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Unmasking the global abortion agenda


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Unmasking the global abortion agenda

  3. 3. FEMINISM “ABORTION IS FOR WOMEN” <ul><li>“ The development of accessible and simple methods of early abortion is a social and humanitarian good from almost every point of view.” </li></ul><ul><ul><li>Editorial on von Hertzen trial of misoprostol regimens reported in the Lancet , 2007 </li></ul></ul>
  4. 4. THE MYTH OF OVERPOPULATION <ul><li>“ The battle to feed all of humanity is over. In the 1970s and 1980s hundreds of millions of people will starve to death in spite of any crash programs embarked upon now. At this late date nothing can prevent a substantial increase in the world death rate...” Paul Ehrlich, 1968 </li></ul>
  5. 5. THE REALITY: Worldwide 83 countries and territories are now below replacement rate, and if *medium variant* fertility assumptions prove true, 56 nations will have negative population growth by 2050. PRI Review Sept/Oct 2003 <ul><li>FERTILITY: POLITICAL </li></ul>
  6. 6. Annual Growth Rate for Development Groups U.N. World Population Prospects: The 2002 Revision
  7. 7. National Fertility Rates
  8. 8. In May, 2009, George Soros, Bill Gates, Warren Buffet, Ted Turner, Michael Bloomberg, David Rockefeller, and Oprah Winfrey met to discuss philanthropic projects to curb the world’s population. DESPITE THE FACT THAT OVERPOPULATION IS A MYTH
  9. 9. Over 70 countries who protect women and children from abortion with a strict life of the mother exception are under pressure to legalize abortion. Countries in dark blue, pink, and orange are most at risk from attempts to change laws and policies restricting abortion. WORLD ABORTION LAWS Map from Center for Reproductive Rights
  10. 10. Worldwide Abortion Laws Countries That Restrict All Abortion or Allow Life of the Mother Exception (in Italic) Panama– PA/R/F Papua New Guinea Paraguay Philippines San Marino Sao Tome & Principe Senegal Solomon Islands Somalia Sri Lanka Sudan–R Suriname Syria–SA/PA Tanzania Tonga Tuvalu Uganda United Arab Emirates–SA/PA Venezuela West Ban & Gaza Strip Yemen Iraq Ireland Kenya Kiribati Laos Lebanon Lesotho Libya–PA Madagascar Malawi–SA Mali-R/I Malta Marshall Islands–U Mauritania Mauritius Mexico–◊R/F Micronesia–U Monaco Myanmar Nicaragua–x Niger Nigeria Oman Palau-U Afghanistan Andorra Angola Antigua & Barbuda Bangladesh Bhutan–R/I/+ Brazil–R Brunei Darussalam Central African Rep. Chile–x Congo (Brazzaville) Côte d'Ivoire Dem. Rep. of Congo Dominica Dominican Republic Egypt El Salvador–x Gabon Guatemala Guinea–Bissau Haiti Honduras Indonesia Iran
  11. 11. ABORTION IS FOR WOMEN <ul><li>“ Expansion of access to early medical abortion is a humane approach that benefits both women and their societies. “ </li></ul><ul><ul><li>Winikoff B, David AR. Lancet, 2007 </li></ul></ul>
  12. 12. Suction Abortion
  13. 13. RU-486 (Mifepristone) Image downloaded,16641,20001009,00.html
  14. 14. RU-486 - “The Abortion Pill” <ul><li>Publication of “The effects of an antiprogesterone steroid in women: interruption of the menstrual cycle and of early pregnancy” </li></ul><ul><li>Originally developed as an immune suppressant (RU-38486) </li></ul><ul><li>Discovered that RU-486 has great affinity for progesterone receptor </li></ul><ul><li>Oral administration disrupts the luteal phase of the menstrual cycle and early pregnancy </li></ul><ul><li>New methodology for birth control and menstrual cycle regulation envisaged </li></ul><ul><li>Herrmann W et. al. C R Seances Acad Sci III . 1982. </li></ul>
  15. 15. Early articles presenting RU-486 as panacea for women’s health problems <ul><li>Promoted as fulfilling the quest for a non-surgical abortion method </li></ul><ul><li>“ The antiprogesterones are coming: menses induction, abortion, and labour?” by Healy DL and Fraser, HM. Br Med J (Clin Res Ed). 1985 </li></ul><ul><li>“ RU-486. Termination of a pregnancy in the privacy of one's home” by Potts M, N C Med J . 1989. </li></ul><ul><ul><li>“ RU-486 is a computer-designed progesterone antagonist with no known side effects other than those predicted by its endocrinological action;” used for early abortion, to terminate pregnancy with fetal demise, to soften cervix, cause luteolysis, facilitate management of ectopic pregnancy, and to induce term labor in primates </li></ul></ul>
  16. 16. Medical Abortion Time Line <ul><li>1981 Roussel-Uclaf synthesizes RU-486 </li></ul><ul><li>1988-1992 RU-486 is approved in France, the UK, China and Sweden for abortion </li></ul><ul><li>1992-1997 Methotrexate research in the U.S. </li></ul><ul><li>1993 Clinton allows importation of RU-486 into the U.S. </li></ul><ul><li>1994-1995 RU-486 Clinical trials in the U.S </li></ul><ul><li>2000 FDA approves RU-486 (Mifeprex) </li></ul><ul><li>2001 Gynuity Symposium on Misoprostol </li></ul><ul><li>2001-present International efforts to disseminate medical abortion by advocacy organizations </li></ul>
