RU486 seminar

RU486 seminar

Dr. Margaret Sparrow spoke to the Women's Health Action RU486 Seminar on 31 October 2000.  

• Mifeprostone (RU486 or Mifegyne or Mifeprex) - paper by Dr Margaret Sparrow
• Medical Abortion - A choice for New Zealand women - overheads by Margaret Sparrow at workshop

MIFEPRISTONE (RU 486 or MIFEGYNE or MIFEPREX)

Dr Margaret Sparrow, October 2000

Mifepristone (RU 486 as it was known during the development phase, or Mifegyne as it is known in the UK or Mifeprex as it is known in the USA) is an antiprogesterone, which when used in conjunction with prostaglandins, has been shown to terminate early pregnancy (up to 7-9 weeks) safely and effectively, providing an alternative to existing surgical abortion methods.

The countries that have licensed mifepristone are France (1988), the U.K. (1991), Sweden (1992) and China (1988). In 1999 nine other EEC countries gave approval: Austria, Belgium, Denmark, Finland, Germany, Greece, Luxembourg, Netherlands, Spain, also approval in 3 non-EEC countries: Israel, Russia, Switzerland.Other uses for mifepristone include:softening and predilatation of the cervix prior to surgical termination of an early or late pregnancy; softening and predilatation of the cervix prior to a later stage prostaglandin medical abortion; labour induction for foetal death in uteropostcoital emergency contraception and as a monthly contraceptive, research is also being conducted into its use in other conditions especially breast cancer and Cushing's syndrome, also meningioma, glaucoma, endometriosis, uterine (fibroids). Mifepristone alone is not enough to produce abortion in most women. It is usually followed by the administration of a prostaglandin. Mifepristone alone has few side effects, although a small number of women report slight nausea after taking the tablets. Most of the side effects are due to the prostaglandin.

The most serious side effect is excessive bleeding (0-1.4%) and the method should only be used where there is access to emergency gynaecological services. There has been research on different types of prostaglandins, at different dosages, through different routes of administration (injection, vaginal, oral) and at different times following the mifepristone. For early terminations tablets of misoprostol or a vaginal pessary such as gemeprost are now commonly used. There is now considerable evidence confirming its usefulness as a postcoital contraceptive. Opposition to mifepristone has come not only from anti-abortion groups but also from groups concerned with the risks associated with its use, and the lack of information on long term side effects. The 6th International Women and Health meeting held in the Philippines in November 1990 opposed the introduction of mifepristone in combination with a prostaglandin, especially in third world countries. At a conference in 1991 at the Massachusetts Institute of Technology three women denounced the drugs as unsafe for women. They have written a book outlining their opposition to mifepristone. Dr Lynette Dumble is a medical scientist at the University of Melbourne, Renate Klein is a lecturer in Women's Studies at Deakin University, Melbourne and Janice Raymond is an ethicist from the Massachusetts Institute of Technology. A major international conference was held in Arlington, Virginia in December 1991 on the ethical, legal and medical issues of antiprogestin drugs. It was sponsored by the American Society of Law and Medicine. The Department of Health sent a representative from New Zealand.

France
Mifepristone was first synthesised in April 1980 by chemists at Roussel-Uclaf during a search for drugs that would block other steroid receptors. The scientist most involved with the development was Dr Etienne-Emile Baulieu. The first clinical trial was conducted in Geneva in 1981 and the first paper on the interruption of early human pregnancy with mifepristone was published in 1982. A breakthrough came in 1985 when it was shown that antiprogestogens increase the sensitivity of the uterus to 'prostglandins. On September 23 1988 the French Government approved marketing of mifepristone. On October 26 1988, Roussel-Uclaf announced the cancellation of their plans citing intense pressure from anti-abortion groups in France and the US with threats of violence and boycott. This decision was condemned by O&G specialists attending the FIGO conference in Rio de Janiero. The French Health Minister, Claude Evin, ordered Roussel to resume distribution on October 28 declaring from "the moment Government approval for the drug was granted, RU 486 became the moral property of women, not just the property of the drug company."
The French Ministry owned 36% of Roussel's stock. Roussel retained tight control of the drug, allowing only a limited amount of research in other countries. It was officially launched in France in April 1990. In April 1991, one death due to myocardial infarction occurred in France, following the injection of sulprostone as the prostaglandin. Roussel Uclaf and Hoechst merged in 1992 and in 1996 the new company merged with a third company, Marion, becoming HMR (Hoechst Marion Roussel). In the decade since the introduction of mifepristone there has not been a rise in the number of abortions and approximately one third of eligible women in France now choose to have a medical termination.

