Can women in less-developed countries use a simplified medical abortion regimen?

The role of midwives in first-trimester abortion care: A 40-year experience in Tunisia

Objective

To review the relevant literature on abortion and summarize interviews with key stakeholders to assess the role of midwives in the evolution of abortion‐related care in Tunisia.

Methods

Interviews with eight stakeholders from different organizations based on a guide developed for the study, focusing on policies, strategies used for implementation, capacities used for expansion, user opinions and experience, obstacles and facilitators, and control and evaluation.

Results

Task‐sharing for midwifes was encouraged in the family planning program from the beginning and when medical abortion was introduced. It allows midwifes to contribute widely, develop good skills and performance for several tasks, and helps reduce regional disparities in human resource allocation. Success and safety of home use of medical abortion confirms the ability of women to manage their own abortion. Yet, obstacles to accessing abortion still exist for several reasons.

Conclusion

This study, based on interviews with personnel with significant experience and solid knowledge of sexual and reproductive health services, allowed us to consider proposals for a future strategy to integrate task‐sharing into abortion care and address the barriers to legal and safe abortion access for all women in Tunisia.

Task‐sharing of abortion care with midwives has a positive impact on quality of services and addresses barriers to accessing abortion in Tunisia.

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.

Early medical abortion with self-administered low-dose mifepristone in combination with misoprostol

AIM

The aim of the present study was to investigate the safety and efficacy of low-dose mifepristone combined with self-administered misoprostol for termination of early pregnancy.

METHODS

A total of 533 women seeking medical abortion in early pregnancy (≤49 days since the last menstrual period) were divided randomly into hospital- (H-Mis, 250) and self- (S-Mis, 283) administered misoprostol groups. Women in two groups took 100 mg of oral mifepristone in hospital followed by 200 μg of sublingual misoprostol 24 h later in hospital or home. The primary outcome parameter was complete abortion without surgical intervention. Secondary outcomes were uterine bleeding, return of regular menses, side effects and patient acceptability.

RESULTS

High rates of complete abortion were observed for both the H-Mis group (243/250; 94.8%) and the S-Mis group (266/283; 94.0%). No significant differences in outcomes (complete abortion/failure rates) or side effects were observed between the two groups. General satisfaction rates were similar for the two groups (H-Mis, 231/250, 92.4%; S-Mis, 263/283, 92.9%; P > 0.05). Higher convenience of administration (H-Mis, 211/250, 84.4%; S-Mis, 270/283, 95.4%; P < 0.05) and privacy protection (H-Mis, 214/250, 85.6%; S-Mis, 267/283, 94.3%; P < 0.05) satisfaction rates were obtained for the S-Mis group than for the H-Mis group.

CONCLUSION

Self-administered sublingual misoprostol is as safe and effective as hospital-administered misoprostol following low-dose mifepristone to terminate early pregnancy (≤49 days of amenorrhoea) with fewer side effects.

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.

Women's perspectives on termination service delivery in Vietnam: a cross-sectional survey in three provinces

Objective

To explore the perspectives of abortion service users regarding termination methods and abortion service delivery in Vietnam.

Materials and methods

Structured exit interviews were conducted between August and November 2011 with women who underwent termination of pregnancy at 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City in Vietnam. All women presenting for termination during the study period were recruited to participate in the study. Following their abortion, women were asked about their perspectives on abortion service delivery and attributes of medical abortion (MA) versus manual vacuum aspiration (MVA). Multiple logistic regression was used to assess the association between current method uptake and each attribute.

Results

A total of 1,233 women were included in the survey: 541 (43.9%) from Hanoi, 163 (13.2%) from Khanh Hoa, and 529 (42.9%) from Ho Chi Minh: 23.1% underwent MA; 78.9% reported that women should be given a choice between MA and MVA; and 77.6% thought that abortion services were accessible. Among the 48% who responded, 30.1% thought that MA should be made available at primary/secondary health care facilities. Among women who had previously undergone both methods, women who reported that MA “feels more natural” (like a menstrual regulation/period) were more likely to choose MA for their current abortion (odds ratio 2.15, 95% confidence interval 1.26–3.69).

Conclusion

MA uptake is significantly lower than MVA uptake. Further insights to women’s perceptions of MA in Vietnam could help improve abortion service delivery in the country.

Attributes and perspectives of public providers related to provision of medical abortion at public health facilities in Vietnam: a cross-sectional study in three provinces

BACKGROUND

The purpose of this study was to investigate attributes of public service providers associated with the provision of medical abortion in Vietnam.

