Home administration of misoprostol for early medical abortion in India

Effectiveness, safety and acceptability of medical abortion at home versus in the clinic: a systematic review and meta-analysis in response to COVID-19

BACKGROUND

Increased access to home-based medical abortion may offer women a convenient, safe and effective abortion method, reduce burdens on healthcare systems and support social distancing during the COVID-19 pandemic. Home-based medical abortion is defined as any abortion where mifepristone, misoprostol or both medications are taken at home.

METHODS

A systematic review and meta-analysis of randomised controlled trials (RCTs) and non-randomised studies (NRSs) were conducted. We searched databases from inception to 10 July 2019 and 14 June 2020. Successful abortion was the main outcome of interest. Eligible studies were RCTs and NRSs studies with a concurrent comparison group comparing home versus clinic-based medical abortion. Risk ratios (RRs) and their 95% CIs were calculated. Estimates were calculated using a random-effects model. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess risk of bias by outcome and to evaluate the overall quality of the evidence.

RESULTS

We identified 6277 potentially eligible published studies. Nineteen studies (3 RCTs and 16 NRSs) were included with 11 576 women seeking abortion up to 9 weeks gestation. Neither the RCTs nor the NRS found any difference between home-based and clinic-based administration of medical abortion in having a successful abortion (RR 0.99, 95% CI 0.98 to 1.01, I2=0%; RR 0.99, 95% CI 0.97 to 1.01, I2=52%, respectively). The certainty of the evidence for the 16 NRSs was downgraded from low to very low due to high risk of bias and publication bias. The certainty of the evidence for the three RCTs was downgraded from high to moderate by one level for high risk of bias.

CONCLUSION

Home-based medical abortion is effective, safe and acceptable to women. This evidence should be used to expand women's abortion options and ensure access to abortion for women during COVID-19 and beyond.

PROSPERO REGISTRATION NUMBER

CRD42020183171.

Self-administered versus provider-administered medical abortion

BACKGROUND

The advent of medical abortion has improved access to safe abortion procedures. Medical abortion procedures involve either administering mifepristone followed by misoprostol or a misoprostol-only regimen. The drugs are commonly administered in the presence of clinicians, which is known as provider-administered medical abortion. In self-administered medical abortion, drugs are administered by the woman herself without the supervision of a healthcare provider during at least one stage of the drug protocol. Self-administration of medical abortion has the potential to provide women with control over the abortion process. In settings where there is a shortage of healthcare providers, self-administration may reduce the burden on the health system. However, it remains unclear whether self-administration of medical abortion is effective and safe. It is important to understand whether women can safely and effectively terminate their own pregnancies when having access to accurate and adequate information, high-quality drugs, and facility-based care in case of complications.

OBJECTIVES

To compare the effectiveness, safety, and acceptability of self-administered versus provider-administered medical abortion in any setting.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE in process and other non-indexed citations, Embase, CINAHL, POPLINE, LILACS, ClinicalTrials.gov, WHO ICTRP, and Google Scholar from inception to 10 July 2019.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and prospective cohort studies with a concurrent comparison group, using study designs that compared medical abortion by self-administered versus provider-administered methods.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted the data, and we performed a meta-analysis where appropriate using Review Manager 5. Our primary outcome was successful abortion (effectiveness), defined as complete uterine evacuation without the need for surgical intervention. Ongoing pregnancy (the presence of an intact gestational sac) was our secondary outcome measuring success or effectiveness. We assessed statistical heterogeneity with Chi² tests and I² statistics using a cut-off point of P < 0.10 to indicate statistical heterogeneity. Quality assessment of the data used the GRADE approach. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified 18 studies (two RCTs and 16 non-randomized studies (NRSs)) comprising 11,043 women undergoing early medical abortion (≤ 9 weeks gestation) in 10 countries. Sixteen studies took place in low-to-middle income resource settings and two studies were in high-resource settings. One NRS study received analgesics from a pharmaceutical company. Five NRSs and one RCT did not report on funding; nine NRSs received all or partial funding from an anonymous donor. Five NRSs and one RCT received funding from government agencies, private foundations, or non-profit bodies. The intervention in the evidence is predominantly from women taking mifepristone in the presence of a healthcare provider, and subsequently taking misoprostol without healthcare provider supervision (e.g. at home). There is no evidence of a difference in rates of successful abortions between self-administered and provider-administered groups: for two RCTs, risk ratio (RR) 0.99, 95% confidence interval (CI) 0.97 to 1.01; 919 participants; moderate certainty of evidence. There is very low certainty of evidence from 16 NRSs: RR 0.99, 95% CI 0.97 to 1.01; 10,124 participants. For the outcome of ongoing pregnancy there may be little or no difference between the two groups: for one RCT: RR 1.69, 95% CI 0.41 to 7.02; 735 participants; low certainty of evidence; and very low certainty evidence for 11 NRSs: RR 1.28, 95% CI 0.65 to 2.49; 6691 participants. We are uncertain whether there are any differences in complications requiring surgical intervention, since we found no RCTs and evidence from three NRSs was of very low certainty: for three NRSs: RR 2.14, 95% CI 0.80 to 5.71; 2452 participants.

