Misoprostol for the termination of pregnancy up to 12 completed weeks of pregnancy

Dantas PB, Trabach CB, Junqueira AA, Nunes CC, Baccaro LF. Analysis of uterine evacuation methods in postabortion care after implementation of a surveillance network (CLAP MUSA-Network) at a university hospital

BACKGROUND

Management of uterine evacuation is essential for increasing safe abortion care. Monitoring through surveillance systems tracks changes in clinical practice and provides information to improve equity in abortion care quality.

OBJECTIVE

This study aimed to evaluate the frequency of manual vacuum aspiration (MVA) and medical abortion (MA), and identify the factors associated with each uterine evacuation method after surveillance network installation at a Brazilian hospital.

METHODS

This cross-sectional study included women admitted for abortion or miscarriage to the University of Campinas Women's Hospital, Brazil, between July 2017 and November 2020. The dependent variables were the use of MVA and MA with misoprostol. The independent variables were the patients' clinical and sociodemographic data. The Cochran-Armitage, chi-square, and Mann-Whitney U tests, as well as multiple logistic regression analysis, were used to compare uterine evacuation methods.

RESULTS

We enrolled 474 women in the study, 91.35% of whom underwent uterine evacuation via uterine curettage (78.75%), MVA (9.46%), or MA (11.54%). MVA use increased during the study period (Z = 9.85, p < 0.001). Admission in 2020 (odds ratio [OR] 64.22; 95% confidence interval [CI] 3.79-1086.69) and lower gestational age (OR 0.837; 95% CI 0.724-0.967) were independently associated with MVA, whereas the only factor independently associated with MA was a higher education level (OR 2.66; 95% CI 1.30-5.46).

CONCLUSION

MVA use increased following the installation of a surveillance network for good clinical practice. Being part of a network that encourages the use of evidence-based methods provides an opportunity for healthcare facilities to increase access to safe abortions.

Toxicity of abortifacients: A review for physicians in the post roe era

BACKGROUND

On June 24, 2022, the Supreme Court overturned Roe v. Wade, which will limit legal abortion in many areas of the U.S. Over half of abortions in the U.S. are performed using medication as opposed to surgical techniques. With widespread access to agents that are used for medication abortion, there may be an increase in emergency department presentations related to improper or unsupervised use of these medications.

METHODS

This narrative review focuses on the contraindications, adverse effects, and toxicities of the most common agents used for medication abortion in the U.S.

RESULTS

Medications included in this review are mifepristone, misoprostol, and methotrexate. Each of these medications has a unique adverse effect and toxicity profile.

CONCLUSION

Agents used for medication abortion have unique contraindications and adverse effects. Improper or unsupervised use may occur in the setting of limited abortion access and emergency medicine physicians are on the front lines in managing these presentations.

Incidence of self-induced abortion with misoprostol, admitted to a provincial hospital in Papua New Guinea: A prospective observational study

BACKGROUND

Misoprostol is a life-savingmedication in obstetric practice but the prevalence of misoprostol-related self-induced abortion is increasing in many communities.

AIMS

To investigate the hospital incidence, clinical management, and legal framework of self-induced abortions with misoprostol.

MATERIALS AND METHODS

This was a prospective observational study conducted over 18 months. All patients <20 weeks pregnant who were admitted with a diagnosis of misoprostol-induced abortion were included in the study.

RESULTS

Of 186 women with abortion-related admissions during the study period, 51 (27.4%) women reported using misoprostol to induce abortion. The majority were young (27.8 ± 5.5) married women (32/51: 62.7%), particularly educated (27/51: 52.9%) employed women (27/51: 52.9%), who were not on any contraception (46/51: 90.1%). Most abortions were induced in the first trimester (39/51: 76.5%) and patients were admitted because of prolonged bleeding (23/51: 45.1%). A significant proportion of participants who did not receive the correct dose of misoprostol developed sepsis compared to those who received a correct dose (6/18 (33.3%) vs 1/30 (3.3%); P = 0.008).