METHODS

We conducted a cross-sectional study via interviewer-administered questionnaire among abortion providers from public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City in Vietnam between August 2011 and January 2012. We recruited abortion providers at all levels of Vietnam's public health service delivery system. Participants were questioned about their medical abortion provision practices and perspectives regarding abortion methods.

RESULTS

A total of 905 providers from 62 health facilities were included, comprising 525 (58.0%) from Hanoi, 122 (13.5%) from Khanh Hoa, and 258 (28.5%) from Ho Chi Minh City. The majority of providers were female (96.7%), aged ≥25 years (94%), married (84.4%), and had at least one child (89%); 68.9% of providers offered only manual vacuum aspiration and 31.1% performed both medical abortion and manual vacuum aspiration. Those performing both methods included physicians (74.5%), midwives (21.7%), and nurses (3.9%). Unadjusted analyses showed that female providers (odds ratio 0.1; 95% confidence interval 0.01-0.30) and providers in rural settings (odds ratio 0.3; 95% confidence interval 0.08-0.79) were less likely to provide medical abortion than their counterparts. Obstetricians and gynecologists were more likely to provide medical abortion than providers with nursing/midwifery training (odds ratio 22.2; 95% confidence interval 3.81-129.41). The most frequently cited advantages of medical abortion for providers were that no surgical skills are required (61.7%) and client satisfaction is better (61.0%).

CONCLUSION

Provision of medical abortion in Vietnam is lower than provision of manual vacuum aspiration. While the majority of abortion providers are female midwives in Vietnam, medical abortion provision is concentrated in urban settings among physicians. Individuals providing medical abortion found that the method yields high client satisfaction.

Outpatient versus inpatient intravaginal misoprostol for the treatment of first trimester incomplete miscarriage: a randomised controlled trial

BACKGROUND

Study objective To assess the efficacy of outpatient misoprostol administration versus inpatient misoprostol administration for the treatment of first trimester incomplete miscarriage.

MATERIALS AND METHODS

A prospective randomised controlled trial was conducted at a tertiary hospital from May 2012 to April 2013. A total of 154 patients with first trimester incomplete miscarriage were randomised to receive misoprostol either as outpatient or inpatient. Intra-vaginal misoprostol 800 mcg was administered eight hourly to a maximum of three doses. Complete evacuation is achieved when the cervical os was closed on vaginal examination or ultrasound showed no more retained products of conception evidenced by endometrial thickness of less than 15 mm. Treatment failure was defined as failure in achieving complete evacuation on day seven hence surgical evacuation is offered.

RESULTS

Outpatient administration of misoprostol was as effective as inpatient treatment with success rate of 89.2 and 85.7 % (p = 0.520). The side effects were not significantly different between the two groups. Side effects that occurred were minor and only required symptomatic treatment. Duration of bleeding was 6.0 days in both groups (p = 0.317). Mean reduction in haemoglobin was lesser in the outpatient group (0.4 g/dl) as compared to in the inpatient group (0.6 g/dl) which was statistically significant (p = 0.048).

CONCLUSION

Medical evacuation using intra-vaginal misoprostol 800 mcg eight hourly for a maximum of three doses in an outpatient setting is as effective as in inpatient setting with tolerable side effects.

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.

Knowledge and provision practices regarding medical abortion among public providers in Hanoi, Khanh Hoa, and Ho Chi Minh City, Vietnam

OBJECTIVE

To assess public service providers' knowledge of medical abortion (MA) and practices, and perspectives on expanding the use of MA to primary and secondary health facilities in Vietnam.

METHODS

A cross-sectional study was conducted via an interviewer-administered questionnaire among abortion providers (n=905) from public health facilities between August 2011 and January 2012.

RESULTS

Overall, 31.1% of providers performed both surgical and medical abortions; 68.9% offered only surgical abortion. Providers were knowledgeable about the regimen/dosage of mifepristone plus misoprostol regimen; however, knowledge scores were low for gestational age limits for MA, adverse effects of the combined drug regimen, and safety and effectiveness of MA compared with surgical abortion. Knowledge scores were significantly lower among providers in rural areas than among those in urban settings. A large proportion of providers (82.9%) thought that MA should be expanded to primary and secondary health facilities. Perceived barriers to MA expansion included lack of knowledge and training, qualified staff, adequate drug supplies, equipment, or facilities, guidelines and protocols on MA, and patient awareness.