  17. 17. Early RU-486 Trials: France Netherlands, U.S. (RU-486 alone ) <ul><li>Termination of very early pregnancy by RU 486--an antiprogestational compound. Kovacs L et al, Contraception . 1984. 25, 50 or 100 mg RU-486 </li></ul><ul><ul><li>61% complete abortion </li></ul></ul><ul><li>Interruption of early pregnancy by an anti-progestational compound, RU 486. Haspels AA. Eur J Obstet Gynecol Reprod Biol. 1985 </li></ul><ul><ul><li>79% complete abortion < 8 weeks; 33%> 8-10 weeks </li></ul></ul><ul><li>Pregnancy termination with a high and medium dosage regimen of RU 486. Shoupe D, Mishell DR, Brenner PF, Spitz IM. Contraception. 1986. </li></ul><ul><ul><li>10 – 72% complete abortion </li></ul></ul>
  18. 18. Improved Results for Complete Abortions with Prostaglandin added to RU-486 <ul><li>Use of mifepristone in the termination of early pregnancy. The experience in France. Dubois C Presse Med . 1989 . </li></ul><ul><ul><li>Experience of 1841 women with RU-486 600 mg </li></ul></ul><ul><ul><li>Sulprostone, gemeprost or meteneprost used </li></ul></ul><ul><ul><li>95% complete expulsions with prostaglandins added to regimen </li></ul></ul><ul><li>RU 486 (mifepristone): clinical trials in China. Zheng SR Acta Obstet Gynecol Scand Suppl . 1989. </li></ul><ul><ul><li>At First Teaching Hosptial of Beijing, Medical University, China; 600 mg RU-486 was used. </li></ul></ul><ul><ul><li>Complete abortion 63.5% with RU-486 alone; 92-98% with prostaglandin added, depending on gestational age </li></ul></ul>
  19. 19. Mifeprex-Misoprostol 1989-2001 <ul><li>Used in Europe with only one fatality (Nadine Walkowiak,1991, France, from myocardial infarction) </li></ul><ul><li>Death thought to be due to cardiac effects of sulprostone I.M., the prostaglandin </li></ul><ul><li>No other fatalities after other oral prostaglandins used </li></ul>
  20. 20. Early termination of pregnancy with mifepristone (RU 486) and the orally active prostaglandin misoprostol <ul><li>Two groups: 505 women and 390 women with pregnancy < 50 days </li></ul><ul><li>Mifepristone and two oral misoprostol regimens </li></ul><ul><li>Results: Complete abortion 96.9% group 1; 98.7% in group 2 </li></ul><ul><ul><li>Medical Department, Laboratoires Roussel , Paris, France. </li></ul></ul><ul><ul><li>Peyron R et. al. N Engl J Med . 1993 </li></ul></ul>
  21. 21. DANIELLE HASSOUN, M.D MEDICAL ABORTION EXPERT IN RESIDENCE, IPAS <ul><li>“ We were thinking that it was a miracle: just a pill could cause an abortion. The idea was so new… In a certain way it felt like a dream.” </li></ul><ul><li>“ Even if we imagine abortion laws becoming very restrictive, women would use medication abortion anyway because they don’t need providers. I would say that abortion is now more under the control of women, and less under the control of providers and politicians.” </li></ul>
  22. 22. California of the 1970’s: The Self-Help Movement
  23. 23. Medical Abortion in Europe 1990’s <ul><li>Recommended regimen used two drugs – a prostaglandin with RU-486 </li></ul><ul><li>Performed in dedicated abortion centers, recently up to seven weeks by specialists (France) </li></ul><ul><li>A hospital bed reserved for all RU-486 abortions (UK) </li></ul><ul><li>Patient stayed in abortion facility until fetus expelled (Denmark) </li></ul>
  24. 24. Predominant Medical Abortion Regimen: France and U.S. Clinical Trials <ul><li>RU-486 600 mg by mouth, given in clinic (up to 49 days gestation) </li></ul><ul><li>Prostaglandin orally two days later given during 3-4 hour clinic visit </li></ul><ul><li>Products of conception expelled, usually under direct observation </li></ul><ul><li>Follow up visit in two weeks </li></ul>
  25. 25. RU-486 Key Complications Emotional/Psychological Reactions <ul><li>The former Roussel Uclaf chairman, said “A woman has to 'live' with her abortion for at least a week using this technique. It's an appalling psychological ordeal.” </li></ul><ul><li>Spokeswomen of Roussel Uclaf said: &quot;When [women] take a pill, they have the feeling they are truly responsible for the abortion…” </li></ul><ul><li>Christian Frenpzel, abortion facility nurse in France, saw 6 surgical dishes w/ 6 embryos in them by the sink. She said “It was like looking at a little row of people. The women too were shocked when they looked at what they had expelled.” </li></ul>Image downloaded
  26. 26. U.S. Experience with Two-drug Regimens <ul><li>RU-486 Regimen – 605 “Adverse Events” reported soon after approval; many of them necessitating blood transfusion and hospitalization </li></ul><ul><ul><li>Gary M et al. “Analysis of Severe Adverse Events Related to the Use of Mifepristone as an Abortifacient,” The Annals of Pharmacotherapy, 2006 Feb. Vol 40). </li></ul></ul><ul><li>5 deaths from toxic shock; four in California </li></ul><ul><ul><li>Fischer M et al. “Fatal Toxic Shock Syndrome Associated with Clostridium sordellii after Medical Abortion.” New England Journal of Medicine 2005 Vol 353:2352-2360. </li></ul></ul>