AUTHORS' CONCLUSIONS

This review shows that self-administering the second stage of early medical abortion procedures is as effective as provider-administered procedures for the outcome of abortion success. There may be no difference for the outcome of ongoing pregnancy, although the evidence for this is uncertain for this outcome. There is very low-certainty evidence for the risk of complications requiring surgical intervention. Data are limited by the scarcity of high-quality research study designs and the presence of risks of bias. This review provides insufficient evidence to determine the safety of self-administration when compared with administering medication in the presence of healthcare provider supervision. Future research should investigate the effectiveness and safety of self-administered medical abortion in the absence of healthcare provider supervision through the entirety of the medical abortion protocol (e.g. during administration of mifepristone or as part of a misoprostol-only regimen) and at later gestational ages (i.e. more than nine weeks). In the absence of any supervision from medical personnel, research is needed to understand how best to inform and support women who choose to self-administer, including when to seek clinical care.

Provision of medical methods of abortion in facilities in India in 2015: A six state comparison

Medical methods of abortion, MMA, has been legal in India since 2002. Guidelines stipulate that it should be administered by a provider or acquired via prescription. 1.2 million women having abortions in India use MMA acquired from health facilities [Singh, S., Shekhar, C., Acharya, R., Moore, A. M., Stillman, M., Pradhan, M. R., … Browne, A. (2018). The incidence of abortion and unintended pregnancy in India, 2015. The Lancet Global Health, 6(1), e111-e120. doi: 10.1016/S2214-109X(17)30453-9 ]. We undertook a study of abortion in Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh in 2015 to better understand under what conditions and how MMA is being administered in facilities. The majority of facilities that provide MMA are in the private sector and located in urban areas. Most facilities offer MMA both at the facility and as a prescription, although some facilities only offer MMA as a prescription. A high proportion of facilities report that women typically take the medication at home. (Re)training providers in MMA protocols and counselling, increasing the number of facilities offering MMA, and stocking of the drugs would help improve women's access to MMA and the information they need to be able to use this method safely. Key Messages: In the six states in our sample, Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh, 8% of abortions in 2015 were done using medical methods of abortion (MMA) acquired from health facilities. The majority of facilities that provide MMA in the six states are in the private sector and are located in urban areas. Health facilities in Madhya Pradesh and Tamil Nadu are comparatively better in their provision of MMA with Assam, Bihar, Gujarat and Uttar Pradesh demonstrating poorer provision of MMA. There are many opportunities for improvement in the practices of MMA provision through improved training of providers, accessibility to the medications and better support of women using MMA.

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.

"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.

Abortion and fertility control in Pakistan: the role of misoprostol

OBJECTIVE

To examine how availability of misoprostol has impacted women's abortion-seeking behaviour in Pakistan.

DESIGN

Focused ethnography.

SETTING

A facility providing reproductive health services, including induced abortions in Chakwal, a small town in Northern Punjab, Pakistan.