CONCLUSION

Provision of MA in Vietnam was found to be disproportionate to surgical abortion provision and to vary by region. Knowledge of MA was moderate, but poorer among providers in rural settings.

Medical abortion practices among private providers in Vietnam

Objective

To describe medical abortion (MA) practices among private providers in Vietnam.

Methods

The study subjects were women (n = 258) undergoing early MA through 12 private providers in Hanoi during February–June 2012. The women were interviewed on the day of their procedure and were followed up by telephone 14 days after mifepristone administration.

Results

Of the 258 women in the study, 97% used a regimen of mifepristone plus misoprostol; 80% were instructed to administer misoprostol at home. MA resulted in a complete termination in 90.8% of cases. All women were provided with information on potential complications and were instructed to return for a follow-up visit. We successfully followed up 77.5% (n = 200) of participants by telephone, while nearly two-thirds of women returned to the clinic for a follow-up visit. At follow-up, 39.5% of women reported having used a Help line service, while 7% had sought help from a health provider. A high unmet need for postabortion family planning was identified.

Conclusion

Follow-up of women, postabortion care, and the provision of family planning have been identified as important areas to address for strengthening MA services in the private sector in Vietnam.

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.

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.

Sublingual misoprostol for first trimester termination of pregnancy

OBJECTIVES

To compare blood loss, efficiency, and acceptability of repeated doses of sublingual misoprostol with the standard Tunisian regimen of mifepristone-misoprostol for first trimester medical abortion.

METHODS

A prospective randomized trial of 252 healthy pregnant women requesting medical abortion in the first trimester (up to 56 days). Participants were randomized to receive 200mg of oral mifepristone followed by 400 microg of oral misoprostol (group 1) or 800 microg of sublingual misoprostol repeated every 4 hours for up to a maximum of 3 doses (group 2). Primary outcome was blood loss assessed by decrease in hematocrit.

RESULTS

Mean decrease in hematocrit at follow-up was significantly greater in group 1 than in group 2 (3.65%+/-1.18% vs 2.69%+/-1.89%, respectively; P=0.02). There was no difference in efficiency rates between groups 1 and 2 (94.5% vs 92.1%; P=0.7). Comparable proportions of women experiencing at least one adverse effect after misoprostol administration were reported in groups 1 and 2 (81.7% vs 79.4%; P=0.75).

CONCLUSION

Compared with the most widely used regimen in Tunisia (mifepristone-misoprostol), sublingual misoprostol alone induces less blood loss (although not clinically significant); it is less expensive and offers reduced interval time to expulsion.

Increasing women's choices in medical abortion: a study of misoprostol 400 microg swallowed immediately or held sublingually following 200 mg mifepristone

OBJECTIVES

To assess the efficacy and acceptability of two misoprostol regimens (400 microg oral or sublingual) following mifepristone for medical abortion.

METHODS

Women seeking abortion with gestations of 56 days or less since onset of their last menstrual period were offered medical abortion as an alternative to a surgical procedure. A total of 207 eligible and consenting women were given mifepristone (200 mg oral) and the option of taking 400 microg misoprostol either orally or sublingually two days later, with the option of home-use. Two weeks later, treatment success, satisfaction, and the frequency and acceptability of side effects were assessed.

RESULTS

Most women (97.6%) opted for home use of misoprostol and almost three quarters selected the oral route. Overall efficacy, acceptability of side effects and satisfaction were high in both groups. The success rate was lower after sublingual than after oral administration but not significantly so (91.3% vs. 96.3%, p = 0.23, RR: 0.93, 95% CI = 0.85-1.02). The frequency and average duration of side effects in both groups were comparable except for pain/cramps and fever/chills, which were more frequently associated with the sublingual route.

CONCLUSIONS

This study re-emphasises the feasibility of integrating medical abortion into health services in Turkey and the potential to increase choices for women.

Medication abortion

Medical methods for pregnancy termination in early gestation offer women an alternative to surgical evacuation and have the potential to improve access globally to safe abortion. Several drug regimens are used with varying efficacy including mifepristone plus misoprostol, misoprostol alone, and methotrexate plus misoprostol. Where available, a mifepristone plus misoprostol regimen is most frequently used and is highly effective for early abortion. We review these drug regimens along with clinical practice recommendations including patient counseling and selection, regimen administration location, expected side effects, and follow-up procedures. Overall, women who choose medical abortion report high levels of satisfaction.

Home use of two doses of misoprostol after mifepristone for medical abortion: A pilot study in Sweden and France

OBJECTIVE

To test the feasibility, safety, and efficacy of home use of two doses of misoprostol for medical abortion (MA) in European settings.