China
Scientists from Roussel Uclaf visited China in 1985 and from 1985-7 studies were conducted with the State Family Planning Commission. Roussel Uclaf refused to sell RU486 and Chinese authorities made their own product which is now widely used.

UK
In the UK the proceedings of a conference organised by the Birth Control Trust on 26 October 1989 at the Royal College of Obstetricians and Gynaecologists, London were published. Early British experience with medical termination of pregnancy using mifepristone has been published. A study from Aberdeen on women's preferences found that 20% of women preferred to use medical abortion and 26% vacuum aspiration. The remainder were willing to use either method. On 14 October 1999, the UK FPA and the Population Council held a seminar in London on medical abortion. The aim was to examine current practice worldwide with emphasis on France, Sweden, the UK and Austria. The conference report has been published.
On 13 March 2000, the Royal College of Obstetricians and Gynaecologists launched the National Evidence-Based Guideline No8 on 'The Care of Women Requesting Abortion'. The chair of the Guideline Development Group was Gillian Penney FRCOG.

USA
In April 1993 Hoechst agreed to make mifepristone available in the USA for clinical trials. In May 1994 the US rights were donated to the Population Council. The Population Council is a nonprofit, nongovernmental institution established in 1952 with headquarters in New York supporting a global network. The Population Council encountered medico-legal problems in making the drug available. In September 1996 the FDA considered the drug safe and effective and issued an "approvable letter" for the use of mifepristone in the termination of early pregnancies, final approval depending on further information on manufacturing from the licensee, The Danco Group.
In June 2000 the Journal of the American Medical Women's Association Vol 55, No 3, has a Supplement on medical abortion.
In August 2000 the American Journal of Obstetrics and Gynecology Vol 183, No 2, has a Supplement on early medical abortion.
On 28 September 2000 the FDA approved the use of Mifeprex for early termination of pregnancy by trained doctors who can accurately diagnose early pregnancy and can either perform surgical abortions themselves or arrange for surgery to be carried out when indicated.
In the USA a number of feminist groups have been involved in the debate on medical abortion.
Pro-choice Feminist Groups
NARAL (National Abortions Rights Action League). Active on this issue since the mid 1980s. A sponsor of the Arlington Conference in 1991. NOW (National Organisation of Women) has campaigned for the introduction of mifepristone in USA.
Feminist Majority
Begun by Ellie Smeal, former President of NOW. RU486 has been a major priority. Petitions organised. "The Web of Influence" campaign.
Women's Health Movement Groups
NWHN (National Women's Health Network). Emphasise the advantages, disadvantages and unknowns.
BWHBC (Boston Women's Health Book Collective). A sponsor of the Arlington Conference in 1991. Judy Norsigian presenter at this conference.

Emphasise choice.
NBWHP (National Black Women's Health Project). Emphasise the rights of black women, poor, disadvantaged.
FINRRAGE (Feminist International Network of Resistance to Reproductive and Genetic Engineering). Opposes RU486 and supports the stance taken by Lynette Dumble in "RU486: Misconception, Myths and Morals". Safety issues paramount.
FFWHC (Federation of Feminist Women's Health Centres). Supports availability.

Australia
In March 1994 clinical trials under the auspices of WHO commenced in Australia. Melbourne trials used the drug both as an abortion pill (with some delays due to controversy) and as an emergency contraceptive.
A Sydney trial used the drug for emergency contraception.
In May 1996 anti-abortion Independent Senator Brian Harradine moved an amendment to the Therapeutic Goods Act that requires ministerial approval for further clinical trials or distribution.

