Assessment of significant factors affecting acceptability of home administration of misoprostol for medical abortion

How task-sharing in abortion care became the norm in Sweden: A case study of historic and current determinants and events

We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife-provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task-shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care.

Preimplantation genetic testing to reduce preterm births in assisted reproductive technology

The 10% rate of preterm birth rate worldwide has not been proved amenable to reduction. Avoiding multiple embryo transfer in assisted reproductive technologies (ART) using in vitro fertilization is one unassailable method. Preimplantation genetic testing (PGT) to select only a single euploid embryo for transfer is one unequivocal way, maintaining 50%-60% pregnancy rates while avoiding twins. Contemporary methodology entails trophectoderm biopsy of a 5-6-day blastocyst, and cryopreservation of biopsied embryos while awaiting analysis by next generation sequencing. Embryo biopsy is safe, analytic validity for chromosomal analysis high, and global access to PGT high.

Counselling before first trimester abortion and acceptability of the procedure: results from a Slovenian cross-sectional study

Objectives: In Slovenia, first-trimester abortion is performed at the woman's request, either surgically under general anaesthesia or medically with mifepristone and misoprostol, in a public hospital. Our study aimed to evaluate pre-abortion counselling and to reveal differences in acceptability and satisfaction with the two abortion methods.Methods: A cross-sectional study was carried out at Ljubljana University Medical Centre between January and June 2015. Women requesting termination of a pregnancy up to 10 weeks' gestation voluntarily completed an anonymous questionnaire after the procedure and were divided into a surgical and a medical abortion group.Results: Of the 266 women who were invited to take part, 229 accepted; 16.6% chose a surgical abortion, 83.4% a medical abortion. The most frequent reason cited for requesting an abortion was economic/housing problems. Most women who chose a surgical abortion did so because it was faster, whereas most women who chose a medical abortion did so on the advice of a primary care gynaecologist. Women choosing a surgical abortion had more previous pregnancies and presented with a higher gestational age pregnancy. The choice of method was not related to the woman's age. There were no differences in acceptability of the two procedures. Pain during the procedure was, however, more severe in the medical abortion group (p = .026), along with bleeding, nausea and chills; there were no differences in severity of vomiting, diarrhoea, dizziness or headache between the groups. Women in the surgical abortion group reported higher satisfaction with the method (p < .001). The study revealed a low frequency of pre-abortion contraceptive counselling.Conclusion: The most common reason given for choosing a surgical abortion was the speed of the procedure; for a medical abortion, it was on the advice of a primary care gynaecologist. Satisfaction was higher with the surgical abortion method. There were no differences in general acceptability of the methods.

Support for and interest in alternative models of medication abortion provision among a national probability sample of U.S. women

OBJECTIVE

The objective was to assess women's personal interest in and support for three alternative models of medication abortion (MA) provision.

STUDY DESIGN

Using an online survey of a U.S. national, probability-based representative sample of women ages 18-49, we gauged personal interest in and general support for three alternative models for accessing abortion pills: (1) in advance from a doctor for future use, (2) over-the-counter (OTC) from a drugstore and (3) online without a prescription. We conducted multivariable analyses to identify characteristics associated with support for these provision models.

RESULTS

Fifty percent (n=7022) of eligible women invited completed the survey. Nearly half (49%) supported and 30% were personally interested in one or more of the three access models; 44% supported advance provision, 37% supported OTC access, and 29% supported online access. Common advantages reported for advance provision, OTC and online access included privacy (49%, 29% and 46%, respectively), convenience (38%, 44% and 38%) and being able to end the pregnancy earlier (48%, 40% and 29%). Common disadvantages included concern that women might take the pills incorrectly (55%, 53% and 57%), not seeing a clinician before the abortion (52%, 54% and 53%) and safety (42%, 43% and 60%). History of abortion and experiencing barriers accessing reproductive health services were associated with greater support for the alternative models.