METHODS

One hundred thirty women (100 in Sweden, 30 in France) presenting for first-trimester MA were administered oral mifepristone in the clinic and sent home with two 400 microg doses of misoprostol, along with instructions to take the misoprostol at 24 h intervals. Women were also asked to complete a daily symptom diary. Outcomes of interest included effectiveness, side-effects, and adherence to and acceptability of the home-use regimen.

RESULTS

Three women (all in France) were lost to follow-up. Of the remaining 127 women, 124 (98%) had a successful MA. All women adhered successfully to the home-use regimen, and satisfaction with home use was high (98%). Most women experienced noticeable, if transitory, side effects after both the first and second doses of misoprostol (97% and 94%, respectively).

CONCLUSIONS

Misoprostol may successfully and satisfactorily be used at home as part of a MA regimen in European settings as it has been for years in the US. Further research to determine if two doses of misoprostol are more effective than a single dose would be useful.

Efficacy, acceptability and safety of medication abortion in low-income, urban Latina women

BACKGROUND

Health care providers may be reluctant to offer medication abortion to low-income, non-English-speaking populations. Concerns include lack of patient interest, incorrect use of misoprostol at home, missing mandatory follow-up visits and inappropriate use of emergency services. We describe the appeal, acceptability, safety and follow-up rates of medication abortion in a low-income Latina population in New York City.

STUDY DESIGN

Nested analysis of 270 subjects up to 63 days' gestation enrolled in a multicenter trial of medication abortion comparing different mifepristone-misoprostol intervals. After receiving mifepristone, subjects were instructed on home use of misoprostol, what to do in an emergency and when to return.

RESULTS

This population was predominantly Spanish-speaking, unmarried, poor and publicly insured. Ninety-six percent took the misoprostol at home correctly, 90% returned as scheduled without reminders and 2% were lost to follow-up. Ninety-six percent described the experience as positive or neutral and 94% would recommend medication abortion to a friend. Three serious adverse events occurred and women accessed emergency services appropriately.

CONCLUSION

Medication abortion can be a very appealing, safe and effective option in low-income, non-English-speaking populations.

Acceptability and feasibility of medical abortion in Nepal

OBJECTIVE

To test the feasibility and acceptability of a simplified mifepristone-misoprostol regimen for early abortion in 2 tertiary teaching hospitals and 2 family planning clinics in Nepal.

METHODS

Consenting pregnant women (n=400) with amenorrhea of 56 days or less seeking termination of pregnancy received 200 mg of oral mifepristone followed 48 hours later with 400 microg of oral misoprostol, administered either at home or at the clinic. Prospective data were collected to determine the women's experience, abortion outcome, and the operational requirements for providing the method.

RESULTS

Most (91.3%) of the 367 women with known outcomes had successful medical abortions. Given the option, most (89.7%) women elected to administer the misoprostol at home.

CONCLUSION

A simplified medical abortion protocol, including home administration of misoprostol, can be successfully integrated into clinical services in Nepal, where abortion services were recently legalized.

Two-pill regimens of misoprostol after mifepristone medical abortion through 63 days' gestational age: a randomized controlled trial of sublingual and oral misoprostol

BACKGROUND

A 400 mcg dose of sublingual misoprostol has high efficacy and few side effects when used with 200 mg mifepristone for medical abortion through 63 days' gestation.

STUDY DESIGN

Eligible and consenting women (n=480) were randomized to 400 mcg of misoprostol sublingually or orally, 24 h after 200 mg of mifepristone. Abortion status was assessed two weeks later.

RESULTS

Complete abortion occurred in 98.7% of the sublingual group and 94.0% of the oral group (p value=.006, RR: 1.05, 95% CI=1.01--1.09). Over 90% of women in both arms expressed high satisfaction with the method. Side effects were similar in both groups, with only fever or chills reported by significantly more women in the sublingual arm.

CONCLUSIONS

The sublingual route appears superior to the regimen of 400 mcg misoprostol used orally and may be a good option for mifepristone medical abortion.

Barriers to access prevention of mother-to-child transmission for HIV positive women in a well-resourced setting in Vietnam

BACKGROUND

According to Vietnamese policy, HIV-infected women should have access at least to HIV testing and Nevirapine prophylaxis, or where available, to adequate counselling, HIV infection staging, ARV prophylaxis, and infant formula. Many studies in high HIV prevalence settings have reported low coverage of PMTCT services, but there have been few reports from low HIV prevalence settings, such as Asian countries. We investigated the access of HIV-infected pregnant women to PMTCT services in the well-resourced setting of the capital city, Hanoi.