  27. 27. Five deaths from toxic shock from Clostridium sordelli infection (four in California) led to a CDC investigation. Fischer,, “Fatal Toxic Shock Syndrome Associated with Clostridium sordelli after Medical Abortion,” NEJM 353 (2005): 2352-2360 Greene, M.F., M.D., “Fatal Infections Associated with Mifepristone-Induced Abortion, NEJM 353 (2005): 2317-18)
  28. 28. Holly Patterson 1985-2003
  29. 29. RU-486: Why did deaths and other adverse events begin to occur in the U.S. and elsewhere after 2001, in contrast to the European experience from 1991-2001 ? <ul><li>Use of ARM Protocols – secret drug trials </li></ul><ul><li>Role of Reproductive Health Advocacy Organizations </li></ul><ul><li>Ideology </li></ul>
  30. 30. Requirements for RU-486 Use Why much less stringent after release? <ul><li>Standard Clinical Trials </li></ul><ul><li>Ultrasound required </li></ul><ul><li>Physician provider </li></ul><ul><li>Provider must be able to perform suction curettage </li></ul><ul><li>Provider must have hospital privileges within two hours of abortion site required </li></ul><ul><li>Post Release </li></ul><ul><li>Ultrasound optional </li></ul><ul><li>Licensed clinician </li></ul><ul><li>Can refer for suction curettage </li></ul><ul><li>Can refer for complications requiring hospitalization </li></ul>
  31. 31. RU-486: LAX STANDARDS AFTER RELEASE IN THE U.S. <ul><li>Barbara Boxer’s in a letter to the FDA (6/6/2000) expressed “grave concerns” about “draconian restrictions” such as requiring prescribing doctors to be trained in surgical abortion and to have hospital admitting privileges </li></ul><ul><li>California: Reproductive Privacy Act of 2002 </li></ul>Margaret Crosby ACLU Attorney
  32. 32. New RU-486 protocols by Reproductive Health Advocacy Organizations <ul><li>Moved abortion care away from gynecologists to primary care physicians and nurses </li></ul><ul><li>Eliminated office visits for misoprostol insertion </li></ul><ul><li>Abortion became a home procedure </li></ul><ul><li>Replaced clinic visits with phone calls and written materials </li></ul><ul><li>Studies stress low cost, simplicity, privacy </li></ul><ul><li>This process began well before RU-486 approval by the FDA </li></ul>
  33. 33. MEDICAL ABORTION MOVES TO THE U.S. <ul><li>MANUFACTURING RU-486 Shanghai Hualian Plant </li></ul><ul><li>In 2006, 18 died after a liver disease prescription was laced with diethylene glycol, 14 died after taking an antibiotic not properly sterilized, and >100 died from a cold medicine containing a mislabeled, toxic chemical </li></ul><ul><li>In 2008, nearly 200 cancer pts were paralyzed or were harmed by contaminated leukemia drugs drugs </li></ul>
  34. 34. Lawrence Lader 1919-2006 <ul><li>“ Father of abortion rights” </li></ul><ul><li>Founder of NARAL </li></ul><ul><li>Left NARAL because it became “too establishmentarian” </li></ul><ul><li>Founded ARM – Abortion Rights Mobilization to legalize RU-486 </li></ul><ul><li>Lobbied for importation of RU-486 into the U.S. </li></ul><ul><li>Sued the IRS to end tax-exempt status of Catholic Church </li></ul>
  35. 35. Abortion Rights Mobilization (ARM) <ul><li>The Population Council obtained U.S. patent rights to mifepristone from Roussel-Uclaf, but was embroiled in legal disputes. Various manufacturers withdrew during 1994-1997. </li></ul><ul><li>ARM developed its own version of RU-486, produced by an American manufacturer whose identity was closely guarded; copying RU-486 for testing was allowed as long as there was no intent to market it </li></ul><ul><li>ARM testing sites were developed in Rochester, Nebraska, Vermont; more added with funding from the John Merck fund </li></ul>
  36. 36. ARM TRIALS: LOWER DOSE, VAGINAL ADMINISTRATION, LATER GESTATION <ul><li>“ Vaginal misoprostol administered at home after mifepristone for abortion”. Schaff EA et al, J Fam Tract, 1997. </li></ul><ul><li>“ Low dose mifepristone and vaginal misoprostol for abortion”. Schaff EA et al, Contraception, 1999. </li></ul><ul><li>“ Low dose mifepristone followed by vaginal misoprostrol at 48 hours for abortion up to 63 days”. Schaff EA et al. Contraception, 2000. </li></ul><ul><li>“ A comparison of the ARM and Population Council trials”. Schaff EA, J Am Med Womens Assoc, 2000. </li></ul>
  37. 37. Reproductive Health Advocacy Organizations <ul><li>Ideology of women’s reproductive autonomy as supreme value </li></ul><ul><li>Dogma that medical abortion is an absolute good </li></ul><ul><li>Belief that abortion should be ordinary medical care </li></ul><ul><li>Willing to accept collateral damage (adverse events, including deaths) to support the aforementioned values </li></ul><ul><li>Systematic planning to promote this ideology and practice internationally </li></ul>