CONCLUSION

The use of misoprostol as an abortifacient is increasing in Papua New Guinea, particularly among educated and employed women. A review of the laws to meet the demand for abortion services and to limit complications of unsafe abortion practices is required.

First Trimester Abortion Care in Low- and Middle-Income Countries

Access to first trimester abortions has increased significantly in the past few decades in low and middle-income countries. Manual vacuum aspiration is now standard of care for procedural abortion and postabortion care. Medication abortion has shifted abortions to being performed earlier in pregnancy and is becoming more widely available with new service delivery strategies to broaden access. Widespread availability of misoprostol has made abortions induced outside of the formal medical sector overall safer. In both legally restrictive and supportive environments, there is increased interested in self-managed abortions as part of a shift towards demedicalizing abortion through task-sharing.

Women's self-reported experiences using misoprostol obtained from drug sellers: a prospective cohort study in Lagos State, Nigeria

OBJECTIVES

This study aimed to assess the safety and effectiveness of self-managed misoprostol abortions obtained outside of the formal health system in Lagos State, Nigeria.

DESIGN

This was a prospective cohort study among women using misoprostol-containing medications purchased from drug sellers. Three telephone-administered surveys were conducted over 1 month.

SETTING

Data were collected in 2018 in six local government areas in Lagos State.

PARTICIPANTS

Drug sellers attempted to recruit all women who purchased misoprostol-containing medication. To remain in the study, participants had to be female and aged 18-49, and had to have purchased the medication for the purpose of abortion. Of 501 women initially recruited, 446 were eligible for the full study, and 394 completed all three surveys.

PRIMARY AND SECONDARY OUTCOME MEASURES

Using self-reported measures, we assessed the quality of information provided by drug sellers; the prevalence of potential complications; and the proportion with completed abortions.

RESULTS

Although drug sellers provided inadequate information about the pills, 94% of the sample reported a complete abortion without surgical intervention about 1 month after taking the medication. Assuming a conservative scenario where all individuals lost to follow-up had failed terminations, the completion rate dropped to 87%. While 86 women reported physical symptoms suggestive of complications, only six of them reported wanting or needing health facility care and four subsequently obtained care.

CONCLUSIONS

Drug sellers are an important source of medical abortion in this setting. Despite the limitations of self-report, many women appear to have effectively self-administered misoprostol. Additional research is needed to expand the evidence on the safety and effectiveness of self-use of misoprostol for abortion in restrictive settings, and to inform approaches that support the health and well-being of people who use this method of abortion.

Conhecimento de médicos residentes em Ginecologia e Obstetrícia sobre o aborto medicamentoso

O aborto medicamentoso ou farmacológico tem demonstrado ser um meio eficaz para a interrupção da gravidez. Entretanto, o treinamento de provedores no uso do misoprostol tem sido limitado. O presente artigo tem como objetivo identificar o grau de conhecimento dos médicos residentes em Ginecologia e Obstetrícia sobre aborto medicamentoso. Realizou-se um estudo transversal multicêntrico com residentes regularmente inscritos no programa de residência em Ginecologia e Obstetrícia de vinte e um hospitais de ensino. Foi utilizado um questionário de autorresposta. As respostas corretas a cada uma das alternativas foram identificadas e uma variável de resposta binária (≥ P70, < P70) foi definida pelo percentil 70 do número de perguntas sobre o misoprostol. Quatrocentos e sete médicos residentes devolveram o questionário, sendo que 404 estavam preenchidos e três em branco. A maioria (56,3%) dos residentes tinha até 27 anos de idade, era do sexo feminino (81,1%) e não vivia junto com um(a) companheiro(a) (70%). A maior proporção (68,2%) estava cursando o primeiro ou segundo ano da residência. Apenas 40,8% dos participantes acertaram 70% ou mais das afirmativas. Na análise múltipla, cursar o terceiro ano de residência ou superior (OR = 2,18; IC95%: 1,350-3,535) e ter participado do atendimento a uma mulher com abortamento induzido ou provavelmente induzido (OR = 4,12; IC95%: 1,761-9,621) mostraram-se associados a um maior conhecimento sobre o tema. Entre os médicos brasileiros residentes em Ginecologia e Obstetrícia, o conhecimento sobre o aborto medicamentoso é muito reduzido e constitui um obstáculo para o bom atendimento dos casos de interrupção legal da gestação.