METHODS

Fifty-two HIV positive women enrolled in a self-help group in Hanoi were consulted, through in-depth interviews and bi-weekly meetings, about their experiences in accessing PMTCT services.

RESULTS

Only 44% and 20% of the women had received minimal and comprehensive PMTCT services, respectively. Nine women did not receive any services. Twenty-two women received no counselling. The women reported being limited by lack of knowledge and information due to poor counselling, gaps in PMTCT services, and fear of stigma and discrimination. HIV testing was done too late for optimal interventions and poor quality of care by health staff was frequently mentioned.

CONCLUSION

In a setting where PMTCT is available, HIV-infected women and children did not receive adequate care because of barriers to accessing those services. The results suggest key improvements would be improving quality of counselling and making PMTCT guidelines available to health services. Women should receive early HIV testing with adequate counselling, safe care and prophylaxis in a positive atmosphere towards HIV-infected women.

Acute Hemolytic Anemia With Acanthocytosis Associated With High-Dose Misoprostol for Medical Abortion

We report a case of acute hemolytic anemia in a 21-year-old Nigerian woman after high-dose misoprostol (4 mg), used for medical abortion. The major causes of inherited or immune hemolytic anemia were excluded. The patient's peripheral blood smear showed acanthocytes and anisopoikilocytosis, which progressively disappeared in the days postingestion. We evaluated RBC features, and we observed reduced RBC Na+ and K+ content and abnormalities in membrane cation transport pathways and in Ca2+ activated K+ channel (Gardos channel), suggesting possible direct effects of misoprostol on RBCs. Although further studies need to be carried out, the present case suggests that high-dose misoprostol, a prostaglandin E1 analogue, severely affects RBC features and causes an acquired acute hemolytic anemia, which is self-limited when misoprostol is withdrawn.

Increasing access to safe abortion services in rural India: experiences with medical abortion in a primary health center

INTRODUCTION

To increase access to safe abortion in rural India, the feasibility and acceptability of mifepristone-misoprostol abortion was assessed in a typical government run primary health center (PHC) in Nagpur district, Maharashtra State, that does not offer surgical abortion services and must refer off-site for emergency and backup services.

MATERIALS AND METHODS

Consenting pregnant women (n=149) with <or=56 days amenorrhea seeking terminations received 200 mg mifepristone, and returned 48 h later for 400-microg sublingual misoprostol and 12 days later for abortion confirmation. Surgical backup was conducted at a nearby community health center (CHC).

RESULTS

Nearly all women (98.6%) with known outcomes had successful medical abortions, and those who did not (1.4%) were successfully referred to the CHC for surgical backup. Women reported the method's ease and simplicity as the best features.

CONCLUSION

Medical abortion provision is feasible and acceptable in an Indian rural PHC that does not offer surgical abortion services. This study suggests that introduction of medical abortion at lower levels of the health-care system could increase access to safe abortion in rural India.

Are two doses of misoprostol after mifepristone for early abortion better than one?

OBJECTIVE

The objective of this study was to determine if a repeat dose of misoprostol following mifepristone or a single dose of misoprostol increases the efficacy of medical termination of pregnancy.

DESIGN

Randomised, placebo controlled trial.

SETTING

K.E.M. Hospital, Pune, India, and the Health Centre, Larsen and Toubro Limited, Mumbai, India.

SAMPLE

A total of 300 women seeking an abortion with amenorrhoea of 8 weeks or less. Methods Women were randomised to receive one or two doses of 400 microgram oral misoprostol at the clinic 48 hours after administration of 200 mg mifepristone. Main outcome measure Complete abortion without surgical intervention. Results The repeat administration of misoprostol 400 microgram improved the complete abortion rate from 86 to 92% and significantly reduced the rate of continuing pregnancy from 7 to 1%. Almost all the women who were administered the additional dose of misoprostol were either very satisfied (58%) or satisfied (37%) with the method. Conclusion While an additional oral dose of 400 microgram misoprostol did not significantly increase the rate of complete abortion without surgical intervention, the additional dose did significantly reduce the rate of continuing pregnancies without compromising the acceptability and ease of use of the method.

