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

Self-management of first trimester medical termination of pregnancy: a qualitative study of women's experiences

OBJECTIVE

To explore the experiences of women in Scotland who return home to complete medical termination of pregnancy (TOP) ≤63 days of gestation, after being administered with mifepristone and misoprostol at an NHS TOP clinic.

DESIGN

Qualitative interview study.

SETTING

One National Health Service health board (administrative) area in Scotland.

POPULATION OR SAMPLE

Women in Scotland who had undergone medical TOP ≤63 days, and self-managed passing the pregnancy at home; recruited from three clinics in one NHS health board area between January and July 2014.

METHODS

In-depth, semi-structured interviews with 44 women in Scotland who had recently undergone TOP ≤63 days of gestation, and who returned home to pass the pregnancy. Data were analysed thematically using an approach informed by the Framework method.

MAIN OUTCOME MEASURES

Women's experiences of self-management of TOP ≤63 days of gestation.

RESULTS

Key themes emerging from the analysis related to self-administration of misoprostol in clinic; reasons for choosing home self-management; facilitation of self-management and expectation-setting; experiences of getting home; self-managing and monitoring treatment progress; support for self-management (in person and remotely); and pregnancy self-testing to confirm completion.

CONCLUSIONS

Participants primarily found self-administration of misoprostol and home self-management to be acceptable and/or preferable, particularly where this was experienced as a decision made jointly with health professionals. The way in which home self-management is presented to women at clinic requires ongoing attention. Women could benefit from the option of home administration of misoprostol.

TWEETABLE ABSTRACT

Women undergoing medical TOP 63 days found home self-management to be acceptable and/or preferable.

Medical abortion with mifepristone and home administration of misoprostol up to 63 days' gestation

OBJECTIVE

To evaluate the acceptability and efficacy of medical abortion at home up to 63 days' gestation without limits on travel distance to a registered institution.

DESIGN

Observational prospective study.

SETTING

Haukeland University Hospital between May 2006 and May 2009.

POPULATION

A total of 1018 women requesting abortion before 63 days' gestation who chose medical termination with mifepristone and home administration of misoprostol.

METHODS

The women took 200 mg mifepristone under nurse supervision and self-administered 800 μg misoprostol vaginally 36-48 h later at home. All were contacted by phone for follow-up and assessment of bleeding, pain and acceptability.

MAIN OUTCOME MEASURES

Evacuation rate, pain, bleeding, acceptability, influence of distance on treatment.

RESULTS

Median gestational age was 50 (range 35-63) days and 70 (7.1%) of the women lived more than 60 min travel from the clinic. The rate of completed abortion was 93.6% and surgical evacuation was performed in 50 (4.9%) cases. Two women requested treatment on the day of misoprostol use. Moderate to strong pain was experienced by 68.4%, and 74.7% reported moderate to heavy bleeding. Parous women experienced less pain than nulliparous women (odds ratio 0.27; 95% confidence interval 0.19-0.34). In all, 95.1% of the women were satisfied with staying at home. Travel distance did not influence treatment outcome variables.

CONCLUSIONS

In our experience, home administration of misoprostol is an effective and acceptable method for abortion up to 63 days of gestation and women should be eligible for this treatment option regardless of their travel distance from hospital.

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.

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.

Setting up an outpatient service for early medical termination

OBJECTIVES

In parts of the UK, demand for termination of pregnancy exceeds local availability on the National Health Service. The study objective was to report on setting up and running a new outpatient service for early medical termination under 7 weeks' gestation. Methods We describe the process of setting up the clinic within the confines of the Abortion Act 1967, the training of staff, acquisition of resources, cost analysis and negotiations with the Primary Care Trust. We report on running the service in the first 12 months, difficulties encountered and how these have been overcome. Our experience is compared with the limited published data available.

RESULTS

Of 171 patients referred in the first year, 148 were offered an appointment and 100 women completed outpatient treatment for medical termination under 7 weeks' gestation. 90% of patients attended follow-up at 2 weeks and the remainder were contacted by telephone. Clinical outcomes were similar to those reported in the literature apart from initially higher numbers of women undergoing evacuation of retained products of conception. The estimated cost per case in the first year was 156 pounds , which represented a considerable cost saving compared to 498 pounds for surgical termination and 423 pounds for inpatient medical termination.

CONCLUSIONS

Our service is successful, viable for the future and has acceptably good patient outcomes, which are improving all the time.