Using a Call Center to Reduce Harm From Self-Administration of Reproductive Health Medicines in Bangladesh: Interrupted Time-Series

BACKGROUND

Annually, there are approximately 25 million unsafe abortions, and this remains a leading cause of maternal morbidity and mortality. In settings where abortion is restricted, women are increasingly able to self-manage abortions by purchasing abortion medications such as misoprostol and mifepristone (RU-486) from pharmacies or other drug sellers. Better availability of these drugs has been shown to be associated with reductions in complications from unsafe abortions. In Bangladesh, abortion is restricted; however, menstrual regulation (MR) was introduced in the 1970s as an interim method of preventing pregnancy. Pharmacy provision of medications for MR is widespread, but customers purchasing these drugs from pharmacies often do not have access to quality information on dosage and potential complications.

OBJECTIVE

This study aimed to describe a call center intervention in Bangladesh, and assess call center use over time and how this changed when a new MR product (combined mifepristone-misoprostol) was introduced into the market.

METHODS

In 2010, Marie Stopes Bangladesh established a care provider-assisted call center to reduce potential harm from self-administration of MR medications. The call center number was advertised widely in pharmacies and on MR product packaging. We conducted a secondary analysis of routine data collected by call center workers between July 2012 and August 2016. We investigated the reported types of callers, the reason for call, and reported usage of MR products before and after November 2014. We used an interrupted time series (ITS) analysis to formally assess levels of change in caller characteristics and reasons for calling.

RESULTS

Over the 4-year period, 287,095 calls about MR were received and the number of users steadily increased over time. The most common callers (of 287,042 callers) were MR users (67,438, 23.49%), their husbands (65,999, 22.99%), pharmacy workers (65,828, 22.93%), and village doctors (56,036, 19.52%). Most MR calls were about misoprostol, but after November 2014, a growing proportion of calls were about the mifepristone-misoprostol regimen. The most common reasons (of 287,042 reasons) for calling were to obtain information about the regimen (208,605, 72.66%), to obtain information about side effects (208,267, 72.54%), or to report side effects (49,930, 17.39%). The ITS analyses showed that after November 2014, an increasing number of calls were from MR users who had taken the complete regimen (P=.02 and who were calling to discuss reported side effects (P=.01) and pain medication (P=.01), and there were fewer calls asking about dosages (P<.001).

CONCLUSIONS

The high call volume suggests that this call center intervention addressed an unmet demand for information about MR medications from both MR users and health care providers. Call center interventions may improve the quality of information available by providing information directly to MR users and drug sellers, and thus reducing the potential harm from self-management of MR medications.

Feasibility of assessing the safety and effectiveness of menstrual regulation medications purchased from pharmacies in Bangladesh: a prospective cohort study

OBJECTIVE

To assess the feasibility of following up women who purchase mifepristone+misoprostol or misoprostol-only from pharmacies in order to measure the safety and effectiveness of self-administration of menstrual regulation.

STUDY DESIGN

A prospective cohort study followed women purchasing mifepristone+misoprostol or misoprostol-only from pharmacies in Bangladesh. Participants were recruited by pharmacy workers either in person or indirectly via the purchaser of the drugs. End users were contacted by phone 2 weeks after recruitment, screened and interviewed.