Women's stories of abortion in southern Gabon, Africa

The purpose of this study was to explore the reasons women in rural, southern Gabon, Africa, chose to terminate their pregnancies, the methods used to induce abortions, and postabortion effects experienced by these women. Abortion is illegal in this country. A descriptive qualitative design guided the methodology for this study. Five women with a history of induced abortion were interviewed in-depth for their abortion story. Reasons cited for an abortion included lack of financial and partner support. Abortion methods included oral, rectal, and vaginal concoctions of leaves, bark, and water and over-the-counter medications, including misoprostol. Affects were physical, spiritual, and relational. Health care professionals need to provide women with guidance for appropriate contraceptive usage. Abortion after-care of women with physical and spiritual needs is important. Future research is suggested on the use of misoprostol in Gabon to understand its affects on women's reproductive health.

Self-administration of vaginal misoprostol after mifepristone for termination of pregnancy: patient acceptability

This was a questionnaire survey involving women who self-administered vaginal misoprostol in the hospital setting following oral mifepristone for medical termination of pregnancy. The sample number was 89 with a median gestational age of 9 weeks; median dose of misoprostol used was 1600 mug and median induction abortion interval was 5.3 h. The success rate was 100% with the majority finding it easy to self-administer vaginal misoprostol and two-thirds did not mind doing this. Only one-third experienced adverse effects of the medication and 83% were satisfied with the procedure. Only one-third was willing to try it at home in future if necessary. Self-administration of vaginal misoprostol for termination of pregnancy in the hospital is safe and effective. Although women were comfortable in self administering the pessaries in the hospital, they do not appear to be keen to do it at home without any supervision. However, as this is the first study in the UK involving women expressing their views regarding this issue, added research in this area is required.

Mifepristone medical abortion in Albania: results from a pilot clinical research study

OBJECTIVE

To explore the acceptability and feasibility of introducing mifepristone-misoprostol for early medical abortion in home and clinic settings in Albania.

METHODS

This was a prospective study testing a simplified mifepristone-misoprostol regimen in two tertiary-level government health facilities in Tirana, Albania. Women (n = 409) with amenorrhea of 8 weeks or less received 200 mg mifepristone in the clinic and then chose whether to take 400 microg of oral misoprostol 2 days later either at home or in the clinic.

RESULTS

Nearly 97% of women successfully terminated their pregnancies using the simplified regimen. Almost all women found the method either satisfactory (49.4%) or highly satisfactory (41.1%). Almost all women who were given the option selected the home use protocol. Women choosing home administration of misoprostol were able to manage the medical abortion process on their own.

CONCLUSION

A reduced dose mifepristone medical abortion regimen with home administration of misoprostol is feasible for introduction into healthcare facilities in Albania.

Misoprostol alone for early abortion: an evaluation of seven potential regimens

INTRODUCTION

A growing body of literature has shown that misoprostol alone could be effective for early medical abortion. We evaluated seven potential regimens in women up to 56 days of gestation in order to potentially identify an optimal regimen.

METHODS

In phase I of the study, women requesting early abortion were randomized to one of three misoprostol regimens (4x400 microg po every 3 h, 2x800 microg po every 6 h, 1x600 pv microg); in phase II, women were randomized to one of two regimens (2x800 microg po every 3 h, 1x800 pv microg). In phase III, we consecutively tested two regimens (800 microg pv wetted with saline repeated after 24 h if intact gestational sac, 2x800 microg pv wetted with saline) to validate previously published results.

RESULTS

Although most women experienced some side effects, all regimens were tolerable and acceptable. Five of the seven regimens resulted in complete abortion rates of 60% or less. Only repeated doses of 800 microg pv misoprostol resulted in efficacy exceeding 60%.

DISCUSSION

Misoprostol-alone abortion regimens using oral misoprostol are too ineffective for clinical use or further investigation. Regimens with repeated dosing of misoprostol 800 microg pv warrant further study to find the optimal treatment protocol.

Regimens of misoprostol with mifepristone for early medical abortion: a randomised trial

OBJECTIVE

To compare the efficacy, adverse effects and acceptability of the three most common misoprostol regimens used with mifepristone for medical abortion.

DESIGN

Randomised nonblinded trial.

SETTING

Three clinics associated with major research universities in Canada; two in major urban areas and one in a periurban area.

POPULATION

Women of reproductive age.

METHODS

Consenting women presenting for abortion services with gestations less than 56 days and who met inclusion criteria were given 200 mg mifepristone orally and then randomised into three misoprostol study groups: (group I) 400 micrograms of oral misoprostol, (group II) 600 micrograms of oral misoprostol, and (group III) 800 micrograms of vaginal misoprostol. Misoprostol was self-administered at home 24-48 hours following mifepristone, and participants were instructed to take a second similar misoprostol dose at 24 hours after the initial dose if bleeding was less than a normal menstrual period.

