Counselling aspects of pregnancy termination with Mifegyne^®

1. The Situation in Austria
2. The choice of method
3. Differences from surgical termination
4. The Course of Medical Abortion
5. Frequently asked questions
6. Summary

Leila Akinyemi, Nurse, Family Planning Adviser, Social Worker
Barbara Laschalt, Mag, Psychologist
Christian Fiala MD,
Peter Safar MD, Head of the department of

Department of Obstetrics and Gynaecology
General Public Hospital
Wiener Ring 3-5
2100 Korneuburg
Austria
October 2, 2000

This article has been published in: Pro Familia Magazin, 3/99 page 32-35
The actual version has been updated.


1. The Situation in Austria

Abortion in Austria is governed by a legal upper time limit. This means that termination of a pregnancy is immune from prosecution up to the third month of pregnancy if it is carried out by a doctor with prior counselling. In contrast to other countries, however, the nature of the counselling is not defined in the law, i.e. it does not represent an obligatory measure in the context of termination of pregnancy. There are also no other restrictions, such as a prescribed waiting period between the first counselling and the termination (three days in Germany, seven days in France).
This non-restrictive framework makes it possible to orient counselling and care exclusively to the very different individual needs of the woman concerned.

On the other hand, in Austria there are no provisions regarding the actual implementation of a termination, nor is there a regulation on the allocation of costs. In consequence, outside Vienna there are very few doctors or hospitals offering abortions to the general public. This means that women outside the capital are still reliant on the "goodwill" of the doctors. Further, the costs of termination are not covered by the national health system (just as little as contraception costs). Terminations are mainly carried out in the surgeries of established specialists or GPs. Prices vary greatly. They are usually between ATS 5,000 and ATS 8,000 (DM 700 – 1,150), depending on the institution and doctor. Occasionally, however, twice this amount is charged.

In the Korneuburg hospital, just outside Vienna, we have been carrying out terminations with Mifepristone (Mifegyne^®) since January 1999. We obtain the medicine direct from the manufacturer in France, where it has been in use for more than 11 years. Owing to the absence of a licence and sales in Austria, its use is only possible with an import licence from the responsible ministry. This procedure is often adopted in order to use medication that is only licensed in other countries. The last time this drew media attention was in the use of Viagra^® before it was licensed for use in Austria.

We treat approximately 50 women per month, the demand being very high. Most of the women come from Vienna and its surrounding area. An (after) curettage was needed for four per cent of women treated.
After completion of the treatment, we asked the women, inter alia through a questionnaire, which method they would choose in any future termination. Of those responding, over 90 per cent would choose this method again.



2. The choice of method

Only when the decision for termination of pregnancy has been taken in principle does the question of how it is to be carried out arise. The decision for the termination itself, however, is independent of the methods available.
No method is better in principle or suitable for all women. It is necessary to emphasise this, because occasionally the media present medical termination as the simplest and best method. Many women have taken in this information and initially base their decision for Mifegyne® on one-sided views or misconceptions. The role of counselling is therefore also to provide detailed information on all methods and to point out their respective advantages and disadvantages. The adviser and the woman concerned must take sufficient time for this.
Further, if possible, administrative and financial considerations should not play any role in the search for the suitable method. Only then can each woman come to the decision that suits her best. There is no such thing as the right or wrong decision in general.

We cannot confirm the publicly expressed fear that with Mifegyne® women feel themselves to be under pressure of time. This should also not be expected, since Mifegyne does not represent a fundamentally better alternative, and a surgical termination remains available as a proven method.
On the contrary, we very often experience the fact that women are relieved that they can have a termination at an early point. It is particularly important that in most cases no embryonic structure and above all no heart activity is visible on the ultra-sound. A surgical termination is seldom carried out at such an early stage, which means that these women would have to wait a further one to two weeks for termination if Mifegyne were not available. Mifegyne thus represents an opportunity for them to avoid an unnecessary wait and the psychological and physical burden associated with it.