RESULTS

Study recruitment rates by pharmacy workers were low (30%, 109 of 642 women informed about the study), but 2-week follow-up rates were high (87%). Of the 109 end users interviewed, 87 purchased mifepristone+misoprostol and 20 misoprostol-only, while 2 women did not know what drugs they had purchased. Mean self-reported number of weeks of pregnancy was 5.7 weeks. Information provision by pharmacy workers was inadequate (40.4% received none, 8.7% received written information or pictures). A total of 80.5% of mifepristone+misoprostol users were sold the correct regimen versus 9 out of 20 misoprostol-only users. A total of 68.8% did not report experiencing any complications (70.0% misoprostol-only; 69.0% mifepristone+misoprostol users, p=1.0). A total of 94.3% of mifepristone+misoprostol users and 75% of misoprostol-only users reported that they were not pregnant at day 15 (p=.020). However, 7.3% of all users sought additional treatment.

CONCLUSIONS

Challenges in assessing outcomes of self-managed menstrual regulation medications purchased from pharmacies must be overcome through further development of this methodology. Interventions are urgently needed to ensure that women have access to correct dosages, accurate information and necessary referrals.

IMPLICATIONS

This paper assesses the outcomes of women who self-manage menstrual regulation medications purchased from pharmacies. The methodology requires further development, but our study provides preliminary positive evidence on the safety and effectiveness of self-management despite low information provision from pharmacy workers.

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

BACKGROUND

Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation.

METHODS

An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country's abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships.

RESULTS

After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides.

CONCLUSIONS

These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa.

Effectiveness of Misoprostol for Induction of First-Trimester Miscarriages: Experience at a single tertiary care centre in Oman

OBJECTIVES

Non-invasive methods of inducing a miscarriage are now considered an effective alternative to surgical evacuation (dilatation and curettage). This study aimed to evaluate the effectiveness of misoprostol in the termination of first-trimester miscarriages.

METHODS

This prospective study was conducted between October 2009 and September 2010 and assessed all patients admitted to the Royal Hospital in Muscat, Oman, for the termination of first-trimester miscarriages during the study period. All patients received misoprostol and the rates of successful termination were measured. Patient satisfaction was assessed using a short questionnaire.

RESULTS

A total of 290 women were included in the study. Termination with misoprostol was successful in 61.38% of the subjects. Of the remaining subjects requiring additional surgical evacuation (n = 112), 58.93% required evacuation due to failed termination with misoprostol and 65.18% underwent early evacuation (≤24 hours since their last misoprostol dose). The majority of patients experienced no side-effects due to misoprostol (89.66%). Pain was controlled with simple analgesics in 70.00% of the subjects. A high satisfaction rate (94.83%) with the misoprostol treatment was reported.

CONCLUSION

Misoprostol was a well-tolerated drug which reduced the rate of surgical evacuation among the study subjects. This medication can therefore be used safely in the management of incomplete miscarriages.

Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries

With changing conditions affecting receipt of postabortion care, an updated estimate of the incidence of treatment for complications from unsafe pregnancy termination is needed to inform policies and programmes. National estimates of facility-based treatment for complications in 26 countries form the basis for estimating treatment rates in the developing world. An estimated seven million women were treated in the developing world for complications from unsafe pregnancy termination in 2012, a rate of 6.9 per 1000 women aged 15-44 years. Regionally, rates ranged from 5.3 in Latin America and the Caribbean to 8.2 in Asia. Results inform policies to improve women's health.

TWEETABLE ABSTRACT

An estimated 7 million women were treated in the developing world for complications of unsafe TOP in 2012.

Induced abortions and unintended pregnancies in pakistan

During the past decade, unmet need for family planning has remained high in Pakistan and gains in contraceptive prevalence have been small. Drawing upon data from a 2012 national study on postabortion-care complications and a methodology developed by the Guttmacher Institute for estimating abortion incidence, we estimate that there were 2.2 million abortions in Pakistan in 2012, an annual abortion rate of 50 per 1,000 women. A previous study estimated an abortion rate of 27 per 1,000 women in 2002. After taking into consideration the earlier study's underestimation of abortion incidence, we conclude that the abortion rate has likely increased substantially between 2002 and 2012. Varying contraceptive-use patterns and abortion rates are found among the provinces, with higher abortion rates in Baluchistan and Sindh than in Khyber Pakhtunkhwa and Punjab. This suggests that strategies for coping with the other wise uniformly high unintended pregnancy rates will differ among provinces. The need for an accelerated and fortified family planning program is greater than ever, as is the need to implement strategies to improve the quality and coverage of postabortion services.

