1. “Who does provide services; and where? ” France: How we are moving medical abortion services away from hospital based Expanding Access to Medical Abortion: Building on Two Decades of Experience Danielle Hassoun MD ICMA Lisbon, Portugal, March 2010

2. 2 Evolution of the percentage of MA since the commercialization in 1990 In 2007, 49% of all abortion up to 14 weeks LMP are medical abortion almost 90% of abortion less than 7 weeks LMP are medical abortion

3. 3 What was the strategy to improve access and acceptability?  Moving services away from hospital based -- The new law makes it possible -- Back up services in case of complications are easily available  Involving different providers, especially GPs in providing MA in their private office or in the primary care centers.

4. 4 Moving services away from hospital based Was made possible by the new abortion law (2001/2004)  Authorizes MA home use  Gives the possibility for doctors (ob-gyns and GPs) to provide MA up to 7 weeks LMP in their private office or in primary care centre provided : -- they are part of a network and connected to an affiliated hospital to deal with eventual complications, -- A contract has to be signed between hospital and individual practitioners with duties and responsibilities for each partner

5. 5 The Setting up of a Network Linking Private Doctors with Hospitals Responsibilities and duties For the Reference Hospital  Answer each request to for information on medical abortion  Treat any resulting complications 24 hours a day and take in charge women with ongoing pregnancy or retentions  Train the providers before they have signed the contract

6. 6 The Setting up of a Network Linking Private Doctors with Hospitals Responsibilities and duties For the practitioners  Respect the abortion law (the week reflexion period, 7 weeks LMP Give all information (methods of abortion, possible complication, STD, Contraception) Written protocol and an informed consent has to be signed  Fill out a medical file with a copy given to patient  Send to the hospital the final result after the follow up visit  Provision of drugs in local pharmacies ordered, purchased and paid for by doctors (91,74€)  “Package Fee” : 191,74€ (155$) reimbursable to patient at a rate of 70%.

7. 7 Creation of REVHO ( Réseau Entre la Ville et l'Hôpital pour l'Orthogénie) www.revho.fr In order to accelerate the scaling up and the availability of the method especially for the GPs within the new regulation, we decided to create in 2004 an association Funded by the ministry of Health (MOH) with the following main objectives:  Help the abortion Centres to create their local network by providing logistic support such as models of all the paperwork needed : (files, information notice for patients)  Provide training sessions for doctors and others health professionals (nurses, social workers, counsellors..)  Create a database to evaluate quality of care, patients satisfaction as well as health providers satisfaction

8. 8 Creation of REVHO ( Réseau Entre la Ville et l'Hôpital pour l'Orthogénie) www.revho.fr REVHO has trained in Ile de France  446 health professionals (working in primary care centers)  252 doctors -- 106 Gynecologists -- 108 General practitioners  15.764 MA performed since 2004 with same efficacy and complications rate as reported in the literature Ile de France Population :11 millions (19% of the French population) 57998 Voluntary abortion in 2005 (25% of all abortion) 41,7% were MA Ile de France Population :11 millions (19% of the French population) 57998 Voluntary abortion in 2005 (25% of all abortion) 41,7% were MA

9. 9 Rationale to involve GPs as providers of MA Abortion should be made available at a district level GPs are the professionals best placed to answer this need:  Closed to family  Women most often come first to their GPs when they are pregnant whatever may be the decision to keep or not the pregnancy.  Fast track support when advise is needed or questions arise

10. 10 Rationale to involve GPs as providers of MA  MA is a simple procedure with high efficacy and safety  No need to set up special facilities  A procedure which can be easily and quickly learnt

11. 11 Did they want to add this service? They were afraid :  To be known as providing abortion and to have too many demands  Of bleeding complication or ectopic pregnancy  They could argue that to provide MA takes time and is not financially incentive

12. 12 Did they want to add this service? They will need be reassured +++  Most of them want to provide abortion only to their own patient but some of them accept few women who are sent by the reference hospital  Network as defined in the law is an extremely structured rigid framework but the advantage in practice is that it is also very reassuring and doctors felt more comfortable.  Training is a critical issue

13. 13 Conclusion Importance of having diversity in the place where women can request an abortion Hospital …for women who need and feel reassured to stay few hours at the hospital More anonymous in certain circumstances Easier for the more complicated cases (medical or social) Private office or primary care centers…. for women, who need a more personalized care, close to home, faster than in the hospital

14. 14 Challenges To give to women the option to go to their GPs is a good way  to increase options and access to good quality health care, provided GPs are well trained and reassured by being connected with a reference hospital.  to include abortion among standard medical procedures contributing to de-stigmatize the issue.  And for doctors to better understand what an abortion does represent for women

15. 15 The challenge still remains to maintain offering women a complete free choice of the method, without involuntarily imposing a procedure over the others

16. 16 Merci, Thank you.