New Zealand
November 1990
The New Zealand Family Planning Association sponsored a visit to New Zealand by Professor E. Baulieu, the French researcher who was most responsible for the development of mifepristone. A seminar was held in Auckland on 20 November 1990 to provide scientific information on mifepristone and to discuss the implications for New Zealand of having this drug available.
June 1992
Dr Christine Roke, National Medical Spokesperson for the New Zealand Family Planning Association, was invited to contribute a guest editorial for "New Ethicals"
September 1992
In September 1992 WHO invited the New Zealand Family Planning Association to participate in a multicentre study on the use of mifepristone as a postcoital contraceptive: WHO PROJECT 92903: "A prospective, randomized, double-blind multicentre study to compare three doses of mifepristone (600mg, 50mg and 10mg) in emergency postcoital contraception". Rousell-Uclaf did not give approval for New Zealand participation. The results of this study have recently been published in the Lancet
June 1995
At the inaugural conference for New Zealand abortion providers held in Wellington Dr Earle Wilson, who has had experience with WHO trials on mifepristone concluded: "The method is established and there has been a very large clinical experience accumulated. It is safe, probably causing less trauma to the cervix than vacuum aspiration and effective.
The existence of such a method widens the choice available to women, and especially for those with a dislike, or fear, of surgical procedures. There seems no good reason why the method should not be available in all countries where abortion is legal."
June 1997
Professor David Healy spoke of his experience with mifepristone in Melbourne clinical trials at the 2nd New Zealand abortion providers' conference, held in Christchurch 13-14 June 1997.
December 1997
Professor David Baird from the MRC Reproductive Biology Unit in Edinburgh, was invited by the Royal New Zealand College of Obstetricians and Gynaecologists as the Visiting Sims Black Professor.
22 February 1999
Istar Limited was incorporated under the Companies Act 1993 as a non-profit company. It was formed by a group of 5 New Zealand doctors specifically to make mifepristone available as a choice for New Zealand women.
28 March 2000
The Minister of Health, The Hon. Annette King received a legal opinion from the Crown Law Office. She had requested this because of uncertainties in the present laws.
May 2000
Istar signs agreement with Exelgyn, making MIFEGYNE available for restricted use. It must be restricted to licensed hospitals or centres having approval to undertake termination of pregnancy. It must be restricted to the following therapeutic indications and the dossier provided only supports the following indications: 3 tablets of MIFEGYNE-200 mg in a single oral dose, for the medical termination of an intra-uterine pregnancy, in sequential use with a prostaglandin analogue administered 36-48 hours after MIFEGYNE intake: either a misoprostol 400(oral tablets) for pregnancies up to 49 day or gemeprost 1 mg (vaginal pessary) for pregnancies up to 63 days of amenorrhoea. 1 tablet of MIFEGYNE 200 mg orally, for softening and dilatation of the cervix prior to early or late surgical pregnancy termination (to facilitate the surgical step).
MIFEGYNE is administered 36-48 hours before surgery. 3 tablets of MIFEGYNE 200mg in a single oral dose for softening and dilatation of the cervix to prepare for the action of prostaglandin analogues in the termination of pregnancy for medical reasons (to reduce the doses of prostaglandin). MIFEGYNE is administered 36-48 hours before the prostaglandin. 3 tablets of MIFEGYNE 200 mg in a single oral dose for 2 consecutive days for labour induction in foetal death in utero (to lead to expulsion or to reduce the dose of prostaglandin). Labour should start within 72 hours after the first administration of MIFEGYNE
9 June 2000
Istar makes application to Medsafe for consent to distribute a new higher-risk prescription medicine: MIFEGYNE
5 September 2000
Istar makes application to Medsafe for licence to sell medicine by wholesale. Licence approved 27 September 2000. To be renewed annually.