CONCLUSION

Women are interested in and support alternative models of MA provision, in particular, advance provision. However, they also reported concerns about incorrect pill use and not seeing a clinician beforehand.

IMPLICATIONS

Offering women more choices in how they access medication abortion, including options where they can safely self-manage their own care, has the potential to expand access to care.

Sociodemographic Characteristics of Women Able to Obtain Medication Abortion Before and After Ohio's Law Requiring Use of the Food and Drug Administration Protocol

Purpose: In 2011, a law went into effect in Ohio that regulates how abortion care providers can offer medication abortion to their patients. We sought to evaluate changes in sociodemographic characteristics of Ohio medication abortion patients before and after the implementation of this law. Methods: We used a retrospective cohort design, comparing characteristics of women obtaining a medication abortion at four abortion facilities before and after the law. We used chart data from January 2010 to January 2011 and February 2011 to October 2014. For any significant changes in sociodemographics found before and after the law, we used stratified cross-tabulations to disentangle whether they were likely related to the restricted gestational limit imposed by the law (lowered from 9 to 7 weeks gestation), or whether they were likely related to other burdens brought on by the law, such as increased costs and visits. Results: Women obtaining a medication abortion after the law were more likely to be older (p=0.01), have higher levels of education (p<0.001), be of white race (p<0.001), have private insurance (p=0.001), have no children (p=0.002), and reside in a higher income zip code (p=0.03). Both the reduced gestational limit and the increased costs and visits likely contributed to declines among black women and women with lower levels of education. The reduced gestational limit for medication abortion likely contributed to a decline among younger women and Medicaid recipient groups. The increased costs and visits imposed by the law likely contributed to the decline in medication abortion among women with no insurance and women with children. Conclusion: The lower gestational limit, higher cost, and time and travel burdens exacted by Ohio's medication abortion law were associated with disproportionate reductions in medication abortion among the most disadvantaged groups. The law was associated with reduced access among women who were younger, of black race, less educated, and in lower socioeconomic groups.

Effectiveness and safety of sublingual misoprostol in medical treatment of the 1st trimester miscarriage: experience of off-label use in Korea

Objective

This study was conducted to determine the effectiveness and safety of medical treatment with sublingual misoprostol (MS) in the 1st trimester miscarriage under the approval by Health Insurance Review and Assessment Service (HIRA) for off-label usage by the single medical center in Korea.

Methods

A retrospective cohort study was performed in one institution between April 2013 and June 2016. Ninety-one patients diagnosed with miscarriage before 14 weeks of gestation and wanted to try medical treatment were included. A detailed ultrasound scan was performed to confirm the diagnosis. Patients took 600 microgram (mcg) of MS sublingually at initial dose, and repeated the same dose 4–6 hours apart. Successful medical abortion was defined as spontaneous expulsion of gestational products (including gestational sac, embryo, fetus, and placenta). If gestational products were not expelled, surgical evacuation was performed at least 24 hours later from the initial dose. Information about side effects was obtained by medical records.

Results

About two-thirds of patients had a successful outcome. The median interval time from pill to expulsion was 18 hours in the successful medical treatment group. There was no serious systemic side effect or massive vaginal bleeding. Presence or absence of vaginal spotting before diagnosis of miscarriage, uterine leiomyomas, subchorionic hematoma, or distorted shape of gestational sac on ultrasound scan were not statistically different between the two groups.

Conclusion

Medical treatment with sublingual MS can be a proper option for the 1st trimester miscarriage, especially for the patient who want to avoid surgical procedure. We can reduce the unnecessary sedation or surgical intervention in the patients with the 1st trimester miscarriage.

Barriers to accessing abortion services and perspectives on using mifepristone and misoprostol at home in Great Britain

OBJECTIVE

To examine reasons for seeking abortion services outside the formal healthcare system in Great Britain, where abortion is legally available.

STUDY DESIGN

We conducted a mixed-methods study among women resident in England, Scotland, and Wales who requested at-home medication abortion through online telemedicine initiative Women on Web (WoW) between November 22, 2016, and March 22, 2017. We examined the demographics and circumstances of all women requesting early medication abortion and conducted a content analysis of a sample of their anonymized emails to the service to explore their reasons for seeking help.