Efficacy of intra-cervical misoprostol in the management of early pregnancy failure

The aim of this prospective study was to assess the efficacy of intra-cervical misoprostol in the management of early pregnancy failure. Twenty women with early pregnancy failure received intra-cervical misoprostol via an endometrial sampling cannula. The first dose was 50 μg of misoprostol dissolved in 5 ml of normal saline. The administration was repeated after 12 h if there was no vaginal bleeding or pain. Nine (45%) women received 1 dose and 11 (55%) women received 2 doses of intra-cervical misoprostol. Abortion within 24 h occurred in 16 (80%) women, and complete abortion was achieved in 14 (70%) cases. Two women with incomplete abortion were managed with 600 μg of misoprostol orally (1 case) and surgical intervention (1 case). The mean time interval between the first dose and the abortion was 10.6 ± 6.3 h. Two women did not respond within 24 h of treatment initiation, 1 woman withdrew consent after the first treatment, and 1 woman developed heavy vaginal bleeding after the first dose and underwent surgical management. Intra-cervical misoprostol is a promising method of medical treatment of early pregnancy failure. Further randomized clinical trials are needed to validate its safety and efficacy.

Comprehensive abortion care: evidence of improvements in hospital-level indicators in Tigray, Ethiopia

OBJECTIVE

Approximately 18% of maternal deaths in East Africa is attributable to unsafe abortion. Availability of comprehensive abortion care (CAC) services at all levels of the healthcare system, including medical abortion, has the potential to increase access to safe abortion thereby reducing the burden of unsafe abortion. This study sought to assess trends in abortion-related morbidity indicators in referral hospitals.

DESIGN

Researchers conducted a secondary data analysis on retrospectively collected data.

METHODS

Data analysed were collected from four hospitals in the Tigray region of Ethiopia that took part in a CAC pilot project. Providers were trained in mid-2009 to provide abortion services using all available technologies. Data records from hospitals were collected in 2012 for the years 2006 through 2012; 2006/2007 data were too sparse to include in the analyses.

RESULTS

Trends in abortion-related services show a significant decrease in treatment of incomplete abortion, inverting the relationship between safe terminations and treatment of incompletes as a percentage of total abortions. Medication abortion was nearly non-existent in 2008, but increased steadily, representing 80% of total procedures in 2012. The inclusion of medication abortion and availability of CAC also contributed to a decline in inpatient procedures and prevalence of complications.

CONCLUSIONS

The trends observed in the data demonstrate how increased availability of CAC services at all levels of the healthcare system, among other factors, can contribute to reductions in the burden of unsafe abortion at referral hospitals.

Improving care of women at risk of unsafe abortion: implementing a risk-reduction model at the Uruguayan-Brazilian border

OBJECTIVE

To describe the initial stages of the implementation of a risk-reduction model designed by Iniciativas Sanitarias to shield women from unsafe abortion in a traditional community on the Uruguay-Brazil border.

METHODS

This mixed-design study was conducted first between 22 and 26 March 2010, and then between 2 and 7 May 2011, in Rivera, Uruguay, to gather information from women seen at health centers, healthcare providers, and local policy makers before the project started and midway through the project.

RESULTS

At baseline most women and providers considered abortion justifiable only on narrow grounds, yet favored the implementation of a risk-reduction model that would include preabortion as well as postabortion counseling, the former providing information on different abortion methods and their risks. By the midterm assessment, the counseling service had assisted 87 women with unwanted pregnancies. Of the 52 who came for a postabortion visit, 50 had self-administered misoprostol, with no complications. Women were highly satisfied with the counseling. At baseline, misoprostol seemed to be available from both pharmacists and informal sellers. At midterm, it was still available from informal vendors but pharmacists said they did not provide misoprostol. The risk-reduction initiative heightened public attention to the abortion issue but the controversy it generated did not seriously impede its implementation.