In our experience, the decision on the method is usually made rationally. We can proceed on the assumption that in the case of those women who decide for a medical termination of pregnancy, it concerns a group of women who:

• want to have a termination as soon as possible
• have had negative experiences with surgical abortion
• want to avoid an anaesthetic
• want to avoid an operation
• do not want to be dependent a doctor
• want to remain conscious during the process of termination
• prefer a "natural" process.

Thus in the choice of general conditions, it is true, they differ from women choosing a surgical termination, but not in their strategy for dealing with the conflict of an unwanted pregnancy.

3. Differences from surgical termination

Counselling acquires an essentially greater significance in medical termination, than the doctors involvement.

&Mac223; The counselling lasts longer and is more intensive than it is for surgical termination.
&Mac223; It is not just a question of the (mainly already taken) decision to terminate the pregnancy, but also that the woman must be enabled to choose between two methods of treatment that she does not know. It is thus also a question of the provision of experience on which method seems to be more or less suited to which woman.
&Mac223; The initial counselling is continued in the form of a care during treatment.
&Mac223; The continuity of the counselling and accompanying person is a new factor.

Since treatment with Mifegyne takes a very different course from woman to woman, it is not possible to make clear-cut predictions of the process and the physical symptoms. We therefore prepare the women for the most unpleasant outcome, but also say that in most cases the process is undramatic and that some women notice no difference to a normal period.

Assuming the classical pregnancy conflicts such as

• socio-cultural conflicts
• socio-economic conflicts
• interpersonal conflicts
• internal emotional conflicts

women who decide for Mifegyne do not differ essentially from those who have chosen a surgical termination in our experience. If one wishes to draw a cautious conclusion, the former are possibly somewhat more controlled. We can also assume that they mainly have a more self-assured approach to their body and thus better bodily awareness.

What does medicinal termination with Mifegyne mean?
The major difference to a surgical termination lies in the fact that treatment with Mifegyne^® is a process extending over several days and which is experienced in a fully conscious state, in contrast to the short, instant intervention of vacuum curettage. It is almost impossible for the women to avoid coming to terms with this active separation, as they are confronted with the physical process.
Inasmuch as they wish consciously to confront this situation, it can help them to deal with the termination in a better way, according to their opportunities and resources. The women perceive the course of the termination more sharply. They usually see the ejected amniotic sac or even bring it into the hospital. This conscious process makes an active leave-taking and conclusion to the situation possible.
Interestingly, the partner is much more involved than in a surgical termination. He experiences the process at close quarters and not, as is usual in a surgical termination, in that he takes the woman to the doctor and collects her again a few hours later, not really having much to do with things. Here, he rather takes on an important caring role and should therefore be present from the beginning (naturally only inasmuch as this is desired by the woman). By being there he also has the opportunity to correct his general misconceptions.

As in any other conflict situation, the process is determined by the clarity of the decision. The more clearly the woman has decided for herself, and the more support she has, the better she can deal with it, and the less complicated the process will be.

What we as counsellors can contribute to this clarity is particularly detailed information and in-depth advice from the moment of the first contact. Even in the run-up we attempt to identify which women we think we can have confidence in for this conscious experience, psychologically as well as physically. In most cases, on the basis of the information, the women decide very quickly in the course of the discussion for the method that suits them best. Occasionally this cannot be settled in the first (telephone) contact however, which necessitates several more telephone calls. The question of how far we should advise a woman for or against Mifegyne is then a matter of degree which can very easily border on patronisation.

On the basis of several contacts with the women, a relationship of trust arises, which is an important factor in the treatment proceeding as well. For the counsellor, however, this means that through her position as chaperone she becomes a part of the process. On the one hand, this is related to an intensive identification with the situation of the woman, on the other hand, it calls for a high degree of distancing for the individual counsellor.