RESULTS

Over a 4-month period, 519 women contacted WoW seeking medication abortion. These women were diverse with respect to age, parity, and circumstance. One hundred eighty women reported 209 reasons for seeking abortion outside the formal healthcare setting. Among all reasons, 49% were access barriers, including long waiting times, distance to clinic, work or childcare commitments, lack of eligibility for free NHS services, and prior negative experiences of abortion care; 30% were privacy concerns, including lack of confidentiality of services, perceived or experienced stigma, and preferring the privacy and comfort of using pills at home; and 18% were controlling circumstances, including partner violence and partner/family control.

CONCLUSION

Despite the presence of abortion services in Great Britain, a diverse group of women still experiences logistical and personal barriers to accessing care through the formal healthcare system, or prefer the privacy of conducting their abortions in their own homes. Health services commissioning bodies could address existing barriers if supported by policy frameworks.

IMPLICATIONS

The presence of multiple barriers to accessing abortion care in Great Britain highlights the need for future guidelines to recommend a more woman-centered approach to service provision. Reducing the number of clinic visits and designing services to meet the needs of those living in controlling circumstances are particularly important goals.

Building Bridges: A Case for Community Health Worker Provision of Misoprostol-Only Abortion in the First Trimester

INTRODUCTION

The consequences of unsafe abortion are devastating to women, their families, and their communities. Medication abortion presents an important alternative to harmful self-induction practices and surgical intervention under questionable circumstances. In settings where mifepristone is unavailable, the use of misoprostol alone is a safe and effective option for terminating an unwanted pregnancy. Studies have demonstrated the safety and efficacy of administration of misoprostol by community health workers (CHW) for indications such as postpartum hemorrhage and treatment of incomplete abortion.

OBJECTIVES

The current study assesses the safety and efficacy of CHW managing misoprostol-only abortion in the first trimester.

METHODS

A retrospective review of clinical files of women who received abortion services in three countries in Latin America between April 2009 and December 2015 included analysis of 173 cases.

RESULTS

In 94% of cases, the pregnancy was terminated without any further intervention. In the remaining cases, clients were referred for manual vacuum aspiration. In four cases, a complication was reported by the provider. In one, the complication was promptly resolved through referral to a higher level of care; in the remaining three, the complication was resolved directly by the provider. In 98% of cases, women reported being satisfied with the treatment they received.

CONCLUSION

This study demonstrates that CHW are able to provide misoprostol-only abortion services to women effectively and safely. The benefits of this model of care also extend beyond the abortion service: CHW are able to offer women a comprehensive range of quality health services, including contraceptive services, increasing access to vital healthcare in areas with few other options.

Self-management of first trimester medical termination of pregnancy: a qualitative study of women's experiences

OBJECTIVE

To explore the experiences of women in Scotland who return home to complete medical termination of pregnancy (TOP) ≤63 days of gestation, after being administered with mifepristone and misoprostol at an NHS TOP clinic.

DESIGN

Qualitative interview study.

SETTING

One National Health Service health board (administrative) area in Scotland.

POPULATION OR SAMPLE

Women in Scotland who had undergone medical TOP ≤63 days, and self-managed passing the pregnancy at home; recruited from three clinics in one NHS health board area between January and July 2014.

METHODS

In-depth, semi-structured interviews with 44 women in Scotland who had recently undergone TOP ≤63 days of gestation, and who returned home to pass the pregnancy. Data were analysed thematically using an approach informed by the Framework method.

MAIN OUTCOME MEASURES

Women's experiences of self-management of TOP ≤63 days of gestation.

RESULTS

Key themes emerging from the analysis related to self-administration of misoprostol in clinic; reasons for choosing home self-management; facilitation of self-management and expectation-setting; experiences of getting home; self-managing and monitoring treatment progress; support for self-management (in person and remotely); and pregnancy self-testing to confirm completion.