  38. 38. Reproductive Health Advocacy Organizations <ul><li>Abortion Rights Mobilization </li></ul><ul><li>Guttmacher Institute </li></ul><ul><li>Population Council </li></ul><ul><li>Center for Reproductive Health Research and Policy, UCSF </li></ul><ul><li>Pathfinder </li></ul><ul><li>Center for Reproductive Rights </li></ul><ul><li>Bixby Center, UC Berkeley School of Public Health </li></ul><ul><li>Gynuity </li></ul><ul><li>Ibis </li></ul><ul><li>Ipas </li></ul><ul><li>Marie Stopes </li></ul><ul><li>ANSIRH </li></ul><ul><li>JPIEGO </li></ul>
  39. 39. Gynuity Health Projects <ul><li>Improving medical abortion regimens </li></ul><ul><li>Reduce doses of mifepristone, thereby lowering the cost of the method </li></ul><ul><li>Offer home administration of misoprostol, entailing fewer clinic visits </li></ul><ul><li>Implement improvements to misoprostol dosage, timing, and route of administration that may increase efficacy and decrease time to completion of abortion; and </li></ul><ul><li>Create simplified alternatives to management of follow-up .  </li></ul>Beverly Winikoff, MD, MPH
  40. 40. Center for Reproductive Health Research and Policy, UCSF Felicia Stewart, MD 1943 -2006 Philip Darney, MD, MPH <ul><li>The center has a staff of 200, working with more than 300 collaborators abroad, and is carrying out over 100 domestic and international projects funded at $36 million annually. </li></ul><ul><li>Abortion and Post-Abortion Care </li></ul><ul><li>Adolescent Sexuality and Reproductive Health  </li></ul><ul><li>Contraceptive Development & Family Planning  </li></ul><ul><li>HIV/AIDS and other Sexually Transmitted Infections </li></ul><ul><li>Safe Motherhood </li></ul>
  41. 41. <ul><li>“ Could American women use mifepristone-misoprostol pills safely with less medical supervision?” </li></ul><ul><li>Evidence suggests that most women can handle most steps of the medical abortion process themselves, effectively and safely. The utility of clinic visits to ingest mifepristone and misoprostol is questionable. For many women, even the follow-up visit could perhaps be replaced by telephone follow-up, combined with home pregnancy tests. </li></ul><ul><li>Harper C, Ellertson C, and Winikoff B. Contraception, 2002 </li></ul>
  42. 42. <ul><li>To reduce the likelihood of unscheduled calls and clinic visits, the investigators recommend developing detailed client materials to inform women about what they can expect when they take misoprostol at home. </li></ul><ul><li>Elul B, Winikoff,B et al. Can women in less-developed countries use a simplified medical abortion regimen? Lancet, 2001 </li></ul>
  43. 43. IBIS <ul><li>Promotion of medical abortion </li></ul><ul><li>Change in terminology: “medication” and “aspiration” abortion” </li></ul><ul><li>Promotion of non-gynecologists and non-physician providers </li></ul><ul><li>Move to unsupervised home abortion </li></ul><ul><li>International propaganda </li></ul>CHARLOTTE ELLERTSON 1966-2004
  44. 44. IBIS <ul><li>Why “Ibis”? </li></ul><ul><li>Ibises, like storks, are associated in many cultures with fertility. The birds also represent forbidden women's health knowledge, including of contraception and abortion. Scholars attribute the association to the birds' curved bills, perhaps resembling clyster syringes used by midwives. The ibis is also the incarnation of the Egyptian lunar deity Thoth. Like the messenger god Hermes, Thoth was also responsible for writing, law, logic, and calculation. </li></ul>
  45. 45. The side effects of misoprostol (e.g. vomiting, diarrhea, and abdominal cramping) may be similar to the initial symptoms of toxic shock syndrome associated with C. sordelli .” Fischer,, “Fatal Toxic Shock Syndrome Associated with Clostridium sordelli after Medical Abortion,” NEJM. 2005 “That’s a real issue where a young woman has to figure out if she’s beyond these so-called normal side effects…to serious adverse events. You have to figure it out, be able to call for help.” Monty Patterson, father of Holly Patterson
  46. 46. Oriane Shevin 1971-2005 <ul><li>Particular attention must be paid to the use of these drugs prior to their widespread, generalized use in developing countries, where the rate of bacterial infection is very high. In Africa, the high frequency of genital infections, along with poor medical care, may result in a significant number of deaths if the use of mifepristone and misoprostol are not examined. </li></ul><ul><li>Didier Sicard, Father of Oriane Shevin and Professor of Internal Medicine; Ann Pharmacother 2005 </li></ul><ul><li> </li></ul>
  47. 47. Rebecca Tell Berg 1987-2003
  48. 48. MEDICAL ABORTION: THE FINNISH EXPERIENCE <ul><li>42,619 patients seven weeks gestation or less </li></ul><ul><li>Half with surgical abortion and half with medical abortion </li></ul><ul><li>Mifepristone-Misoprostol regimen used for medical abortions </li></ul><ul><li>Adverse events four times more common in medical abortion group (20% of medicalabortions) </li></ul><ul><li>Main complications hemorrhage, incomplete abortion requiring surgery </li></ul>Ninimaki M et al. Obstet Gynecol 2009. 114(4): 795-804.