4. The Course of Medical Abortion

4.1 First telephone contact
The first telephone contact usually begins with a detailed discussion of information on abortion itself, though also on the details of the various methods. The discussion then proceeds rapidly – according to the situation – to a counselling session. This discussion is often of great importance in the Mifegyne® counselling, as it lays the foundation stone for the relationship and thus also the course of the process. The telephone calls are often long, or the woman rings several times within two or three days.

It is therefore important that the same person also provides the continuing counselling and escort functions. As previously mentioned, the counsellor must go through a selection process with the patient in relation to the medical and psychological criteria in order to choose the most suitable method. If the women seems to be shure on her decission we make an appointment. Often, however, we also give information on other establishments that are either nearer or which carry out surgical terminations under local or full anaesthetic.
Despite the surge of interest in Mifegyne and the frequent calls to our advice line, only approximately 20 per cent of the callers actually go on to termination with Mifegyne.

- The period from first contact to the taking of Mifegyne:
In this phase, women are confronted by unrealistic worries and illusions. The question repeatedly poses itself: what is really going to happen to me, what have I let myself in for, have I made the right decision? Seen as a whole it is the most uncertain and problematic phase.

4.2 First counselling in the hospital
The first personal contact in the hospital is divided into the medical examination and the counselling. Teamwork between the doctor and the counsellor is crucial in this. They must divide the consultation and reciprocally accept their competences in order to guarantee the best possible care.
Detailed information on the method and the process should where possible deal with any misconceptions. Women are particularly relieved when there are (still) no embryonic structures, and in particular no heart activity, visible on the ultrasound scan. Further, it should be emphasised that the taking of Mifegyne is the actual termination of the pregnancy. This is the point of no return. The prostaglandin two days later serves only to support the expulsion of the already terminated pregnancy.
As already mentioned, an exact prediction of the further course of the process is not possible because of the great individual variations. The women should be advised of this. In particular, the varying courses of the process do not allow any conclusions to be drawn on whether the method functions or not.

In our experience it is particularly important and helpful for the woman if the partner or a contact person is integrated into the course of the process, so that he/she can have a supportive effect. Naturally, this can only happen with the agreement of the woman concerned.

- The period from the taking of Mifegyne to the taking of Prostaglandin:
In this phase the problem with the body comes to the fore. The decision for termination has already been implemented. Now the uncertainty over the further course of the process and the waiting for the period are the main issues.


4.3 Care after the taking of Prostaglandin
The atmosphere is now essentially more relaxed than at the previous contact. The woman knows the doctor and counsellor and knows at least theoretically what awaits her. Further, there is no longer any decision to be made, only the continuation of a process that has already been started. For some women, morning sickness has already receded and in a few cases the women have already ejected the amniotic sac. (in these cases the treated is thereby concluded).

Most women are worried about possible pains after the taking of the Prostaglandin. The offer of the appropriate escort by a trusted person over a generous time frame is therefore very important. As far as possible this should however remain an offer, and not be seen as a compulsory measure. Some women are hardly affected by the termination and therefore have no need of an escort. This should also be taken into account in the organisation of the process.
In this phase, medical care recedes into the background, in favour of escort by the counsellor and the partner/friend. Some 20-40% of the women require mild analgesics.
- From the taking of Prostaglandin to the check-up
Heavy bleeding and cramps can occur in this phase. The main concern is the uncertainty whether the method has worked. Future fertility is suddenly also an important issue again.

4.4 After-care
The further medical check-up after a week to ten days is seen by most women as a great relief and the definitive conclusion of the process. For many women the period up to the check up is stressful because of the uncertainty over whether the pregnancy has actually been terminated. Most women are thus all the more pleasantly surprised if everything has gone well.

Occasionally a second or third medical check-up is necessary, and in about three per cent of cases a curettage. For these women, too, the appropriate counselling should be envisaged.
As always there is the question of psychological-psychotherapeutic after-care, which is however only rarely taken up after a medicinal termination.

