that the Ministry of Health is not in favour of telemedicine for abortion. 

In India, it is not possible to get medical abortion pills without prescription in a few states, such as Maharashtra. This forces women to go to a clinic to get safe abortion services (if doctors are willing to give them during this crisis) or they will have to get the pills from other sources or cross state lines for them. 

FOGSI (Federation of Obstetric & Gynaecological Societies of India) published a short-term advisory in response to the pandemic but it said nothing about abortion services though it recommended stopping many routine and non-urgent maternity and SRH services.

In many places, the Indian Medical Association and/or district administrations have sent advisories to suspend all clinical work. They are concerned India may see shortages of medications, contraceptives, HIV antiretrovirals and antibiotics to treat STIs due to disruptions in supply chains from companies in China or India.

For every early abortions with pills, doctors can provide pills to the patients. But with the current lockdown in most cities in India, e.g. in Mumbai, Pune and Delhi, there is no public transport and doctors are unable to reach their clinics. The Family Planning Association of India have struggled to keep their clinics open. Without public transport, young women cannot reach clinics. There is a lot of fear around visiting public places, especially hospitals, where numbers of people with the virus are increasing. 

Our advisor at Hidden Pockets recommended that “Below 6 weeks or even up to 9 weeks doctors can do medical management and provide help with tablets. We are only dealing with medical emergencies like ectopic pregnancies.” Other advice includes: specialized abortion care centres at low at risk of COVID-19 should ideally continue to provide services, no routine antenatal visits, minimise evacuations if they can be managed medically or expectantly, suspend all infertility management, suspend cervical screening but manage abnormal smears, 

Hidden Pockets says: “Don’t panic…  WhatsApp us at 8861713567 with any query.”

E-mail: Shilpa Shroff, 23 March 2020 ; Hidden Pockets, 23 March 2020 ; Hidden Pockets, 24 March 2020

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USA

Planned Parenthood abortion clinics are staying open during the coronavirus outbreak

One Planned Parenthood affiliate said it’s actually seeing an increase in patients showing up for appointments as people grow concerned about their health insurance and access in the future.

Planned Parenthood USA wants people to know that its doors are still open, even as the coronavirus epidemic sweeps the nation. “Our doors will stay open because sexual and reproductive health care is extremely important, and we have to ensure access to it,” Meera Shah, chief medical officer for Planned Parenthood in the New York City suburbs of Long Island, Westchester, and Rockland, one of the hardest-hit regions in the country, told BuzzFeed News Thursday over the phone. “Pregnancy-related care, especially abortion care, is essential and life-affirming, especially now when there is so much insecurity around jobs and food and paychecks and childcare.”

BuzzFeed, by Ema O’Connor, 20 March 2020

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Abortion access is under threat as coronavirus spreads

In many states, abortion clinics are holding on by a thread. Last week, Joe Nelson, a physician who provides abortions in Texas, felt a tickle in his throat. Then he started coughing. His temperature soared. Unable to obtain a coronavirus test, he began self-quarantining for 14 days. In a phone call with HuffPost, Nelson said he was mostly worried about how his unplanned absence might affect women’s ability to get abortions in the state.

HuffPost US, by Melissa Jeltsen, 17 March 2020

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TelAbortion: a model for telemedicine during this public health crisis

Telemedicine for abortion has the advantage that staff can work remotely, and during the epidemic can work from home with flexible schedules. This safeguards the health and welfare of staff, patients, partners and community, and ensures access to an essential health service without a clinic visit during this public health crisis. Gynuity is adapting the TelAbortion model to be able to expand quickly to serve more people needing abortion now that doctors are given permission to provide care outside their states of licensing and the Food & Drug Administration’s realization that not all recommended tests will be possible (or necessary) for all patients. Gynuity is committed to conducting ground-breaking research helping to develop new clinical care models. 