  49. 49. Medical Abortion as a percentage of all abortions <ul><li>Sweden 2008 64.2% </li></ul><ul><li>Scotland 2007 61.4% </li></ul><ul><li>France 2006 46% </li></ul><ul><li>England and Wales 2007 35% </li></ul><ul><li>USA 2005 9.9%; 184,000 abortions 2008 </li></ul><ul><li>China ??? 10 million abortion pills sold annually </li></ul>
  51. 51. IPAS <ul><li>Ipas has worked for three decades to increase women's ability to exercise their sexual and reproductive rights </li></ul><ul><li>Manufactures manual vacuum aspirators for abortion </li></ul><ul><li>Publishes numerous training manuals for health providers on medical and surgical abortion in multiple languages </li></ul><ul><li>Focuses on public policy and changing attitudes, as well as medical practice </li></ul>
  52. 52. <ul><li>Mission: to protect the poorest and most vulnerable women and their families from unintended pregnancy and in the process help create a prosperous, more ecologically sustainable, less divided and less conflict-ridden world </li></ul><ul><li>Strengths: The greatest strength and opportunity driving the Bixby Program is the supply of committed, intelligent …young professionals. As an endowed chair, the Bixby Program has essential independence in a controversial area to follow the evidence base and to avoid making political compromises </li></ul><ul><li>Goals: Develop cost-effective innovations in family planning and reproductive health with the potential of being brought to large scale use, </li></ul>Bixby team members dance with traditional Ethiopian birth attendants at a misoprostol training for postpartum hemorrhage
  53. 54. EngenderHealth <ul><li>Working for 60 years to make reproductive health services safe, available, and sustainable for women and men worldwide </li></ul><ul><li>Major projects in more than 40 countries including Ghana and Kenya </li></ul>
  54. 56. Strategies to Promote Medical Abortion <ul><li>Political: legalization or liberalization of existing abortion laws </li></ul><ul><li>Educational ventures with teaching institutions </li></ul><ul><li>Sponsorship of medical journal articles </li></ul><ul><li>Promoting abortion drugs for non-abortion uses </li></ul><ul><li>Obfuscation: Promotion of “menstrual regulation” </li></ul><ul><li>Training of community providers; pharmacists </li></ul><ul><li>Promotion and organization of pre and post abortion care </li></ul><ul><li>Internet-based support for providers and patients </li></ul>
  55. 58. History of Misoprostol <ul><li>Misoprostol </li></ul><ul><ul><li>A prostaglandin </li></ul></ul><ul><ul><li>1987 Used to prevent gastric ulcers </li></ul></ul><ul><ul><li>1990’s Second drug in medical abortion regimen </li></ul></ul>Image downloaded from
  56. 59. MISOPROSTOL: AN EMERGING TECHNOLOGY FOR WOMEN’S HEALTH <ul><li>Seminar brought together 60 international leaders, academics and activists in population control in 2001 </li></ul><ul><li>Review of research on misoprostol for induced abortion, together with uterine evacuation after pregnancy failure, labor induction, post-partum hemorrhage, and cervical priming for ob/gyn procedures </li></ul><ul><li>Discussion of priorities for research and policy </li></ul>
  57. 60. Drug Availability
  58. 61. A comparison of medical management with misoprostol and surgical management for early pregnancy failure <ul><li>652 women with first trimester pregnancy failure </li></ul><ul><li>Randomized to misoprostol 800 mcg pv or suction curettage </li></ul><ul><li>Misoprostol dose repeated after two days if no expulsion; suction curettage if incomplete in 8 days </li></ul><ul><li>Misoprostol group: 71% expulsion by day 3; 84% expulsion by day 8 </li></ul><ul><li>Study accompanied by editorial by B. Winikoff ; “Pregnancy failure and misoprostol – time for a change” </li></ul>Zhang J , Gilles JM , Barnhart K , Creinin MD , Westhoff C , Frederick MM , NEJM, 2005.
