The acceptability of home medical abortion to women in UK settings

Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review

OBJECTIVE

To inform UK service development to support medical abortion at home, appropriate for person and context.

DESIGN

Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion.

INTERVENTIONS

Interventions and new models of abortion care relevant to the UK.

OUTCOME MEASURES

Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory.

RESULTS

We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception.

CONCLUSIONS

Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.

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.

Pain during medical abortion, the impact of the regimen: a neglected issue? A review

OBJECTIVES

To evaluate pain and other early adverse events associated with different regimens of medical abortion up to nine weeks of amenorrhoea.

METHODS

The literature was searched for comparative studies of medical abortion using mifepristone followed by the prostaglandin analogue misoprostol. Publications, which included pain assessment were further analysed.

RESULTS

Of the 1459 publications on medical abortion identified, only 23 comparative, prospective trials corresponded to the inclusion criteria. Patients in these studies received different dosages of mifepristone in combination with different dosages of misoprostol administered via diverse routes or at various intervals. Information on pain level was reported in 12/23 papers (52%), information regarding systematic administration of analgesics in 12/23 articles (52%) and information concerning analgesia used was available for only 10/23 studies (43%).

CONCLUSIONS

Neither pain nor its treatment are systematically reported in clinical trials of medical abortion; this shortcoming reflects a neglect of the individual pain perception. When data are mentioned, they are too inconsistent to allow for any comparison between different treatment protocols. Standardised evaluation of pain is needed and the correlation between the dosage of misoprostol and the intensity of pain must be assessed in future studies.

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

BACKGROUND

Knowledge on factors affecting acceptability of medical abortion with mifepristone followed by home administration of misoprostol is scarce. The objective of this study was therefore to assess factors affecting acceptability and experience of home use of misoprostol for medical abortion up to 63 days' gestation.

STUDY DESIGN

Prospective observational study with acceptability assessed through questionnaires. Factors affecting acceptability were analyzed using multivariate logistic regression.

RESULTS

A total of 395 women were included. Independent factors for acceptability were having a partner/friend present and having a positive low-sensitivity urine hCG at follow-up, although most of these patients had successful abortions. Age, gestational length and requirement of extra pain medication did not affect acceptability.

CONCLUSION

Home administration of misoprostol is highly acceptable. Increasing the number of complete abortions should be a focus of future research. Women should be encouraged to have a partner/friend present during home administration of misoprostol.

Service provision for women undergoing termination of pregnancy: progress in Wales, UK

BACKGROUND

This audit established a recent picture of termination of pregnancy services in Wales, UK using the Royal College of Obstetricians and Gynaecologists' Guidelines as a baseline. The context of abortion is rapidly changing and services need to be adaptable to meet women's needs.

METHODS

A questionnaire survey was sent to all National Health Service (NHS) Trusts in Wales; 10 out of 13 responded.

RESULTS

In the nine Trusts performing abortions in Wales, medical abortions accounted for 57% and surgical abortions for 43%. Doctors in training were involved in six Trusts. All but one Trust complied with referral times. Five Trusts provided a dedicated clinic. Written information provided prior to abortion varied in accessibility and quality. Choice of abortion within gestation bands was limited in some Trusts with some only providing medical termination. Essential abortion aftercare was performed by Trusts, whereas follow-up and counselling were less comprehensive.

DISCUSSION

Trusts are willing to adapt to new methods of working with an increasing number of medical terminations, although this advantage was offset by a lack of choice of abortion methods offered by some Trusts. Doctors in training should be offered exposure to abortion procedures in all Trusts as this has been shown elsewhere to improve attitudes. Providing dedicated abortion clinics, quality written information and comprehensive abortion aftercare should improve compliance with the guidelines.

CONCLUSION

Overall, in Wales there is compliance with national guidelines, although for a number of the guideline recommendations there remains room for improvement.

Care closer to home

In 2008, in total there were 202 158 abortions performed in England and Wales and 13 817 in Scotland, unfortunately one of the most common gynaecological procedures. 'Care closer to home' applied to this service, as part of a holistic integrated care pathway, can improve access and choice and reduce cost whilst continuing to focus on clinical quality and safety and work towards reducing the number of primary and repeat abortions. Whilst constraints remain within Law, there are ways to change services to help reduce barriers to access not just to abortion but also the essential allied interventions of contraception, sexual health and counselling and support. The first will be reflected in the number of women able to have their abortions earlier, therefore more safely and at lesser cost. It would build on service changes to date, which has allowed women more choice of the method of abortion. The integration of contraceptive services should impact positively on the currently high level of repeat abortions. Bringing care closer to home, into the communities within which women spend their lives, is an important strategy in addressing the quality agenda in abortion care.

Supporting the significant other in women undergoing abortion

Abortion remains an ethical, legal and professional challenge to nurses. In the last decade there have been many innovations in abortion care and nurses have developed woman-centred, responsive services. Despite this progress, the needs of significant others - particularly partners attending with women - have yet to be fully met. A significant other is encouraged to stay with the woman during certain parts of the procedure if it is a surgical abortion, or may remain with the woman continuously during a medical abortion. There are benefits in encouraging significant others to stay with the woman, including the provision of additional support during the procedure as well as health promotion opportunities. The nurse has a vital function in assisting them in their role, as it is essential that significant others are adequately prepared and supported throughout. Providing they are managed proactively, involving significant others in supporting the woman undergoing abortion is commended.

