Misoprostol Alone for Early Medical Abortion in a Latin American Clinic Setting

How Effective Is Misoprostol Alone for Medication Abortion?

AbstractWith recent severe restrictions to abortion accessibility in the United States and a pending Supreme Court case challenging the Food and Drug Administration's approval of mifepristone, evidence-based strategies to protect and expand access to abortion care are needed. Two safe and effective regimens for medication abortion are widely used globally - misoprostol-only and misoprostol in combination with mifepristone. However, misoprostol-only regimens are rarely used in the United States. In 2023, the National Abortion Federation and the Society of Family Planning updated their recommended protocol for misoprostol-only for medication abortion to 800 μg of misoprostol administered buccally, sublingually, or vaginally every 3 hours for three or more doses. To characterize the data supporting this specific regimen, this article reviews the relevant literature to address the question of how effective misoprostol-only is for medication abortion. The authors conclude that the updated misoprostol regimen is highly effective and a potential strategy for expanding access to abortion.

The chemical geographies of misoprostol: Spatializing abortion access from the biochemical to the global

C22W38O5 is a chemical that travels. Better known as misoprostol, it was designed as a stomach ulcer drug but is now used around the world as an abortion pill due to the self-experimentation of Latin American communities who were seeking ways to end unwanted pregnancies. We develop a chemical geography approach to misoprostol that allows us to scale inward to understand the chemical properties of this medication while also being able to scale out to understand how medicinal effects are interwoven with and determined by global politics. Misoprostol as a chemical alone does not guarantee a successful abortion and instead 'scaffolding' in the form of mobility and information is required to transform misoprostol from a chemical to a safe and effective technology of abortion. First, we examine how misoprostol is moved by feminist networks in Mexico and Peru. Second, we argue that in order to be useful it is not enough just to access the pills, information on how to use them is required. These themes culminate in our contribution of 'pharmacokinetical geographies'; the micro-geography of the placement of pharmaceuticals in and on a body and its ramifications. The chemical geographies of misoprostol tell a story of power, bodily autonomy, and resistance.

Effectiveness and safety of misoprostol-only for first-trimester medication abortion: An updated systematic review and meta-analysis

OBJECTIVES

This study aimed to update our 2019 systematic review of data on the effectiveness and safety of misoprostol-only for first-trimester abortion.

STUDY DESIGN

We searched PubMed on December 18, 2022, to find published articles describing the outcomes of treatment with misoprostol-only for abortion of viable intrauterine pregnancy at ≤91 days of gestation. From each article identified, two authors independently abstracted relevant data about each group of patients treated with a distinct regimen. We assessed the risk of bias using four defined indicators. We estimated the proportion of patients with treatment failure using meta-analytic methods as well as the proportion hospitalized or transfused after treatment. We examined associations between treatment failure and selected characteristics of the groups.

RESULTS

We identified 49 papers with 66 groups that collectively included 16,354 evaluable patients, of whom 2960 (meta-analytic estimate 15%, 95% CI 12%, 19%) had treatment failures. Of 9228 patients assessed for ongoing pregnancy after treatment, 521 (meta-analytic estimate 6%, 95% CI 5%, 8%) had that condition. Failure risk was significantly associated with misoprostol dose, the total allowed number of doses, the maximum duration of dosing, and certain indicators of risk of bias. Among 11,007 patients allowed to take at least three misoprostol doses, the first consisting of misoprostol 800 mcg administered vaginally, sublingually, or buccally, the meta-analytic estimate of the failure risk was 11% (95% CI 8%, 14%). At most, 0.2% of 15,679 evaluable patients were hospitalized or received transfusions.

CONCLUSIONS

Although some studies in this updated review were adjudicated to have a high risk of bias, the results continue to support the key conclusion of our 2019 analysis: misoprostol-only is effective and safe for the termination of first-trimester intrauterine pregnancy.

IMPLICATIONS

Misoprostol-only is a safe and effective option for medication abortion in the first trimester if mifepristone is unavailable or inaccessible.

Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review

OBJECTIVE

To summarize available data on the effectiveness and safety of single-agent misoprostol for medical abortion in the first trimester.

DATA SOURCES

We searched MEDLINE, CABI, Cochrane, EMBASE, LILACS, the Web of Science, and ClinicalTrials.gov for English-language studies that evaluated misoprostol alone for abortion of a viable pregnancy in the first trimester.

METHODS OF STUDY SELECTION

Our search yielded 1,562 citations, of which 38 included data from 53 trial groups that met our inclusion and exclusion criteria.