  59. 62. Misoprostol as the primary agent for medical abortion in a low-income urban setting. <ul><li>440 women in inner-city Boston 2001-2002 </li></ul><ul><li>Restrospective chart review </li></ul><ul><li>Gestations < 8 weeks </li></ul><ul><li>800 mcg misoprostol , repeated in 24 hours </li></ul><ul><li>Follow up visit in 2-3 days </li></ul><ul><li>90.8% completed the abortion medically </li></ul><ul><li>Mean time to tissue passage 8.5 hours </li></ul>Borgatta L et al.. Contraception . 2004
  60. 63. Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: a randomised controlled equivalence trial <ul><li>2066 healthy pregnant women with gestations 63 days or less </li></ul><ul><li>Funded by WHO, UNFPA, World Bank </li></ul><ul><li>11 teaching hospitals in six countries: Armenia, Georgia, Cuba, India, Mongolia and Vietnam </li></ul><ul><li>Randomised to four treatment groups of misoprostol; sublingual vs vaginal; q 3 hours vs q 12 hours. </li></ul>Von Hertzen et. al, Lancet, 2007
  61. 64. Two and One Drug Regimens: The Reality <ul><li>Mifepristone and Misoprostol – 3-8% incomplete abortions; higher if more than 7 weeks </li></ul><ul><ul><li>Peyron R et al. “Early termination of pregnancy with mifepristone (RU 486) and the orally active prostaglandin misoprostol .” N Engl J Med. 1993 May 27;328(21):1509-13. </li></ul></ul><ul><ul><li>Spitz IM et al.”Early Pregnancy Termination with Mifepristone and Misoprostol in the United States.” New England Journal of Medicine, 2008 338 1241-47. </li></ul></ul><ul><li>Finnish study 2009 – 20% of medical abortions had major complications </li></ul><ul><ul><li>Niinimaki M et al. “Immediate Complications After Medical Compared with Surgical Termination of Pregnancy.” Obstetrics and Gynecology . 2009. Vol. 114 795-804. </li></ul></ul><ul><li>Misoprostol alone – 16% incomplete abortion; continuing living pregnancy 6% </li></ul><ul><ul><li>Von Hertzen H et al.“Efficacy of two intervals and two routes of administration of misoprostol for termina­tion of early pregnancy: a randomized controlled equivalence trial.“ Lancet . 2007 Jun 9;369(9577):1938-46. </li></ul></ul>
  62. 65. <ul><ul><ul><ul><ul><li>STRATEGY: MISOPROSTOL ABORTION </li></ul></ul></ul></ul></ul><ul><li>Malcolm Potts and his wife, Martha Campbell, formed Venture Strategies to gain registration of misoprostol throughout Africa and Asia supposedly for treatment of PPH. </li></ul><ul><li>Potts and Campbell make a case for population control, linking it to problems such as global warming, war, and violence. </li></ul><ul><li>“ All these terrorists come from places where it’s difficult to get birth control,” says Potts. </li></ul><ul><li>“ We’ve never found a country that has gotten out of poverty while maintaining high birth rates,” says Campbell. </li></ul>
  63. 66. MISOPROSTOL ABORTION <ul><li>Venture Strategies states: </li></ul><ul><li>“At the request of countries' ministries of health and leading health care providers, Venture Strategies is facilitating the initial registration of misoprostol for postpartum hemorrhage in developing countries throughout Africa and Asia.”  </li></ul>
  64. 68. <ul><li>“ Uso de prostaglandinas para la interrupción legal y segura del embarazo en el primer trimestr” </li></ul><ul><li>This brochure was designed for health care providers who are using the prostaglandin misoprostol for legal abortion. It provides basic information about when it can be used, its efficacy, safety and use, as well as a list of useful references. The brochure can be used during counseling. </li></ul>
  66. 70. Women on Waves: How can I do an abortion? The Borndiep Portugal, 2004
  67. 71. UNDP/ UNFPA/ WHO/ WORLD BANK Special Programme of Research, Development and Research Training in Human Reproduction Social Science and Operations Research in Sexual and Reproductive Health CALL FOR PROPOSALS/CONCEPT PAPERS FOR RESEARCH ON EXPANDING ACCESS TO MEDICAL ABORTION IN DEVELOPING COUNTRIES We are particularly interested in moving beyond formative research and into operations /intervention studies that test the feasibility of various approaches to expanding access. APRIL, 2010
  69. 73. A risk reduction strategy to prevent maternal deaths associated with abortion <ul><li>Study performed in Montivideo, Uruguay where abortions have been illegal since 1938 </li></ul><ul><li>Women were offered “before abortion” and “after abortion” visits at clinic per strategy of the Incintivas Sanitarias (Sanitary Initiatives Against Unsafe Abortion); incomplete abortions given suction curettage </li></ul><ul><li>675 women used misoprostol in the first and early second trimester </li></ul><ul><li>Results: no maternal deaths, no serious complications; one minor infection and two cases of hemorrhage </li></ul><ul><li>Incomplete abortions initially 30%; later 18% </li></ul><ul><li>Previous years – average of four deaths per year </li></ul>Briozzo L et. al., Int J Gynaecol Obstet , 2006
  70. 74. Availability of medical abortion pills and the role of chemists: a study from Bihar and Jharkhand, India <ul><li>Survey of 209 chemists (pharmacists) in India </li></ul><ul><li>34% stocked mifepristone and misoprostol </li></ul><ul><li>Demand existed for less expensive alternatives </li></ul><ul><li>Men bought most prescriptions </li></ul><ul><li>OTC sales occurred </li></ul><ul><li>Conclusion: chemists needed information, written materials, promotion of pregnancy tests and to encourage women to see providers </li></ul><ul><li>“ The best course is to increase the availability of low-cost, safe abortion services at primary care level.” </li></ul><ul><li>Ganatra B et al. Reprod Health Matters . 2005. </li></ul>
  71. 75. Abortion practice in the northeast Caribbean: &quot;Just write down stomach pain&quot; <ul><li>Three-year study in 2001-2003 of abortion practice on several islands of the northeast Caribbean: Anguilla, Antigua, St Kitts, St Martin and Sint Maarten </li></ul><ul><li>In depth interview of 26 physicians; 16 performed abortions despite illegality </li></ul><ul><li>Women travelled to preserve anonymity </li></ul><ul><li>More women are self-inducing abortions with misoprostol to avoid doctors, high fees and public stigma </li></ul>Pheterson G , Azize Y ., Reprod Health Matters . 2005
  72. 76. Mexico City, 2006
  73. 77. THREE PREGNANT MINORS IN LATIN AMERICA <ul><li>Recife, Brazil 2009: Nine year old impregnated with twins by stepfather obtained abortion (legal only in case of rape or threat to life) . The Church offered counseling and assistance; IPAS facilitated abortion. Archbishop Sobrinho excommunicated doctors and family of girl; reverberations in Vatican </li></ul><ul><li>Recife, Brazil 2010: New Archbishop Saburido initially appeared to condone similar abortion; then clarified retracted under pressure </li></ul><ul><li>Quintana Roo, Mexico 2010: Ten year old impregnated by stepfather (and her mother) resist offer by Center for Reproductive Rights to fly her to Mexico City for abortion </li></ul>
  74. 78. Ending the silent pandemic of unsafe abortion is an urgent public-health and human rights imperative. David Grimes in “ Unsafe abortion: the preventable pandemic”, The Lancet , 2006.