POPULATION

Women who came to the clinic seeking an abortion or who had had one in the last 6 months (n=23) and all healthcare providers working in the facility (n=14).

METHODS

Semi-structured interviews (n=37), a focus group discussion (n=1) and participant observation (n=41). Latent content analysis was conducted drawing on principles of constant comparison to generate key themes in reported experiences.

RESULTS

All the respondents had sought an abortion to limit their fertility. Although some reported contraceptive use, improper use, undesirable side effects and restrictions on use had led to the unwanted pregnancy. All the women specifically requested misoprostol within days of their pregnancy, suggesting that they not only had knowledge of misoprostol as a backup in case of contraceptive failure, but may have pre-planned its use of in place of using contraception. Women reconciled their decision to undergo an abortion by describing it as a mistake, miscarriage or menstrual cycle issue.

CONCLUSIONS

Misoprostol's availability, ease of use and effectiveness have increased the role of abortion in fertility control.

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.

Delivering medical abortion at scale: a study of the retail market for medical abortion in Madhya Pradesh, India

BACKGROUND

Medical abortion (mifepristone and misoprostol) has the potential to contribute to reduced maternal mortality but little is known about the provision or quality of advice for medical abortion through the private retail sector. We examined the availability of medical abortion and the practices of pharmacists in India, where abortion has been legal since 1972.

METHODS

We interviewed 591 pharmacists in 60 local markets in city, town and rural areas of Madhya Pradesh. One month later, we returned to 359 pharmacists with undercover patients who presented themselves unannounced as genuine customers seeking a medical abortion.

RESULTS

Medical abortion was offered to undercover patients by 256 (71.3%) pharmacists and 24 different brands were identified. Two thirds (68.5%) of pharmacists stated that abortion was illegal in India. Only 106 (38.5%) pharmacists asked clients the timing of the last menstrual period and 38 (13.8%) requested to see a doctor's prescription - a legal requirement in India. Only 59 (21.5%) pharmacists correctly advised patients on the gestational limit for medical abortion, 97 (35.3%) provided correct information on how many and when to take the tablets in a combination pack, and 78 (28.4%) gave accurate advice on where to seek care in case of complications. Advice on post-abortion family planning was almost nonexistent.

CONCLUSIONS

The retail market for medical abortion is extensive, but the quality of advice given to patients is poor. Although the contribution of medical abortion to women's health in India is poorly understood, there is an urgent need to improve the practices of pharmacists selling medical abortion.

Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India--study protocol and intervention adaptation of a randomised control trial

BACKGROUND

The World Health Organisation suggests that simplification of the medical abortion regime will contribute to an increased acceptability of medical abortion, among women as well as providers. It is expected that a home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic.

METHODS/DESIGN

This study protocol describes a study that is a randomised, controlled, non-superiority trial. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. The randomisation list will be generated using a computerized random number generator and opaque sealed envelopes with group allocation will be prepared. Randomization of the study participants will occur after the first clinical encounter with the doctor. Eligible women randomised to the home-based assessment group will use a low-sensitivity pregnancy test and a pictorial instruction sheet at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. The primary objective of the study this study protocol describes is to evaluate the efficacy of home-based assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet 10-14 days after an early medical abortion. Providers or research assistants will not be blinded during outcome assessment. To ensure feasibility of the self-assessment intervention an adaption phase took place at the selected study sites before study initiation. This resulted in an optimized, tailor-made intervention and in the development of the pictorial instruction sheet with a guide on how to use the low-sensitivity pregnancy test and the danger signs after a medical abortion.

DISCUSSION

In this paper, we will describe the study protocol for a randomised control trial investigating the efficacy of simplified follow-up in terms of home-based assessment, 10-14 days after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01827995. Registered 04 May 2013.