A review of developments in medical termination of pregnancy

AIM

This literature review aims to supplement guidelines by providing an overview of recent evidence relevant to medical termination of pregnancy.

BACKGROUND

Termination of pregnancy is available to women in the UK within legal parameters. Although guidelines form a strong body of evidence on which nurses and midwives can base their practice, there is a need to supplement them with up-to-date robust research findings.

METHOD

A systematic search of the literature with high sensitivity and low specificity was undertaken on five databases using medical subject headings (MeSH) terms including (medical) induced abortion, therapeutic abortion and termination of pregnancy.

RESULTS

The literature search revealed articles under the following headings: The importance of choice for the women involved the need for the optimal medication type, dose, route and interval between stages one and two, and the optimum place for medical termination to take place.

CONCLUSION

It was found that women attach a great deal of importance to the opportunity to choose their method of termination. The first stage of mifepristone is now a standard practice and an optimum dose has been determined. Several studies examined misoprostol used in the second stage of medical termination. There was some evidence for repeated doses of misoprostol, particularly in later gestation, with conflicting evidence on the optimal route. There were some grounds for reducing the interval between stages. Consideration should be given to home medical termination based on individual circumstances and choice. Gestation and previous obstetric history is an important factor to take into account when determining optimal regimen. Relevance to clinical practice. The number of medical termination of pregnancies performed has risen in recent years together with the nurses' involvement. As new research is published, it is imperative that nurses adapt to base their involvement on the best available evidence.

Collaboration with the voluntary sector in setting up an early medical abortion service in the PCT

The 1967 Abortion Act and the 1990 Human Fertilisation and Embryology Act amendment allow abortions in acute hospitals or licensed premises only. Provision of abortions in community unlicensed premises is unlicensed and not legal. At abortion assessment, counselling, chlamydia testing and/or treatment/partner notification and a contraceptive package is included. This works towards the overall aim of reducing unwanted pregnancies and reducing the burden of sexually transmitted infections in the community, thus removing the silo approach to abortion. A 92% completed abortion outcome was achieved. Route of administration of misoprostol will be reconsidered. Efficacy could be improved by vaginal administration. The findings support the introduction of an early medical abortion service in collaboration with a partner organisation. Our experience provides useful preliminary data for others contemplating a similar service, with room for improvement.

Review of medical abortion using mifepristone in combination with a prostaglandin analogue

Induced abortion is still a major health problem in the world and the most frequently performed intervention in obstetrics and gynecology with an estimated total of 46 million worldwide each year. Medical abortion with mifepristone and prostaglandin was first introduced in 1988 and is now approved in 31 countries. This combination of drugs has recently been included in the List of Essential Medicines by the World Health Organisation. The present review summarizes the development, physiology and the development of the currently used regimens.

Medical abortion: issues of choice and acceptability

Although more than one method of abortion has been available for many years, in most countries the provider chooses the method and may be skilled in one method only. This paper discusses choice and acceptability of medical abortion from the perspective of both women and abortion providers and argues that choice of method is important for both. Safety, efficacy, number of visits, how the method works, how long it takes for the abortion to be complete and cost all affect acceptability. Medical abortion is considered more natural because it happens in women's own bodies and can take place at home before nine weeks of pregnancy; surgical abortion with vacuum aspiration is simple and over quickly. Unless the costs of both methods are similar, however, women and providers will tend towards whichever is the cheaper option, limiting choice. Medical abortion is effective from when a woman misses her period through 24 weeks of pregnancy, and more women and providers need to be made aware of this. In legally restricted situations, complications tend to be less serious and easier to treat with early medical abortion than after unsafe invasive methods. Ideally, both medical and surgical methods should be available, but each can be provided without the other.

Home self-administration of misoprostol for medical abortion up to 56 days' gestation

OBJECTIVE

Studies from the USA have suggested the feasibility and acceptability of home medical abortion, however the issue has not been addressed in the UK. This study aimed to assess the feasibility, efficacy and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation.

METHODS

Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 600 microg and advised to take them sublingually 36-48 hours later. The main outcome measures were (1) feasibility, assessed through successful completion of abortion at home without the need for hospital admission, (2) efficacy, assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure as assessed by questionnaire.

RESULTS

A total of 49 women participated in this study. Of these, 48 women aborted at home while one opted to be admitted to hospital after receiving misoprostol at home. One woman underwent surgical evacuation 5 weeks following abortion for excessive bleeding and retained products of conception. A total of 43/44 (98%) women were satisfied with having the abortion at home. Side effects experienced by women included nausea [32/40 (80%], vomiting [17/41 (42%)], diarrhoea [17/41 (42%)], shivering [26/40 (65%)], tiredness [32/40 (80%)], headache [12/39 (31%)], hot flushes [14/40 (35%)], dizziness [24/39 (62%)] and unpleasant mouth taste [19/38 (50%)].

CONCLUSIONS

This study suggests the feasibility and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. These findings need to be assessed in the context of a randomised trial.