TABULATION, INTEGRATION, AND RESULTS

We abstracted data about each trial group, including study characteristics, treatment regimen, clinical protocol, number of women treated and followed, and numbers with outcomes of interest. We used meta-analytic methods and logistic regression to examine factors associated with surgical intervention after treatment. Among all 12,829 evaluable women, 2,536 (meta-analytic estimate 22.0%, 95% CI 18.8-25.5%) had surgical uterine evacuation. Multiple factors were significantly associated with this proportion, including misoprostol amount per dose and route of administration, loss to follow-up rate, publication date, geographic region, number of misoprostol doses, duration of dosing, and time between dosing and evaluation. Of 6,359 evaluable women, 384 (meta-analytic estimate 6.8%, 95% CI 5.3-8.5%) had ongoing pregnancies. At most 26 of 12,184 evaluable women (meta-analytic estimate 0.7%, 95% CI 0.4-1.0%) were transfused or hospitalized for abortion-related reasons. In trials that provided satisfaction data, most women were satisfied or very satisfied with the treatment (meta-analytic estimate 78%, 95% CI 71-85%).

CONCLUSIONS

Misoprostol alone is effective and safe and is a reasonable option for women seeking abortion in the first trimester. Research is indicated to further refine the regimen and to establish efficacy in the late first trimester.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018083589.

Abortion as empowerment: reproductive rights activism in a legally restricted context

BACKGROUND

This paper analyzes the strategies used by activist health professionals in Argentina who justify providing abortion despite legal restrictions on the procedure. These "insider activists" make a case for abortion rights by linking pregnancy termination to a woman's ability to exert agency at a key point in her reproductive life, and argue that refusing women access to the procedure constitutes a grievous health risk. This argument frames pregnancy termination as an issue of empowerment and also as a medical necessity.

METHODS

This article is based on ethnographic research conducted in Argentina in 2013 and 2015, which includes in-depth interviews with abortion activists and health professionals and ethnographic observation at activist events and in clinics.

RESULTS

During the period of my field research, the medical staff in one clinic shifted from abortion counseling, based on a harm reduction model, to legal pregnancy termination, a new mode of abortion provision where they directly provided abortions based on the legal health exception. These insider activists formalized the latter approach by creating a diagnostic instrument that frames women's "bio-psycho-social" reasons for wishing to terminate a pregnancy as medically justified.

CONCLUSIONS

The clinical practice analyzed in this article raises important questions about the potential for health professionals to take on an activist role by making safe abortion accessible, even in a context where the procedure is highly restricted.

"My friend who bought it for me, she has had an abortion before." The influence of Ghanaian women's social networks in determining the pathway to induced abortion

BACKGROUND

Even given the liberal abortion law in Ghana, abortion complications are a large contributor to maternal morbidity and mortality. This study sought to understand why young women seeking an abortion in a legally enabling environment chose to do this outside the formal healthcare system.

METHODS

Women being treated for complications arising from a self-induced abortion as well as for elective abortions at three hospitals in Ghana were interviewed. Community-based focus groups were held with women as well as men, separately. Interviews and focus group discussions were conducted until saturation was reached.

RESULTS

A total of 18 women seeking care for complications from a self-induced abortion and 11 seeking care for an elective abortion interviewed. The women ranged in age from 13 to 35 years. There were eight focus groups; two with men and six with women. The reasons women self-induce are: (1) abortion is illegal; (2) attitudes of the healthcare workers; (3) keeping the pregnancy a secret; and (4) social network influence. The meta-theme of normalisation of self-inducing' an abortion was identified.

DISCUSSION

When women are faced with an unplanned and unwanted pregnancy, they consult individuals in their social network whom they know have dealt with a similar situation. Misoprostol is widely available in Ghanaian cities and is successful at inducing an abortion for many women. In this way, self-inducing abortions using medication procured from pharmacists and chemical sellers has become normalised for women in Kumasi, Ghana.

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.