References:
Baulieu E-E. The Albert Lasker Medical Awards. RU-486 as an antiprogesterone steroid. From receptor to contragestion and beyond. JAMA 1989; 262, 13: 1808-1814.
Baulieu E-E. Contragestion and other clinical applications of RU 486, an antiprogesterone at the receptor. Science 1989;245:1351.
Frydman R, Baten C, Lelaider C, et al. Mifepristone for induction of labor. Lancet 1991;337:488.
Cabrol D, Dubois C, Cronje H, et al. Induction of labor with mifepristone (RU 486) in intrauterine fetal death. Am J Obstet Gynecol 1990;163:540
Dubois C, Ulmann A, Baulieu E-E. Contragestion with late luteal administration of RU 486 (Mifepristone). Fertil Steril 1988;50:593-6.
Peplow PV. RU 486 combined with PGE 1 analog in voluntary termination of early pregnancy - a comparison of recent findings with gemeprost or misoprostol. Contraception 1994;50:69-75
Glasier A, Thong KJ, Dewar M, Mackie M, Baird DT. Postcoital contraception with mifepristone. [Letter] The Lancet 1991; 337: 1444-5
Swahn ML, Gemzell K, Bygdeman M. Contraception with mifepristone. [Letter] The Lancet 1991; 338: 942-3
Ledger WI, Sweeting VM, Hillier H, Baird DT. Inhibition of ovulation by low dose mifepristone (RU 486). Hum Reprod 1992;7:945-50
Webb AMC, Russel J, Elstein M. Comparison of the Yuzpe regimen, danazol and mifepristone (RU486) in oral postcoital contraception. Br Med J 1992;305:927-31
Glasier A, Thong KJ, Dewar M, Mackie M, Baird DT. Mifepristone (RU 486) compared with high-dose estrogen and progestogen for emergency postcoital contraception. N Engl J Med 1992; 327;15:1041-4
Grimes DA, Cook RJ. "Mifepristone (RU 486) &endash; An abortifacient to prevent abortion?" [Editorial] New Engl J Med 1992; 327, 15: 1088-89
Haspels AA. Emergency contraception: A review. Contraception 1994;50:101-8
Task Force on Postovulatory Methods of Fertility Regulation Comparison of three single doses of mifepristone as emergency contraception: a randomised trial. Lancet 1999;353:697-702
Klein R, Raymond JG, Dumble LJ. RU 486 Misconceptions, myths and morals. Melbourne: Spinifex Press; 1991
Silvestre L, Dubois C, Renault M et al. Voluntary interruption of pregnancy with mifepristone (RU 486) and a prostaglandin analogue. N Engl J Med 1990;322:645
Peyran R, Aubery E, Targosz V. Early termination of pregnancy with mifepristone (RU 486) and orally active prostaglandin misoprostol. N Engl J Med 1993;328:1509
Ulmann A et al. Medical termination of early pregnancy with mifepristone (RU 486) followed by a prostaglandin analogue. Acta Obstetrica et Gynecologia Scandinavia 71:278-83
Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. New Engl J Med April 30, 1998
Winikoff B, Ellerston C, Elul B, Sivin I. Acceptability and feasibility of early pregnancy termination by mifepristone-misoprostol: Results of a large multi-centre trial in the United States. Archives of Family Medicine July/August 1998
Williams C, editor. The `abortion pill' (mifepristone/RU 486) Widening the choice for women. London: Birth Control Trust; 1990
Heard M, Guillebaud J. Medical abortion - safe, effective and legal in Britain. BMJ 1992;304:195-6
McKinley C et al. The effect of dose of mifepristone and gestation on the efficacy of medical abortion with mifepristone and misoprostol. Human Reproduction 8:1502-5
Henshaw RC et al. Comparison of medical abortion with surgical vacuum aspiration: women's preferences and acceptability of treatment. B Med J 1993;307:714-7
Hobden J. [Ed] Medical Abortion Meeting Women's Needs. London: FPA; 2000.
Roke C. Mifepristone (RU 486) A New Zealand perspective. New Ethicals June 1992 29;6:11-16
Wilson E. Antiprogestogens for medical termination of pregnancy in Sparrow M [ed] Proceedings of the inaugural conference for New Zealand abortion providers held in Wellington 23-24 June 1995. Wellington: 1995; 90-98

Medical Abortion - a choice for New Zealand Women

Presentation at meeting organised by Women's Health Action in Auckland on Tuesday 31 October 2000
by Dr Margaret Sparrow

What is a medical abortion?

Traditional methods in many cultures. A pregnancy is terminated by taking medication as an alternative to a surgical procedure. Currently two drugs are used by medical professionals:

• methotrexate (a folic acid antagonist)
• mifepristone (an antiprogesterone)

Both are followed in 36-48 hrs by a prostaglandin analogue (PG) to expel the embryo (8 wks) or foetus. Where available mifepristone is preferred because of greater efficacy and safety.

What is mifepristone?

Mifepristone is also known as RU486 or Mifegyne (UK) or Mifeprex (USA)

It is a synthetic steroid derived from 19-nor-testosterone, its abortifacient action due to its antiprogesterone effect as a progesterone receptor blocker.

Other possible uses of mifepristone:

As a post-coital contraceptive or once-a-month contraceptive, and in the following medical conditions: uterine fibroids, endometriosis, Cushing's disease, meningioma, breast cancer etc.