CONCLUSION

It is feasible to implement the proposed risk-reduction model in a traditional community such as Rivera, not only in Uruguay but in any country irrespective of its abortion laws.

Knowledge of medical abortion among Brazilian medical students

OBJECTIVE

To assess the knowledge of Brazilian medical students regarding medical abortion (MA) and the use of misoprostol for MA, and to investigate factors influencing their knowledge.

METHODS

All students from 3 medical schools in São Paulo State were invited to complete a pretested structured questionnaire with precoded response categories. A set of 12 statements on the use and effects of misoprostol for MA assessed their level of knowledge. Of about 1260 students invited to participate in the study, 874 completed the questionnaire, yielding a response rate of 69%. The χ(2) test was used for the bivariate analysis, which was followed by multiple regression analysis.

RESULTS

Although all students in their final year of medical school had heard of misoprostol for termination of pregnancy, and 88% reported having heard how to use it, only 8% showed satisfactory knowledge of its use and effects. Academic level was the only factor associated with the indicators of knowledge investigated.

CONCLUSION

The very poor knowledge of misoprostol use for MA demonstrated by the medical students surveyed at 3 medical schools makes the review and updating of the curriculum urgently necessary.

Clinical diagnosis of completeness of medical abortion by nurses: a reliability study in Mozambique

BACKGROUND

The provision of medical abortion continues to rely on routine use of ultrasound to confirm expulsion of pregnancy. However, the absence of ultrasound in most of the health facilities in developing countries and the additional training required to enable providers to use ultrasound is often prohibitive. The purpose of this study was to compare clinical history and physical examination with ultrasound in confirming completion of abortion.

STUDY DESIGN

A total of 718 women consented for medical abortion with misoprostol and were assessed for pregnancy expulsion by nurses and gynecologists. Nurses used history and physical examination while gynecologists used ultrasound to establish their diagnoses.

RESULTS

Nurses' clinical diagnoses for complete abortion, incomplete abortion and ongoing pregnancy were 83% (SE 0.01), 15% (SE 0.01) and 2% (SE 0.01), respectively. When gynecologists used ultrasound, the diagnoses for complete abortion, incomplete abortion, an ongoing pregnancy were 80% (SE 0.01), 17% (SE 0.01) and 3% (SE 0.01), respectively. Overall, nurses agreed with gynecologist diagnoses in 84% of cases, with a κ coefficient of 0.49 (SE 0.06) and chance-corrected first-order agreement (AC(1)) of 0.81 (SE 0.02). Agreement was very high for the diagnosis of complete abortion (AC(1) 0.89; SE 0.02), while it was moderate for ongoing pregnancy (AC(1) 0.58; SE 0.22) and incomplete abortion (AC(1) 0.45; SE 0.08).

CONCLUSIONS

Clinical history and physical examination alone, without the use of ultrasonography, are effective for the determination of successful pregnancy expulsion. However, greater emphasis is required on the clinical identification of ongoing pregnancy during any training of providers.

Perceptions and practices of illegal abortion among urban young adults in the Philippines: a qualitative study

This study draws on in-depth interviews and focus group discussions with young adults in a metropolitan area of the Philippines to examine perceptions and practices of illegal abortion. Study participants indicated that unintended pregnancies are common and may be resolved through eventual acceptance or through self-induced injury or ingestion of substances to terminate the pregnancy. Despite the illegality of abortion and the restricted status of misoprostol, substantial knowledge and use of the drug exists. Discussions mirrored broader controversies associated with abortion in this setting. Abortion was generally thought to invoke gaba (bad karma), yet some noted its acceptability under certain circumstances. This study elucidates the complexities of pregnancy decisionmaking in this restrictive environment and the need for comprehensive and confidential reproductive health services for Filipino young adults.