A case of toxic shock due to clandestine abortion by misoprostol self-administration

Maternal mortality and morbidity are the leading causes of death and illness, respectively, among women of reproductive age in many countries throughout the world. Of all maternal deaths, those related to unsafe abortions are the most widely underestimated, but they are also the most largely preventable. Medical abortion is a safe and reliable method for termination of a pregnancy in early gestation, although it is important to be aware of signs and symptoms of severe infection and toxic shock syndrome after the medical termination of pregnancy; case studies in literature are rarely fatal events. We report the first case of septic shock syndrome following a clandestine pregnancy termination with a misoprostol-only regimen (12 tablets 200 μg each). Autopsy findings and histopathological examination proved that the woman died from septic shock. This case suggests to improve the forensic investigations in case of unsafe, often clandestine, abortion is suspected.

Women's satisfaction with early home medical abortion with telephone follow-up: a questionnaire-based study in the U.K

A questionnaire-based study was undertaken to assess women's satisfaction with the home medical abortion service. Over a 15-month period, questionnaires were conducted at 24 h and 2 weeks following the procedure. A total of 127 women took part in the study and filled in a questionnaire at 24 h, with 77 completing the questionnaire at 2 weeks. At 24 h, over 95% of women who responded, agreed or strongly agreed that they felt prepared for the pain and bleeding that they experienced at home. At 2 weeks, 97.3% of respondents felt that they had had enough information and knew what to expect, and were therefore satisfied with the procedure. Only 15% of women were lost to clinical follow-up at 2 weeks. The majority of women are satisfied with the home medical abortion service. These high satisfaction rates are maintained at 2 weeks. Telephone follow-up 2 weeks after the abortion was safe and effective.

Acceptability and feasibility of medical abortion with mifepristone and misoprostol in Nigeria

OBJECTIVE

To examine the acceptability and feasibility of medical abortion in Nigeria.

METHODS

In total, 250 women who were eligible for legal pregnancy termination with a gestational age of up to 63 days since last menstrual period were enrolled in Benin City and Zaria between May 2005 and October 2006. Participants received 200 mg of oral mifepristone in the clinic and then took 400 μg of oral misoprostol 2 days later-choosing to either return to the clinic or take it at home. Women returned 2 weeks later for an assessment of abortion status.

RESULTS

The vast majority (96.3%) of women had successful complete abortions. Ultrasound was used to determine outcome in less than one-third (28.9%) of participants. Most women (83.2%) took the misoprostol at home. Almost all (96.2%) participants were satisfied or very satisfied with the abortion method.

CONCLUSION

The introduction of medical abortion with mifepristone and misoprostol could greatly expand current method options and improve the quality of reproductive health care in Nigeria and other settings in which access to legal abortion services is limited.

Efficacy and acceptability of early mifepristone-misoprostol medical abortion in Ukraine: results of two clinical trials

BACKGROUND

Abortion services are legally available in Ukraine although there are issues in quality and access. Two studies were conducted in Ukraine to expand options for women, and to determine the efficacy and acceptability of medical abortion.

STUDY DESIGN

Two open-label clinical trials were conducted at six clinics in Ukraine. Women were given 200 mg mifepristone followed after 48 hours by 400 μg oral misoprostol (Study One) and mifepristone followed after 24 hours by 400 μg sublingual misoprostol (Study Two). Follow-up visits were scheduled for two weeks after mifepristone administration to assess whether complete uterine evacuation had occurred.

RESULTS

Success rates were 97% in the first study and 98% in the second one. The vast majority of participants were satisfied or very satisfied with their abortion method (Study One: 94%; Study Two: 98%).

CONCLUSIONS

The two studies demonstrate high rates of success and acceptability of early medical abortion in Ukraine.

Clinic-level introduction of medical abortion in Vietnam

OBJECTIVE

To assess the efficacy of medical abortion and patient satisfaction in the clinic setting, in addition to determining healthcare providers' views.

METHODS

From 2006 to 2008, 2400 women were enrolled at 10 Vietnam Family Planning Association (VINAFPA) clinics in an operations research project. Participants took 200mg of oral mifepristone in the clinic and 400 μg of oral misoprostol 2 days later at home or in the clinic. Abortion status was assessed at follow-up. Furthermore, in 2006, 900 clinicians at 45 health facilities answered a knowledge, attitudes, and practices survey to capture providers' views.