History of mifepristone:

1980 Synthesis of RU486 by Roussel-Uclaf

Sept 1988 Registered for use in France as abortifacient

26/10/88 Roussel-Uclaf announces plans to cancel distribution

28/10/88 French Health Minister, Claude Evin, orders it be available

1988 China manufactures its own RU486

1991 Approved for use in the UK

1992 Approved for use in Sweden

Aug 1997 Commercial rights transferred to Exelgyn

1999 Approval in 9 EEC countries: Austria, Belgium, Denmark, Finland, Germany, Greece, Luxembourg, Netherlands, Spain
Approval in 3 Non-EEC countries: Israel, Russia, Switzerland

History in USA:

1983 FDA issues testing permit to Population Council

June 1989 Importation for personal use banned

1993 President Clinton issues Executive Order for RU486

May 1994 Roussel-Uclaf donates patent to Population Council

1995 Population Council conducts clinical trials in 17 centres

Sept 1996 FDA grants "approvable status"

28/9/00 FDA approves Mifeprex

Conditions for use in USA:

• Women to receive an approved Medication Guide (see separate handout)
• Doctors must be trained to diagnose early pregnancy and exclude ectopic pregnancy
• Doctors must make advance arrangements for surgical back-up

Making mifepristone available in New Zealand:

Nov 1990 FPA invites Prof. Baulieu to speak in Auckland

Sept 1992 FPA invited by WHO to participate in postcoital research

June 1995 Method discussed at 1st Abortion Providers' conference

June 1997 Pro. David Healy, Melbourne, speaks at 2nd Abortion Providers' conference

Dec 1997 Prof David Baird, Edinburgh, invited by RNZCOG

Feb 1999 Istar Limited incorporated as a Company

March 2000 Minister of Health, Annette King obtains legal opinion from Crown Law Office

May 2000 Istar signs agreement with Exelgyn for Mifegyne

June 2000 Istar makes application to Medsafe

Sept 2000 Istar receives licence to sell medicine by wholesale

Proposed restrictions on availability:

• Only available on restricted basis as in the UK
• Not available through pharmacies
• Not available for use as a postcoital contraceptive
• Before drug approval may be used under Sect 29 of the Medicines Act

Legal issues:

• Must conform to CS&A Act and Crimes Act
• Medications must be given in licensed premises
• Section 18 CS&A Act states that no abortion shall be performed elsewhere than in an institution licensed for the purpose
• Difference of legal opinion as to whether foetus must be expelled in a licensed institution

Exelgyn/Istar Agreement for early MTOP:

• Up to 63 days gestation
• Mifegyne 200 mg x3 in single oral dose
• 36-48 hrs later, PG:
• up to 49 days, misoprostol 400 mcg orally
• up to 63 days, gemeprost 1mg vaginally
• Gemeprost expensive and unstable at room temperature

More recent research:

• Dose of Mifegyne can be lowered to 200 mg
• Misoprostol can be given vaginally

Informed consent:

• Explanation of options
• Explanation of medical TOP
• Advantages v. disadvantages
• Risks v. benefits
• Medical contraindications to method
• Safety issues, telephone, transport
• Surgery for approx 5% (Range 1.3 - 7.5%)

Medical risks:

• Haemorrhage requiring admission. (Range 0 - 1.4%). Risk increases with gestational age. Transfusion approx 1 in 400. Haemostatic curettage approx 1 in 300.
• Incomplete abortion requiring surgical curettage (Range 1.3 - 4.6%)
• If pregnancy continues, risk of foetal abnormality especially after misoprostol (Range 0.3 - 1.5% unsuccessful)
• 1 death in France in April 1991, myocardial infarction following injection of sulprostone
• ?? Long term risks

Disadvantages:

• Heavy bleeding in approx 5%, surgery in approx 5%
• May be more cramping over longer period than surgery, especially after PG
• Analgesics used in 16 - 68%
• Gastrointestinal side effects especially after PG - nausea (approx 50%), vomiting (approx 20%), diarrhoea (approx 15%)
• Uncommon - hypotension, fatigue, headache, skin rash, allergy, disturbance of thermo-regulation with symptoms of hot flushes, dizziness, chills, fever
• 3 visits minimum after referral

Medical contraindications to mifepristone:

• Confirmed or suspected ectopic
• Corticosteroids, long-term, current
• Bleeding disorders, current anticoagulants
• IUCD in situ
• Chronic adrenal gland failure
• Allergy to mifepristone

Medical contraindications to prostaglandins:

• Cardiovascular disease (angina, Raynaud's disease, cardiac arrhythmias, cardiac failure, severe hypertension)
• Women >35 yrs + smoking >10 cigarettes per day (no longer absolute)
• Allergy to prostaglandin

Benefits:

• Effective very early in pregnancy
• No surgical risks to cervix, uterine perforation
• Not dependent on skill of surgeon
• No anaesthetic risks, LA or GA
• Infection uncommon if screened, prophylactic antibiotics not recommended
• The woman feels more in control
• Surgery more intrusive
• "Surgical" methods also employ drugs, pre-op, during op and post-op

Protocol for early MTOP:

• Early diagnosis by GP/FPA with swabs, smear, blood tests and ultrasound
• Counselling and certification as required by CS&A Act
• 3 visits mandatory

  Day 1 Administration of Mifegyne, approx 3% will abort before PG

  Day 3 Administration of misoprostol or gemeprost. Observation for 4-6 hrs, during which 60-80% will abort.

  Day 10-15 Follow-up visit to verify expulsion complete. Serum -hCG could be done the day before.

Management of incomplete MTOP:

• If -hCG >2000 arrange ultrasound
• If foetal heart seen, progress to surgery
• If sac but no foetal heart discuss options of waiting or progressing to surgery

Issues for early MTOP:

• Legal issues, present law, Sect 18, changes for future, abortion politics, ASC
• Health issues, risks v. benefits, advantages v. disadvantages, costs
• Women's issues, informed consent, preferences, privacy, cultural issues, attitudes to embryo or foetus, support
• Service delivery issues, early diagnosis and referral, ?self-referral, staff attitudes, waiting lists, option of early surgical TOP, reducing medicalisation
• Professional issues, information & training, GPs, specialists, certifying consultants, nurses, counsellors, audit of clinical experience
• Public issues, information & education, role of media, anti-abortion protests

Mifepristone in Australia:

1994 Clinical trials WHO

May 1996 Independent senator Brian Harradine moved amendment to Therapeutic Goods Act that requires ministerial approval for further clinical trials or distribution.

Mifepristone in UK:

• Initially used on a named patient basis until 1993
• In 1995 licensed for use in second trimester TOP

Second trimester MTOP

Day 1 Mifegyne 600 mg orally

Day 3 Admit for misoprostol

600-800 mcg vaginally then
200-400 mcg 3-6 hrly for 24 hrs

Advantages for second trimester MTOP or induction for intra-uterine death:

• Shorter inpatient time, 7 hrs v. 15 hrs from administration of PG
• Less PG required, fewer side effects, less analgesia required
• Cheaper

Issues for mid-trimester MTOP:

• Options - laminaria/misoprostol, vaginal/oral misoprostol, gemeprost, surgery (D&E)
• Risks v. benefits
• ? Bleeding before admission
• Professional information and training
• Audit of clinical experience

Issues for Medical TOP

(1) Legal issues:
Present law outdated and written with the focus on surgical procedures, Sect 18 CS&A Act and various interpretations, changes for future to streamline procedures, abortion politics, lobbying parliamentarians, role of Abortion Supervisory Committee, role of Ministry of Health.

(2) Health issues:
Risks, e.g. heavy bleeding, incomplete abortions, need for surgery in approx 5%, possible foetal abnormality if pregnancy continues. Disadvantages, e.g. medicalisation, need for minimum of 3 visits, cramping & pain, uncertainty of outcome. Benefits. Differences between early MTOP, mid-trimester MTOP and induction for foetal death. Costs to health providers?? Long term risks.

(3) Women's issues:
Informed consent, women's preferences, making a choice under present law where decision is made by certifying consultants, respecting privacy, reducing medicalisation, making services more responsive to women's needs, cultural issues, attitudes to foetus, placenta.

(4) Service delivery issues:
Early diagnosis, pregnancy tests, ultrasound scans, referral by doctor or self-referral, staff attitudes, waiting lists, option of early surgical TOP, counselling issues, rural women, geographical disparities and travel to nearest service.

(5) Professional issues:
Information & training for medical and nursing students, GPs, specialists, certifying consultants, nurses/midwives, counsellors. Audit of clinical experience and sharing of expertise. Keeping up to date with medical advances.

(6) Public issues:
Information & education, in school and out of school, young persons and adults. Role of media. Entering public debates. Dispelling myths and correcting misinformation. Anti-abortion protest activity.

Margaret Sparrow, 31/10/00