Private medical providers' knowledge and practices concerning medical abortion in Nigeria

To investigate the knowledge and practices regarding medical abortion and postabortion care in northern Nigeria among private physicians--the principal providers of such services in the area--122 doctors operating separate clinics in five states--Bauchi, Borno, Kaduna, Niger, and Taraba--were interviewed by means of a structured questionnaire. The results showed that 22 percent of the doctors reported that they terminate unwanted pregnancies, whereas nearly all reported that they manage complications of unsafe abortion. Manual vacuum aspiration and dilatation and curettage performed singly or in combination were the most common methods of abortion and postabortion care reported by the doctors. Only one doctor reported exclusive use of medical abortion in the first trimester, and three reported its exclusive use in the second trimester. Only 35 percent of the doctors listed misoprostol as a drug that they knew could be used for abortion and postabortion care, and only 12 percent listed mifepristone. By contrast, 49 percent listed inappropriate or dangerous drugs for use in abortion provision in the first and second trimesters of pregnancy. We conclude that private practitioners in northern Nigeria have limited knowledge of medical abortion and postabortion care, and that a capacity-building program on the subject should be instituted for them.

Aborto provocado: redução da frequência e gravidade das complicações. Consequência do uso de misoprostol?

OBJETIVOS: verificar a frequência e a gravidade das complicações por abortos provocados e suas possíveis associações com o uso de misoprostol. MÉTODOS: estudo de corte transversal. Durante dez meses aplicou-se uma lista de verificação (critérios da World Health Organization) a todas as 543 mulheres internadas por aborto em dois hospitais na cidade de Campinas, São Paulo. Àquelas classificadas como aborto possível, provável ou certamente provocado foi aplicado também um questionário. RESULTADOS: dentre todas as mulheres internadas, 259 (48%) foram classificadas como aborto possível, provável ou certamente induzido e responderam ao questionário; 25 mulheres declararam a indução do aborto e, destas, nove referiram uso de misoprostol. Complicações infecciosas e hemorrágicas ocorreram respectivamente em 10% e 13% das 259 mulheres. As que usaram misoprostol se complicaram menos que as que usaram outros métodos, porém essa diferença não foi estatisticamente significativa, talvez pela baixa freqüência de complicações. CONCLUSÕES: os dados mostram redução da freqüência e da gravidade das complicações do aborto, mas não permitem avaliar o papel do misoprostol.

New and underutilised technologies to reduce maternal mortality and morbidity: what progress have we made since Bellagio 2003?

In 2003, maternal health experts met in Bellagio, to consider new and underutilised technologies vital to pregnancy-related health services in low-resource settings. Five years later, we examine what progress has been made and what new opportunities may be on the horizon. Based on a review of literature and consultation with experts, we consider technologies addressing the five leading causes of maternal mortality: postpartum haemorrhage, eclampsia, obstructed labour, puerperal sepsis, and unsafe abortion (pregnancy termination and miscarriage). In addition, we consider technologies related to obstetric fistula, which has received more attention in recent years.

Saving maternal lives in resource-poor settings: facing reality

OBJECTIVE

Evaluate safe-motherhood interventions suitable for resource-poor settings that can be implemented with current resources.

METHODS

Literature review to identify interventions that require minimal treatment/infrastructure and are not dependent on skilled providers. Simulations were run to assess the potential number of maternal lives that could be saved through intervention implementation according to potential program impact. Regional and country level estimates are provided as examples of settings that would most benefit from proposed interventions.

RESULTS

Three interventions were identified: (i) improve access to contraception; (ii) increase efforts to reduce deaths from unsafe abortion; and (iii) increase access to misoprostol to control postpartum hemorrhage (including for home births). The combined effect of postpartum hemorrhage and unsafe abortion prevention would result in the greatest gains in maternal deaths averted.

DISCUSSION/CONCLUSIONS

Bold new initiatives are needed to achieve the Millennium Development Goal of reducing maternal mortality by three-quarters. Ninety-nine percent of maternal deaths occur in developing countries and the majority of these women deliver alone, or with a traditional birth attendant. It is time for maternal health program planners to reprioritize interventions in the face of human and financial resource constraints. The three proposed interventions address the largest part of the maternal health burden.