Gynuity Health Projects. E-mail, 20 March 2020

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Ohio abortion providers told to stop all ‘non-essential and elective’ surgical abortions

Ohio’s attorney general cited federal guidance for this ruling intended to help conserve “needed medical supplies” during the pandemic. There are concerns that the demand for hospital beds could exceed supply in the US — and medical providers are currently experiencing a severe shortage of the personal protective equipment that allows them to safely interact with infected patients. Trump administration officials have asked “every American and every American hospital and healthcare facility to postpone any elective medical procedures”. However, abortion is not “elective”: you can’t put it off for some time in the future. Planned Parenthood responded by saying they are complying, but added: “Under that order, Planned Parenthood can still continue providing essential procedures, including surgical abortion, and our health centers continue to offer other health care services that our patients depend on.”

Vox, by Riley Beggin, 22 March 2020 ; National Public Radio, by Sarah McCammon, 21 March 2020

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UK

On 23 March 2020, an e-mail notice came from the Royal College of Obstetricians and Gynaecologists that the Government had announced two temporary changes to abortion care that would allow clinics to offer a remote service, limiting the potential spread of COVID-19 and helping to maintain access to abortion care:

  • The home of a registered medical practitioner is approved as a class of place for treatment for the termination of pregnancy for the purposes only of prescribing the medicines known as mifepristone and misoprostol… 
  • The home of a pregnant woman who is undergoing treatment for the purposes of termination of her pregnancy is approved as a class of place where the treatment for termination of pregnancy may be carried out…

However, the bad news is this policy change was withdrawn by the Secretary of State for Health six hours later without explanation. Parliament has been shut down yet again so we don’t know how to fight this.

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NORTHERN IRELAND

Early medical abortion coming to three health service trusts as advocates argue for telemedicine

During Northern Ireland questions in the UK House of Commons, Labour MP Diana Johnson asked for an assessment of the effect of the collapse of the airline Flybe on the ability of women in Northern Ireland to access abortion services in England, due to the European Union 30-day ban on all ‘non-essential’ travel. Activists are fighting for the legalisation of telemedicine for abortion or to deem travel for abortions “essential travel”. Alliance for Choice NI believes telemedicine will provide a safe way to support abortion seekers throughout the coronavirus crisis. Today, we heard, thanks to the work of Doctors for Choice NI, it looks as though there will be an Early Medical Abortion service available in the Belfast, Northern and Western Trusts from as early in April 2020 as soon as the medication is available to those Trusts, covering 70% or more of the NI population. Those Trusts’ leaders are likely to look after women in the rest of the regions until the remaining Trusts follow suit. 

FROM: Belfast Telegraph, by Jonathan Bell, 18 March 2020 ; Marie Claire, by Niamh McCollum, 18 March 2020 ; E-mail from Goretti Horgan, Alliance for Choice Derry, 26 March 2020

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FRANCE/(SPAIN+ NETHERLANDS)

A situation report with things changing daily

Most of the Mouvement Français pour le Planning Familial centres have had to close because we could not ensure the protection of the staff (no masks, no hydroalcoholic gel, no public transport). Some remain open, and we have increased the number of staff answering phone calls. There are many more calls now… 725 last week compared to 250 in the same week last year. Our doctors and midwives provide medical abortion. Medical abortion at home is possible, and women can be followed by telemedicine, but women must see a doctor to get the pills. It would be great if they could do the whole process via telemedicine and get the pills from a pharmacy, but it’s not possible right now. An emergency law was passed last weekend, but they did not agree to extend the abortion time limit. Telemedicine for abortion has not yet been discussed, but it has been proposed. For later abortions, we were told that women could be authorized to travel to Spain or the Netherlands with a special paper; it works for most of them but not all. Some have been stopped at the border. 

In Spain, some clinics are open for the moment. In the Netherlands, too, but women must present alone, their temperature is taken when they arrive, and they must not have symptoms of the virus.

We advocated for the existing law on urgent care to be applied to abortions. The government accepted this and published the notice, and we will be more than vigilant about it. We will go on advocating for a higher upper time limit, abortion for medical reasons without restrictions, access to later abortions for fetal disease or malformation or risk to the woman, and for abortion through telemedicine.