  75. 79. Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries Susheela Singh . The Lancet , 2006 . <ul><li>Complications from unsafe abortions account for the largest proportion of gynecological admissions in developing countries </li></ul><ul><li>One in eight pregnancy related deaths due to abortion (WHO) </li></ul><ul><li>WHO has provided estimates of abortion mortality and incidence for the last 15 years; data is scarce </li></ul><ul><li>Unsafe abortion negatively affects women, their families, public health systems and economic productivity </li></ul><ul><li>Morbidity and mortality changing due to increased contraception and introduction of misoprostol </li></ul>
  76. 80. Unsafe abortion: the preventable pandemic <ul><li>Assertion: 19-20 million unsafe abortions per year with 68,000 deaths </li></ul><ul><li>Cites traditional abortion methods with foreign objects and caustic substances </li></ul><ul><li>Morbity and mortality have fallen due to safer abortion; increased legalization and advocacy; technique of aspiration and introduction of misoprostol </li></ul><ul><li>Sexual and Reproductive Health 4: Unsafe abortion: the preventable pandemic. Grimes D et al. The Lancet. 2006 . </li></ul>
  77. 81. <ul><li>A global pro-abortion strategy seeks to advance access to legal abortion through judicial action, legislation, and health department regulations. </li></ul><ul><li>Pro-abortion NGOs, UN committees, donor countries and regional bodies argue that access to the full range of comprehensive reproductive health care services will reduce maternal mortality, alleviate poverty and empower women. </li></ul><ul><li>International and regional bodies include: </li></ul>United Nations (UN) European Union (EU) African Union (AU) Organization of American States ( OAS) INTERNATIONAL PRESSURE TO CHANGE LAWS ON ABORTION
  78. 82. MILLENIUM DEVELOPMENT GOALS <ul><li>In 2000 the UN General Assembly announced the formation of the MDG’s to be achieved by 2015 </li></ul><ul><li>1 Eradicate Extreme Poverty and Hunger </li></ul><ul><li>2 Achieve Universal Primary Education </li></ul><ul><li>3 Promote Gender Equality and Empower Women </li></ul><ul><li>4 Reduce Child Mortality </li></ul><ul><li>5 Improve Maternal Health </li></ul><ul><li>6 Combat HIV, AIDS and Other Diseases </li></ul><ul><li>7 Ensure Environmental Sustainability </li></ul><ul><li>8 Develop a Global Partnership for Development </li></ul>
  79. 83. Universal Declaration of Human Rights <ul><li>Article 3: Everyone has the right to life, liberty and security of person </li></ul><ul><li>Article 25.   (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection </li></ul><ul><li>Article 16: </li></ul><ul><li>(1) Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution. </li></ul><ul><li>  (2) Marriage shall be entered into only with the free and full consent of the intending spouses. </li></ul><ul><li>  (3) The family is the natural and fundamental group unit of society and is entitled to protection by society and the State. </li></ul>
  80. 84. SAFE MOTHERHOOD <ul><li>1987 Global Safe Motherhood Initiative Initiated </li></ul><ul><li>2002-2005 UNICEF Safe Motherhood Initiative merged with UNFPA health initiatives </li></ul><ul><li>Feminists disagreed with Safe Motherhood concept </li></ul><ul><li>Agreement on reducing maternal mortality </li></ul><ul><li>Maternal Mortality Rate vs Maternal Mortality Ratio </li></ul>
  81. 85. MDG 5 IMPROVING MATERNAL HEALTH <ul><li>MDG 5 goal shifted away from decreasing maternal mortality, substituting instead: “Increasing Access to Reproductive Health” </li></ul><ul><li>Emphasis shifted to “Unsafe Abortion” </li></ul><ul><li>Women Deliver Conference marked a triumph of the feminist (UNFPA) part of the partnership over the Safe Motherhood part of the partnership. </li></ul>
  82. 86. WOMEN DELIVER CONFERENCE LONDON, 2007 <ul><li>Culmination of years of strategy </li></ul><ul><li>Co-opted by pro-abortion agenda </li></ul><ul><li>Attended by heads of government,donors, NGO’s </li></ul><ul><li>Shifted MDG5 from decreasing maternal mortality to “increasing access of reproductive health” </li></ul><ul><li>Used invented statistics on maternal mortality </li></ul>
  83. 87. WOMEN DELIVER OBSTACLES TO UNIVERSAL ACCESS TO REPRODUCTIVE HEALTH <ul><li>The presence of Protestant missionaries in Africa and of the Catholic church in health care in South America </li></ul><ul><li>Health care workers “right of conscience” allowing them to refuse to do abortions </li></ul><ul><li>The use of ultrasound in obstetrics </li></ul><ul><li>The people themselves </li></ul><ul><li>do not want abortion </li></ul>