MAIN OUTCOME MEASURES

Successful abortion without surgery was 94.1%, with no significant differences across the three study groups (94.7% in group I, 93.4% in group II, and 94.3% in group III; P= 0.975).

RESULTS

Efficacy and adverse effects did not differ significantly across the three study groups. Pain increased significantly across the study and the gestational age groups and was associated with lower acceptability.

CONCLUSIONS

There appears to be a range of safe and effective options for early medical abortion with mifepristone including a choice between oral and vaginal administration of misoprostol.

Knowledge and attitudes about abortion legislation and abortion methods among abortion clients in Latvia

OBJECTIVE

To assess knowledge of abortion legislation and knowledge and attitudes about medical and surgical abortion among women seeking a legal abortion in Latvia.

METHODS

Data are drawn from a survey of 371 abortion clients from 16 purposively selected abortion clinics in Latvia. A semi-structured questionnaire was used to collect socio-demographic data and information on women's knowledge of and attitudes toward abortion law and abortion methods.

RESULTS

Most women knew that abortion is legal either under any (53%) or certain (37%) circumstances. Almost one third (31%) of women interviewed were aware of medical abortion. After hearing a description of medical abortion, respondents felt the method as described would be advantageous because it could avoid a surgical intervention (33%) or found it simple, easy, convenient, or natural (12%). Women were concerned that the method might not be completely effective (38%) or be associated with side-effects (22%).

CONCLUSIONS

Respondents were interested in medical abortion as a less invasive option to surgical abortion. Efforts should be undertaken to inform women about the safety and efficacy of the method.

Study Supports the Introduction of Early Medical Abortion in Turkey

In Turkey, there is an unmet need for induced abortion services provided by the public health services, especially in rural and semi-urban areas. The objective of this clinical study was to show that early medical abortion could be introduced safely in Turkey to improve women's access to services. In the study, women aged 18-49 up to 56 days of pregnancy were offered a choice between medical abortion with 200 mg mifepristone followed by 400 mcg oral misoprostol and MVA with local anaesthesia. 209 chose medical and 149 surgical abortion. Data from an additional 112 women were collected to obtain a similar number of surgical abortion cases. Women's preference for and satisfaction with the chosen method, side effects and complications up to the 14-day follow-up visit were recorded. 75% of women who chose medical abortion opted for home use of misoprostol. Pain with medical abortion on average lasted 3.6 +/- 3.0 days and with surgical abortion 3.7 +/- 2.9 days. 90% of women who had medical abortion said they would prefer it again compared to 70% of those having surgical abortion. There were 1.4% ongoing pregnancies in the medical abortion group and none in the surgical group. Provider training and familiarity with medical abortion are crucial. The high incomplete abortion rate indicates that the dose and regimen of misoprostol should be reconsidered. The findings support the introduction of early medical abortion in Turkey.

From research to reality: the challenges of introducing medical abortion into service delivery in Vietnam

Following the inclusion of mifepristone + misoprostol for early pregnancy termination into the Vietnam National Reproductive Health Guidelines in 2002, a team from the Ministry of Health, World Health Organization and Ipas assessed how best to move from clinical research to widespread public sector availability. After field visits to hospitals and discussions with stakeholders, the team endorsed the phased introduction of medical abortion alongside vacuum aspiration services to expand choice. They stressed the importance of patient-oriented information on what to expect as the abortion process takes place and the need for follow-up, also crucial in training of providers. Routine use of ultrasound to detect ectopic pregnancies or determine that abortion was complete was considered unnecessary The mandated four-hour observation period following misoprostol administration could be reduced. The National Guidelines, appropriately conservative at the start of the programme, should be amenable to modification as experience grows. Introduction is not possible without a steady supply of drugs at affordable prices. Ways to reduce the high price of mifepristone and deal with provider expectations of extra allowances, as with surgical abortion, are needed. Making medical abortion a viable option for most Vietnamese women will require provision at commune-level clinics through mid-level providers, and with home use an option. Other challenges include use of misoprostol alone and regulating provision in the private sector.

High-dose misoprostol used in outpatient management of first trimester spontaneous abortion

AIM

The aim of this study was to evaluate the efficacy and tolerance of a high dose of vaginal misoprostol for outpatient medical management of missed abortion.