The joint platform Avortement Europe: les femmes décident (Abortion Europe: Women Decide) have launched an online petition for the following: 

• Mandatory maintenance of abortion services and supply of contraceptives;

• A supply of masks and hydroalcoholic gels for clinics so that they can continue to function;

• Removal of the requirement of a second appointment for minors, 48 hours after their first appointment;

• That a woman requesting an abortion can find it locally, whatever her place of residence or her healthcare cover, and with or without the right to remain in France. 

The recommendations of the French National College of Gynaecologists and Obstetricians for abortions and contraception during COVID-19. Thankfully, they changed their minds about cancelling consultations for contraception. Women can renew a prescription for contraception at the pharmacy by showing the previous prescription.

E-mail from Veronique Sehiers, Co-Director, MFPF, 26 March 2020

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ITALY

Avoid putting abortion at risk by facilitating access to abortion pills outside hospitals 

The evolution of the COVID-19 epidemic in Italy from its outbreak in the Lodi area has shown how hospitals are the places most at risk at the moment. The government should therefore stop unnecessary hospital services in this moment of emergency, to protect people and medical personnel from infection and maximise the scarce resources in the public health system. Yet this is not happening with medical abortion. It is time to introduce abortion care by telemedicine in Italy.

In Italy medical abortion is available only in the first 7 weeks with hospitalisation for three days. Some regions use a day-hospital regime for medical abortion. These barriers to accessing medical abortion are justified on grounds of protecting women’s health. Yet, curettage is still practiced in Italy (e.g. in 41% of cases in Sardinia), while medical abortion is used only in 18% of cases.

We have observed how the pandemic provides a legal basis for strong limitations on our freedoms. Extraordinary measures for supplying abortion pills can be arranged on the same basis. Considering all the interests at stake, it is time for telemedical abortion.

Abortion services are now stopping in Lombardy. This is testified by Sara Martelli, coordinator of the Safe Abortion campaign: “Abortion services are stopped at three hospitals, and at a fourth, medical abortion provision was interrupted. Many departments in Milan are now dedicating beds to COVID-19. There are other hospitals in Lombardy that have had to close their abortion clinics and almost half of the healthcare centres are closed in Milan. The situation is constantly changing and it is almost impossible to obtain information. What is happening highlights not only the usefulness of de-hospitalising medical abortion [to local healthcare centres], which is supported by AOGOI, the Italian Hospital Gynaecologists & Obstetricians Association, but also the need to have a regional information and coordination centre. Elsa Viora, president of AOGOI says: “The change of the upper limit from 7 to 9 weeks is a request already made to AIFA (Italian Medicines Agency). In almost all countries where the abortion pill is used up to 9 weeks, there is no increase in complications. But today the system has been suspended because medical abortion involves returning to hospital twice for the two kinds of pills, while surgical abortion is resolved in one day. Certainly a rule that requires hospital provision of medical abortion is ideological, not based on scientific evidence; so the goal is to change it. Anna Pompili and Mirella Parachini, gynaecologists of the Association of Italian Doctors for Contraception and Abortion, wrote in a recent letter to Quotidiano Sanità, “In many centres around the world, procedures have been implemented with telemedicine services, which have given excellent results.”

Il fatto quotidiano, by Eleonora Cirant, Pro-Choice Network member, 26 March 2020 ; 

La 27esimaora, Corriere della Sera, by Elena Caruso, PhD student, Kent Law School, UK, Marina Toschi, Gynaecologist, European Society of Contraception & Reproductive Health, 26 March 2020 ; English translation from Italian, by Elena Caruso

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LUXEMBOURG

Malgré la crise du coronavirus, le Planning familial essaye de garantir ses services en ayant recours au téléphone, à Skype et aux mails 

(Despite the coronavirus crisis, Planning Familial will try to guarantee its services by telephone, skype and emails)

Family planning is a medical service, so it is not closed and will not be closed. The services have been adapted to the situation. Meetings, for example, are organized via Skype and psychological and sexology services are provided by phone or Skype as well. Advisory and support services continue to operate. It is particularly important that people who need help because they are victims of domestic violence can be helped immediately. To do this, there is the address “Violence.lu”. In an exceptional situation like this, the number of cases is likely to increase.


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