CONCLUSIONS

Participants primarily found self-administration of misoprostol and home self-management to be acceptable and/or preferable, particularly where this was experienced as a decision made jointly with health professionals. The way in which home self-management is presented to women at clinic requires ongoing attention. Women could benefit from the option of home administration of misoprostol.

TWEETABLE ABSTRACT

Women undergoing medical TOP 63 days found home self-management to be acceptable and/or preferable.

"Who Wants to Go Repeatedly to the Hospital?" Perceptions and Experiences of Simplified Medical Abortion in Rajasthan, India

The aim of this study is to explore women's experiences and perceptions of home use of misoprostol and of the self-assessment of the outcome of early medical abortion in a low-resource setting in India. In-depth interviews were conducted with 20 women seeking early medical abortion, who administered misoprostol at home and assessed their own outcome of abortion using a low-sensitivity pregnancy test. With home use of misoprostol, women were able to avoid inconvenience of travel, child care, and housework, and maintain confidentiality. The use of a low-sensitivity pregnancy test alleviated women's anxieties about retained products. Majority said they would prefer medical abortion involving a single visit in future. This study provides nuanced understanding of how women manage a simplified medical abortion in the context of low literacy and limited communication facilities. Service delivery guidelines should be revised to allow women to have medical abortion with fewer visits.

Male Partners' Involvement in Abortion Care: A Mixed-Methods Systematic Review

CONTEXT

Although some women may desire the involvement of their partners when obtaining abortion care, male partners are not routinely included in the abortion process. A review of the literature on how male involvement relates to women's abortion experiences may help guide facilities that are considering incorporating male partners in abortion care.

METHODS

PubMed, PsycINFO (Ovid), the Cumulative Index to Nursing and Allied Health Literature, the Latin American and Caribbean Health Sciences Literature database, and the Cochrane Library were systematically searched without restrictions through September 23, 2015, to identify qualitative and quantitative primary studies investigating male partner accompaniment during the abortion process in noncoercive situations. Analysis focused on identifying different types of male involvement and their associations with women's abortion experiences.

RESULTS

Some 1,316 unique articles were reviewed; 15 were analyzed. These studies were conducted in six countries and published between 1985 and 2012, primarily with observational designs. Four types of male partner involvement emerged: presence in the medical facility, participation in preabortion counseling, presence in the room during the surgical abortion procedure or while the woman is experiencing the effects of abortifacient medications, and participation in postabortion care. Studies explored relationships between type of involvement and women's access to abortion care and their emotional and physical well-being. Most findings suggested that male involvement was positively associated with women's well-being and their assessment of the experience; no negative associations were found.

CONCLUSION

In noncoercive circumstances, women who include their male partners in the abortion process may find this involvement beneficial.

Clinical Outcomes and Women's Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa

Objective

To document clinical outcomes and women’s experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only.

Methods

Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2–4 weeks after discharge for the 2014 cohort.

Results

The 2014 cohort received 200 mg mifepristone, which was self-administered 24–48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3–4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts.

Conclusion

The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.

Women's Acceptability of Misoprostol Treatment for Incomplete Abortion by Midwives and Physicians - Secondary Outcome Analysis from a Randomized Controlled Equivalence Trial at District Level in Uganda

Objective

This study aimed to assess women´s acceptability of diagnosis and treatment of incomplete abortion with misoprostol by midwives, compared with physicians.

Methods

This was an analysis of secondary outcomes from a multi-centre randomized controlled equivalence trial at district level in Uganda. Women with first trimester incomplete abortion were randomly allocated to clinical assessment and treatment with misoprostol by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and stratified for health care facility. Acceptability was measured in expectations and satisfaction at a follow up visit 14–28 days following treatment. Analysis of women’s overall acceptability was done using a generalized linear mixed-effects model with an equivalence range of -4% to 4%. The study was not masked. The trial is registered at ClinicalTrials.org, NCT 01844024.