METHODS

Three doses of 400 mug misoprostol were administered intravaginally every 4 h daily, for a maximum period of 3 days, to 108 women with uneventful first trimester pregnancy failure.

RESULTS

A total of 98 women (90.7%) were managed successfully, with 74 (68.5%) of them within the first 24 h. The mean dose of misoprostol administered was 1,113.0 microg (range 400-3,600 microg), and the mean time required was 19.5 h (range 7-65 h). Only 6 out of 108 women (9.3%) required surgical intervention as the result of retained products of conception. The side effect profile was minimal.

CONCLUSION

This protocol of 400 mug intravaginally misoprostol every 4 h as three daily doses for a maximum of 3 days, may offer an efficacious and safe alternative to the outpatient management of first-trimester missed abortion.

Expanding medical abortion in Tunisia: women's experiences from a multi-site expansion study

From November 2000 to July 2001, 321 consenting women were enrolled at four sites across the country in an effort to demonstrate that mifepristone medical abortion could safely be used by providers throughout Tunisia. Women who met the study's inclusion criteria were given 200 mg oral mifepristone and offered the choice of taking 400 microg oral misoprostol 2 days later either at home or at the clinic. At follow-up, women were examined to determine completed abortion status and surveyed to gauge their satisfaction with the method. Ninety-six percent of women had a successful abortion using this method. Women expressed a strong preference for home use of misoprostol, indicating that it is more confidential (34%), easier (28%) and requires fewer clinic visits (28%). The high rate of success, demonstrated safety and acceptability of the method in new facilities and with new providers suggests that medical abortion can be safely expanded to new settings with reasonable levels of training and supervision.

[The efficacy and acceptability of mifepristone medical abortion with home administration misoprostol provided by private providers linked with the hospital: a prospective study of 433 patients]

BACKGROUND

Until July 2001 medical abortion was only authorized in France in public hospitals or private clinics. A new law effective in July 2001 allows private practitioners (gynaecologists or general practitioners) to provide medical abortion in their offices as long as they are linked to a hospital official agreement. Unfortunately mifepristone was not available outside hospitals before September 2004, so the study was conducted still providing the drugs in the hospital family planning clinic.

OBJECTIVE

To evaluate the efficacy and the acceptability of mifepristone medical abortion with home administration of misoprostol provided by private practitioners linked with the hospital.

PATIENTS AND METHODS

Four hundred thirty-three women seeking medical abortion before 7 weeks LMP were included between 2 January 2003 and 7 July 2004. All consultations before abortion and 2 weeks after abortion took place in a private provider's office. Drugs were administrated in the hospital family planning clinic: patients were given 3 tablets of mifepristone (600 mg) orally by the midwife and received 2 tablets of misoprostol (400 microg) that they would take at home 48 hours later. In case of any problems or complications, patients could phone or meet their private providers, phone the hospital midwife or go to the hospital emergency service. Private providers received training in medical abortion training and could at any time reach a medical specialist in the hospital family planning clinic for information or to refer a patient.

RESULTS

- Efficacy was evaluated for 339 women, because 94 patients were lost to follow-up (21.7%). Efficacy of medical abortion was 93.8% (318/339). There were 21 surgical aspirations (6.2%): for women's decision in 1.5% of cases, for medical decision without complications in 3.5% of cases, and for failure of the method in 1.2% of cases (2 ongoing pregnancies and 2 heavy haemorrhages with transfusion). The family planning midwife received a phone call from 21 patients after mifepristone (4.8%), Twenty-five patients had an emergency consultation (5.7%), and 22 patients went back to their private providers before their appointment for follow-up (5%). Twenty-two patients (5%) were referred by the private provider to the hospital medical specialist. Acceptability is known for 26% of patients; 96.2% thought that the abortion procedure was acceptable.

DISCUSSION AND CONCLUSIONS

The failure rate of medical abortion in this study is largely due to aspirations for incomplete abortion. To improve the efficacy of medical abortion offered by private providers linked with the hospital, all the relevant professionals (private providers, residents in the emergency service, family planning providers) must be well trained in medical abortion, especially in how to interpret and react to ultrasound images obtained in the follow up visit. The procedure is very acceptable to women. Medical abortion offered via a network should be well accepted by practitioners, since only 5% of women will need more than two consultations and only 6.2% will need surgical aspiration in the hospital. This study allows us to be optimistic about the expansion of medical abortion in France outside the hospital via a provider-hospital network based on the fact that since September 2004 private providers can get mifepristone directly in the pharmacies of the city.