Latin American women's experiences with medical abortion in settings where abortion is legally restricted

Abortion is legally restricted in most of Latin America where 95% of the 4.4 million abortions performed annually are unsafe. Medical abortion (MA) refers to the use of a drug or a combination of drugs to terminate pregnancy. Mifepristone followed by misoprostol is the most effective and recommended regime. In settings where mifepristone is not available, misoprostol alone is used.Medical abortion has radically changed abortion practices worldwide, and particularly in legally restricted contexts. In Latin America women have been using misoprostol for self-induced home abortions for over two decades.This article summarizes the findings of a literature review on women's experiences with medical abortion in Latin American countries where voluntary abortion is illegal.Women's personal experiences with medical abortion are diverse and vary according to context, age, reproductive history, social and educational level, knowledge about medical abortion, and the physical, emotional, and social circumstances linked to the pregnancy. But most importantly, experiences are determined by whether or not women have the chance to access: 1) a medically supervised abortion in a clandestine clinic or 2) complete and accurate information on medical abortion. Other key factors are access to economic resources and emotional support.Women value the safety and effectiveness of MA as well as the privacy that it allows and the possibility of having their partner, a friend or a person of their choice nearby during the process. Women perceive MA as less painful, easier, safer, more practical, less expensive, more natural and less traumatic than other abortion methods. The fact that it is self-induced and that it avoids surgery are also pointed out as advantages. Main disadvantages identified by women are that MA is painful and takes time to complete. Other negatively evaluated aspects have to do with side effects, prolonged bleeding, the possibility that it might not be effective, and the fact that some women eventually need to seek medical care at a hospital where they might be sanctioned for having an abortion and even reported to the police.

The potential of medical abortion to reduce maternal mortality in Africa: what benefits for Tanzania and Ethiopia?

Background

Unsafe abortion is estimated to account for 13% of maternal mortality globally. Medical abortion is a safe alternative.

Methods

By estimating mortality risks for unsafe and medical abortion and childbirth for Tanzania and Ethiopia, we modelled changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion. We selected Ethiopia and Tanzania because of their high maternal mortality ratios (MMRatios) and contrasting situations regarding health care provision and abortion legislation. We focused on misoprostol-only regimens due to the drug's low cost and accessibility. We included the impact of medical abortion on women who would otherwise choose unsafe abortion and on women with unwanted/mistimed pregnancies who would otherwise carry to term.

Results

Thousands of lives could be saved each year in each country by implementing medical abortion using misoprostol (2122 in Tanzania and 2551 in Ethiopia assuming coverage equals family planning services levels: 56% for Tanzania, 31% for Ethiopia). Changes in MMRatios would be less pronounced because the intervention would also affect national birth rates.

Conclusions

This is the first analysis of impact of medical abortion provision which takes into account additional potential users other than those currently using unsafe abortion. Thousands of women's lives could be saved, but this may not be reflected in as substantial changes in MMRatios because of medical abortion's demographic impact. Therefore policy makers must be aware of the inability of some traditional measures of maternal mortality to detect the real benefits offered by such an intervention.

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.

Exploring the costs and economic consequences of unsafe abortion in Mexico City before legalisation

An assessment of abortion outcomes and costs to the health care system in Mexico City was conducted in 2005 at a mix of public and private facilities prior to the legalisation of abortion. Data were obtained from hospital staff, administrative records and patients. Direct cost estimates included personnel, drugs, disposable supplies, and medical equipment for inducing abortion or treating incomplete abortions and other complications. Indirect patient costs for travel, childcare and lost wages were also estimated. The average cost per abortion with dilatation and curettage was 143 US dollars. For manual vacuum aspiration it was 111 US dollars in three public hospitals and 53 US dollars at a private clinic. The average cost of medical abortion with misoprostol alone was 79 US dollars. The average cost of treating severe abortion complications at the public hospitals ranged from 601 US dollars to over 2,100 US dollars. Increasing access to manual vacuum aspiration and early abortion with misoprostol could reduce government costs by 62%, with potential savings of up to 1.6 million US dollars per year. Reducing complications by improving access to safe services in outpatient settings would further reduce the costs of abortion care, with significant benefits both to Mexico's health care system and women seeking abortion. Additional research is needed to explore whether cost savings have been realised post-legalisation.

Reducing maternal mortality due to elective abortion: Potential impact of misoprostol in low-resource settings

Over 99% of deaths due to abortion occur in developing countries. Maternal deaths due to abortion are preventable. Increasing the use of misoprostol for elective abortion could have a notable impact on maternal mortality due to abortion. As a test of this hypothesis, this study estimated the reduction in maternal deaths due to abortion in Africa, Asia and Latin America. The estimates were adjusted to changes in assumptions, yielding different possible scenarios of low and high estimates. This simple modeling exercise demonstrated that increased use of misoprostol, an option for pregnancy termination already available to many women in developing countries, could significantly reduce mortality due to abortion. Empirical testing of the hypothesis with data collected from developing countries could help to inform and improve the use of misoprostol in those settings.