5. Frequently asked questions

The questions asked by the women concerned vary greatly from those of the largely male participants in the public debate. In female reality the worries are very different from those of the male imagination.

5.1 Questions by women concerned:

Can I still have children?
This is one of the women’s most frequently asked questions, because of the still prevalent myth that a woman cannot become pregnant again after an abortion. There are no known negative effects on later fertility. Rather the woman can possibly become pregnant again immediately after the termination.

Will the termination be carried out anonymously?
For most women the protection of their anonymity is extremely important; i.e. their data must be particularly well protected.

How much experience is there so far?
Precisely with Mifegyne®, the question of the length of the trial period and the medical experience related to it arises more frequently than for a surgical termination. Mifegyne® in combination with Prostaglandin has been used in France since October 1988. Further, it has been licensed in England since 1991 and in Sweden since 1992. More than 500.000 women in Europe have beent treated so far.

I am afraid of pains and that it will not work.
Some women imagine that for them in particular a termination using Mifegyne will not work. This function relates less to the actual medical process than to the illusion that their body is not "normal" and that the treatment will not work in their case. The fear of pain is understandably very high among women. Many women have lower abdominal pains, usually after taking Prostaglandin. There are, however, also some women who do not experience any pain.

What is the best method? "What would you chose?"
There is no good, and also no bad method. The decision is always for the woman herself to take in the context of her own situation.

What are the advantages? (Questions about the disadvantages are more seldom asked)
The major advantage in treatment with Mifegyne® is that the termination can be carried out very early and no operation is necessary.

What is the natural method?
Taking account of the great moral pressure which still prevails in connection with termination of pregnancies, treatment with Mifegyne® can be seen as "more natural".
Seen objectively, both surgical and medical termination are an externally induced termination of the pregnancy.

What does it cost and do I have to pay again if a curettage is necessary?
We offer both methods for the same price. If a follow-up curettage is needed the women do not have to pay again in any case.

5.2 Questions in the public debate

Are women under time pressure because they only have until the seventh week to decide?
Women very often know they are pregnant shortly after missing their period and they can check this with the new tests. The reality is that many women who would like a (surgical) termination have to put it off for one to two weeks because this will usually only be carried out from the sixth to seventh week.

Can it be assumed that women will more easily decide for a termination if they have the opportunity of a medicinal termination?
The decision for the termination of a pregnancy is always taken before the decision on the method and is independent of the methods available. Further, termination with Mifegyne is no easier in principle, so there is no reason for the above-mentioned assumption. In addition, the number of terminations in France, England and Sweden has not increased since the introduction of Mifegyne®.

Do women often face a conflict between the taking of Mifegyne® and the Prostaglandin? Might they possibly break off the treatment?
There are naturally conflicts and doubts in every phase of the treatment. Termination of the pregnancy, however, takes place with the taking of Mifegyne®, not just with the administration of Prostaglandin. Of the women we have treated, none has so far broken off the treatment. We have no indication that this phase involves any more strain than the time of the decision before taking Mifepristone (Mifegyne^®).

6. Summary

Mifegyne^® does not essentially change the counselling in the conflict case of an unwanted pregnancy. The previous counselling only has to be supplemented when it comes to the specific implementation. Here, good information and counselling with sufficient time are necessary, so that each woman can arrive at the best decision regarding the method for her. This and sympathetic counselling during the treatment form the basis for a good course of the process and a high level of satisfaction on the part of the women. Under these preconditions, termination with Mifegyne is a sensible alternative for many women. Further, we have the experience that the treatment proceeds essentially more calmly and less dramatically than the public debate. In the specific work, we have found no projections from the public debate.


It is incomprehensible that there is so much resistance if women in the rest of Europe are to be offered this alternative with an 11-year delay. It would be far more desirable for women everywhere to be able to choose between all existing methods. Above and beyond this, efforts should be undertaken in future to research possibilities for a further improvement of this method.