  84. 88. Problems with “Women Deliver” <ul><li>The “abortion first” approach contradicts the consensus of the medical community (increase skilled birth attendants and emergency obstetrical care) </li></ul><ul><li>Diverts necessary attention and funding from the real health care needs of women to abortion </li></ul><ul><li>The commonly used figure of 500,000 – 600,000 maternal deaths annually is based on unreliable and unsubstantiated data. </li></ul>
  85. 89. More Problems with “Women Deliver” <ul><li>The “abortion first” approach undermines the rule of law by abusing the UN human rights monitoring system to promote abortion rights. </li></ul><ul><li>Women’s lives are endangered because the “abortion first” approach undermines health care standards and national regulations by deliberately bypassing national laws and medical regulations. </li></ul><ul><li>The “abortion first” approach targets religion, culture, and the family. </li></ul>
  86. 90. WILL BETTER ACCESS TO ABORTION REDUCE MATERNAL MORTALITY? <ul><li>NO!!! </li></ul><ul><li>Ireland has the lowest maternal mortality rate in the world (1/100,000 births) and prohibits abortion </li></ul><ul><li>Poland and Malta 8/100,000 with restrictive abortion laws </li></ul><ul><li>Russia 28/100,000 with permissive laws </li></ul><ul><li>Mauritius 15/100,000 with restrictive laws </li></ul><ul><li>Ethiopia 720/100,000 with permissive laws </li></ul><ul><li>Chile 16/100,000 with restrictive laws </li></ul>
  87. 91. What kills mothers? “The Global Burden of Disease 2004” W.H.O
  88. 92. How can Maternal Health be improved? <ul><li>Eliminate what sickens and kills mothers raising children. </li></ul><ul><li>Make childbearing safer. </li></ul>
  89. 93. How can Maternal Health be improved? <ul><li>Eliminate what sickens and kills mothers raising children. </li></ul><ul><li>Make childbearing safer. </li></ul>
  90. 94. How can Maternal Deaths be decreased? <ul><li>Decrease the number of women who become mothers. </li></ul><ul><li>“ Family Planning” </li></ul><ul><li>?NFP? </li></ul><ul><li>?Artificial contraception methods? </li></ul><ul><li>?Induced Abortion? </li></ul><ul><li>Eliminate what sickens and kills mothers raising children. </li></ul><ul><li>Make childbearing safer. </li></ul>
  91. 95. IS THE SITUATION HOPELESS? <ul><li>NO!!!! </li></ul><ul><li>COUNTERACTING THE GLOBAL ABORTION AGENDA </li></ul><ul><li>Government recognition of demographic decline </li></ul><ul><li>The Roman Catholic Church and other churches </li></ul><ul><li>Pro-Life and Pro-Family Organization </li></ul>
  92. 96. GROUPS FIGHTING THE ABORTION AGENDA <ul><li>Population Research Institute </li></ul><ul><li>Human Life International </li></ul><ul><li>CFAM </li></ul><ul><li>PNCI </li></ul><ul><li>AAPLOG </li></ul><ul><li>World Congress of Families </li></ul><ul><li>International Right to Life </li></ul><ul><li>Numerous U.S. organizations have expanded internationally (CWFA, CareNet) </li></ul>
  93. 97. OFFICIAL RESPONSES TO DEMOGRAPHIC DECLINE <ul><li>UN Conference on Policy Responses to Ageing and Declining Populations in October, 2000; smaller and older populations will have major impact on economies, workforce, and social security </li></ul><ul><li>Australia offers $4100 bonus for every baby </li></ul><ul><li>France, Italy, Poland and some Japanese localities offer bonuses and monthly payments to families </li></ul><ul><li>Singapore: $3,000, $9,000 and $18,000 for first, second and third children </li></ul>
  94. 98. DEMOGRAPHIC WINTER The Decline of the Human Family <ul><li>“ Schools will be turned into nursing homes” </li></ul>
  95. 99. KOREA <ul><li>In 1970’s and 1980’s government instituted fines for third child due to concerns about overcrowding and overpopulation </li></ul><ul><li>Abortion illegal but not prosecuted </li></ul><ul><li>Major source of income (cash) for obstetrician-gynecologists </li></ul><ul><li>2008 Korea has second lowest birth rate in the world </li></ul><ul><li>1.19 births per woman; 4.5 in 1970 </li></ul>
  96. 100. GYNOB <ul><li>New organization of 680 Korean obgyn’s who stopped doing abortions </li></ul><ul><li>Had “forgiveness ceremony” for having performed abortions </li></ul><ul><li>“ We sold our soul for money” </li></ul><ul><li>Dr. Anna Choi </li></ul>
  97. 101. Mexico City Policy <ul><li>U.S. Government Policy </li></ul><ul><li>Requires all U.S. funded NGO’s (non-governmental organizations) to refrain from promoting or performing abortions in other countries </li></ul><ul><li>Policy in place from 1984-1993 and 2001-2009 </li></ul>
  98. 103. “ Close them all down..” Dr. Jean Kagia, Kenyan obstetrician