RESULTS

In total, 93.8% of participants had successful medical abortions. The majority (84.5%) administered misoprostol at home. Adverse effects included bleeding, pain/cramps, and nausea. Most women (92.6%) were satisfied/very satisfied with the method. Most providers who took the survey (85.6%) recommended that medical abortion be introduced at VINAFPA clinics.

CONCLUSION

The operations research data demonstrate the safety, efficacy, and acceptability of medical abortion at VINAFPA clinics. The majority of surveyed providers endorsed adding medical abortion at their own facilities. Developing national guidelines for providing medical abortion at the clinic level is an important step in expanding access to services in Vietnam.

Perspectives of Chinese healthcare providers on medical abortion

OBJECTIVE

To evaluate Chinese healthcare providers' knowledge regarding medical abortion, to understand provider preferences for abortion methods, and to investigate the role of remuneration on providers' decision making.

METHODS

Between November 2009 and May 2010, 658 abortion service providers from family-planning service centers and hospitals in Shenzhen and Henan, China, were surveyed via self-administered questionnaires.

RESULTS

The knowledge score (out of a maximum of 32) regarding medical abortion was 16-20 for 60.9% of the providers; 20.4% of the providers preferred medical abortion to surgical abortion, whereas 35.0% preferred surgical abortion. Overall, 72.2% of providers stated that they did not receive any commission for providing medical abortion or surgical abortion.

CONCLUSION

Most healthcare providers believed that surgical abortion was preferable to medical abortion. Efforts should be made to overcome the perceived disadvantages of medical abortion.

Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review

OBJECTIVE

To compare medical abortion practised at home and in clinics in terms of effectiveness, safety and acceptability.

METHODS

A systematic search for randomized controlled trials and prospective cohort studies comparing home-based and clinic-based medical abortion was conducted. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Popline were searched. Failure to abort completely, side-effects and acceptability were the main outcomes of interest. Odds ratios and their 95% confidence intervals (CIs) were calculated. Estimates were pooled using a random-effects model.

FINDINGS

Nine studies met the inclusion criteria (n = 4522 participants). All were prospective cohort studies that used mifepristone and misoprostol to induce abortion. Complete abortion was achieved by 86-97% of the women who underwent home-based abortion (n = 3478) and by 80-99% of those who underwent clinic-based abortion (n = 1044). Pooled analyses from all studies revealed no difference in complete abortion rates between groups (odds ratio = 0.8; 95% CI: 0.5-1.5). Serious complications from abortion were rare. Pain and vomiting lasted 0.3 days longer among women who took misoprostol at home rather than in clinic. Women who chose home-based medical abortion were more likely to be satisfied, to choose the method again and to recommend it to a friend than women who opted for medical abortion in a clinic.

CONCLUSION

Home-based abortion is safe under the conditions in place in the included studies. Prospective cohort studies have shown no differences in effectiveness or acceptability between home-based and clinic-based medical abortion across countries.

A qualitative assessment of the acceptability and potential demand for medical abortion among university students in Durban, South Africa

OBJECTIVES

To assess the acceptability of medical abortion as a method for pregnancy termination among young South African women, and further investigate the potential demand for medical abortion.

METHODS

Qualitative study based on in-depth interviews. The interviews were conducted with 20 sexually active, female university students in Durban, South Africa.

RESULTS

The findings suggest that there is a demand for medical abortion among this sample of young women. Most of them find medical abortion an acceptable method, and would choose it if they were faced with an unwanted pregnancy. Some of the positive aspects of medical abortion raised were: increased privacy; avoidance of surgery; and sense of greater control. Some of the negative aspects of medical abortion were: fear of adverse side effects; high cost; follow-up visits; and potential psychological stress. While the majority of women find this method acceptable, there were reservations and concerns about introducing it into the public sector such as misuse and abuse of the medication by clients and providers.

CONCLUSION

Medical abortion should be introduced into the public sector in South Africa, and this method be made affordable, accessible, and available for women.