Pharmacy provision of medical abortifacients in a Latin American city

PURPOSE

Access to legal abortion services is restricted in Latin America. Nonetheless, previous research suggest that women frequently use misoprostol to self-induce abortion. In many settings, women obtain the medication from a pharmacy. This study was conducted to better understand pharmacy staff knowledge and provision practices of misoprostol and other medical abortifacients.

METHODS

We first interviewed staff at a random sample of 102 pharmacies in a Latin American city. Mystery clients were subsequently sent to the same pharmacies to ascertain prescribing practices and counseling.

RESULTS

Nearly half of the pharmacy staff interviewed reported that they were familiar with at least one abortifacient, and an abortifacient was recommended in 74% of the mystery client encounters. Hormonal injections were most frequently recommended as abortifacients in the survey (67%) and the mystery client encounters (71%), followed by misoprostol (60% and 39%, respectively). Few of the pharmacy staff (6% in the survey and 17% in the mystery client encounters) recommended a misoprostol dosing regimen that is potentially effective.

CONCLUSION

Abortifacient provision is common at pharmacies but knowledge about medications is low among pharmacy staff.

Providing medication abortion information to diverse communities: use patterns of a multilingual web site

OBJECTIVE

This study analyzes the use patterns of , an English-, Spanish-, Arabic- and French-language web site dedicated to three methods of early pregnancy termination: mifepristone/misoprostol, methotrexate/misoprostol and misoprostol alone.

METHODS

This study examines both the overall and language-specific use patterns of the web site from October 1, 2004, through September 30, 2005. Data were recorded using Wusage 8.0, a web site statistics program.

RESULTS

Over the 12-month study period, received more than 78,000 visits and nearly 240,000 page requests. The English version is the most popular version of the web site (accessed in 46.1% of all visits), followed by the Spanish (35.0%), Arabic (10.4%) and French (8.8%) versions. Spanish-language visits are nearly three times as likely to access the misoprostol-only section of the web site when compared with the other language versions (p<.001).

CONCLUSION

This study confirms that multilingual, medically accurate online resources have the potential to expand information about medication abortion to both providers and women considering the option of abortion in diverse communities. Analysis of the language-specific use patterns highlights the different priorities of various types of web site visitors and suggests future priorities for educational outreach, collaboration and research.

Reaching women with instructions on misoprostol use in a Latin American country

In Latin America, where restrictive laws limit women's access to safe abortion services, misoprostol is being used to induce abortions, often without correct information on dosage or regimens. This study in an unnamed Latin American country aimed to identify appropriate channels through which instructions on misoprostol use could be disseminated to women. In-depth interviews were carried out with physicians, pharmacy staff, women who had had safe abortions and women from the community, as well as focus group discussions with advocates of safe abortion. Participants considered physicians to be the most appropriate source of information and for ensuring confidentiality for both women and provider. Participants considered midwives, pharmacists and women's groups as appropriate referral points, but not providers of information. Legal restrictions and professional risk were the primary reasons why pharmacists rejected this role, though many are selling misoprostol. There was a general lack of information about misoprostol for medical abortion among both health professionals and women. Accurate information about misoprostol use for a wide range of gynaecologic and obstetric purposes, including induced abortion, could be incorporated into training and educational materials for physicians, midwives and other appropriate mid-level providers, as well as pharmacists. Without these alternative information channels, access to information would be severely restricted, especially in rural areas.

Women's Perspectives on Medical Abortion in Mexico, Colombia, Ecuador and Peru: A Qualitative Study

In Latin America, where abortion is almost universally legally restricted, medical abortion, especially with misoprostol alone, is increasingly being used, often with the tablets obtained from a pharmacy. We carried out in-depth interviews with 49 women who had had a medical abortion under clinical supervision in rural and urban settings in Mexico, Colombia, Ecuador and Peru, who were recruited through clinicians providing abortions. The women often chose medical abortion to avoid a surgical abortion; they thought medical abortion was less painful, easier or simpler, safer or less risky. They commonly described it as a natural process of regulating their period. The fact that it was less expensive also influenced their decision. Some, who experienced a lot of pain, heavy bleeding or a failed procedure requiring surgical back-up, tended to be more negative about it. Regardless of legal restrictions, medical abortion was being provided safely in these settings and women found the method acceptable. Where feasible, it should be made available but cost should not have to be women's primary reason for choosing it. Psychosocial support during abortion is critical, especially for those who are more vulnerable because they see abortion as a sin, who are young or poor, who have limited knowledge about their bodies, whose partners are not supportive or who became pregnant through sexual violence.