Results

From April 2013 to June 2014, 1108 women were assessed for eligibility of which 1010 were randomized (506 to midwife and 504 to physician). 953 women were successfully followed up and included in the acceptability analysis. 95% (904) of the participants found the treatment satisfactory and overall acceptability was found to be equivalent between the two study groups. Treatment failure, not feeling calm and safe following treatment, experiencing severe abdominal pain or heavy bleeding following treatment, were significantly associated with non-satisfaction. No serious adverse events were recorded.

Conclusions

Treatment of incomplete abortion with misoprostol by midwives and physician was highly, and equally, acceptable to women.

Trial Registration

ClinicalTrials.gov NCT01844024

Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial

INTRODUCTION

Although home use of misoprostol for early medical abortion is considered to be safe, effective and feasible, it has not become standard service delivery practice. The aim of this study was to compare the efficacy, safety, and acceptability of home use of misoprostol with clinic misoprostol in a low-resource setting.

MATERIAL AND METHODS

This was a secondary analysis of a randomized controlled trial conducted in six primary care clinics in India. Women seeking medical abortion within up to nine gestational weeks (n = 731) received mifepristone in the clinic and were allocated either to home or clinic administration of misoprostol. Follow-up contact was after 10-15 days.

RESULTS

Of 731 participants, 73% were from rural areas and 55% had no formal education. Complete abortion rates in the home and clinic misoprostol groups were 94.2 and 94.4%, respectively. The rate of adverse events was similar in both groups (0.3%). A greater proportion of home users (90.2%) said that they would opt for misoprostol at home in the event of a future abortion compared with clinic users (79.7%) who would opt for misoprostol at the clinic in a similar situation (p = 0.0002). Ninety-six percent women using misoprostol at home or in the clinic were satisfied with their abortion experience.

CONCLUSIONS

Home-use of misoprostol for early medical abortion is as effective and acceptable as clinic use, in low resource settings. Women should be offered a choice of this option regardless of distance of their residence from the clinic and communication facilities.

Acceptability of Home-Assessment Post Medical Abortion and Medical Abortion in a Low-Resource Setting in Rajasthan, India. Secondary Outcome Analysis of a Non-Inferiority Randomized Controlled Trial

BACKGROUND

Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education.

OBJECTIVE

To investigate women's acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India.

DESIGN

Secondary outcome of a randomised, controlled, non-inferiority trial.

SETTING

Outpatient primary health care clinics in rural and urban Rajasthan, India.

POPULATION

Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85 mg/l and were below 18 years.

METHODS

Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1:1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible.

MAIN OUTCOME MEASURES

Women's acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups.

RESULTS

731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001).

CONCLUSION

Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01827995.

How women perceive abortion care: A study focusing on healthy women and those with mental and posttraumatic stress

Objectives To identify perceived deficiencies in the quality of abortion care among healthy women and those with mental stress. Methods This multi-centre cohort study included six obstetrics and gynaecology departments in Sweden. Posttraumatic stress (PTSD/PTSS) was assessed using the Screen Questionnaire-Posttraumatic Stress Disorder; anxiety and depressive symptoms, using the Hospital Anxiety Depression Scale; and abortion quality perceptions, using a modified version of the Quality from the Patient's Perspective questionnaire. Pain during medical abortion was assessed in a subsample using a visual analogue scale. Results Overall, 16% of the participants assessed the abortion care as being deficient, and 22% experienced intense pain during medical abortion. Women with PTSD/PTSS more often perceived the abortion care as deficient overall and differed from healthy women in reports of deficiencies in support, respectful treatment, opportunities for privacy and rest, and availability of support from a significant person during the procedure. There was a marginally significant difference between PTSD/PTSS and the comparison group for insufficient pain alleviation. Conclusions Women with PTSD/PTSS perceived abortion care to be deficient more often than did healthy women. These women do require extra support, relatively simple efforts to provide adequate pain alleviation, support and privacy during abortion may improve abortion care.