Nurse versus physician-provision of early medical abortion in Mexico: a randomized controlled non-inferiority trial

Brief of over 300 reproductive health researchers as Amici Curiae in FDA v. Alliance for Hippocratic Medicine

On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case that could have severely impacted access to mifepristone, one of the two drugs commonly used in medication abortion. The researchers summarize the legal challenges to the US Food and Drug Administration's (FDA's) original approval of mifepristone in 2000 and its 2016 and 2021 decisions modifying mifepristone's Risk Evaluation and Mitigation Strategy (REMS) Program and label, the responses from the FDA and drug manufacturer to the challenges, and the potential implications of the Court's decision on access to mifepristone in the US. The researchers detail how the FDA relied on a robust scientific record analyzing tens of thousands of patient experiences that conclusively demonstrated the safety and effectiveness of the changes to the mifepristone REMS Program and label and urge the Supreme Court to rely on the clear scientific record and preserve access to mifepristone without reimposing restrictions. What follows is a reprint of this brief.

Multicountry research on comprehensive abortion policy implementation in Latin America: a mixed-methods study protocol

INTRODUCTION

Access to comprehensive abortion care could prevent the death of between 13 865 and 38 940 women and the associated morbidity of 5 million women worldwide. There have been some important improvements in Latin America in terms of laws and policies on abortion. However, the predominant environment is still restrictive, and many women, adolescents and girls still face multiple barriers to exercise their reproductive rights. This research will systematically assess comprehensive abortion policies in five Latin American countries (Argentina, Colombia, Honduras, Mexico and Uruguay). The aim is to identify barriers, facilitators and strategies to the implementation of abortion policies, looking at four key dimensions-regulatory framework, abortion policy dynamics, abortion service delivery and health system and health outcomes indicators-to draw cross-cutting lessons learnt to improve current implementation and inform future safe abortion policy development.

METHODS AND ANALYSIS

A mixed-method design will be used in the five countries to address the four dimensions through the Availability, Accessibility, Acceptability and Quality of Care model. The data collection tools include desk reviews and semi-structured interviews with key actors. Analysis will be performed using thematic analysis and stakeholder analysis. A regional synthesis exercise will be conducted to draw lessons on barriers, facilitators and the strategies.

ETHICS AND DISSEMINATION

The project has been approved by the WHO Research Ethics Review Committee (ID: A66023) and by the local research ethics committees. Informed consent will be obtained from participants. Data will be treated with careful attention to protecting privacy and confidentiality. Findings from the study will be disseminated through a multipurpose strategy to target diverse audiences to foster the use of the study findings to inform the public debate agenda and policy implementation at national level. The strategy will include academic, advocacy and policy arenas and actors, including peer-reviewed publication and national and regional dissemination workshops.

The global impact of COVID-19 on abortion care

Background

The COVID-19 pandemic placed unprecedented strain on healthcare globally, which exacerbated factors leading to unplanned pregnancies.

Objectives

The primary objective was to analyze the effect of COVID-19 on abortion services globally. Secondary objectives were to discuss issues regarding access to safe abortion and provide recommendations on continued access during pandemics.

Search strategy

A search for relevant articles was conducted by utilizing multiple databases (PubMed, Cochrane, etc.).

Selection criteria

Studies on COVID-19 and abortion were included.

Data collection & analysis

The legislation governing abortion services across the globe was examined, inclusive of modifications to service provision during the pandemic. Global data on abortion rates and analyses of selected articles were also included.

Main results

14 countries instituted legislative changes related to the pandemic, 11 relaxed abortion regulations, while three restricted abortion access. An increase in abortion rates was seen particularly where telemedicine was available. Where abortions were postponed, second-trimester abortions increased after services resumed.

Conclusions

Legislation, risk of exposure to infection, and access to telemedicine affect access to abortion. The use of novel technologies, maintaining existing infrastructure and enhancing the roles of trained manpower for safe abortion access is recommended to avoid the marginalization of women's health and reproductive rights.

Medical abortion drug dispensing practices among private pharmacy workers in Nepal: A mystery client study

BACKGROUND

Pharmacies are the first point of contact for women seeking medical abortion (MA) and act as important sources of information and referral in Nepal. Over the counter sale of MA drugs is not currently allowed in Nepal. This study aimed to assess the MA drug dispensing practices of pharmacy workers using mystery clients in Nepal.

METHODS

A cross-sectional study using the mystery client approach was conducted in 266 pharmacies in September-October 2019. These pharmacies had either received harm reduction training or medical detailing visits. A total of 532 visits were conducted by six male and six female mystery clients. Mystery clients without prescription approached the sample pharmacy and filled out a standard digital survey questionnaire using the SurveyCTO application immediately after each interaction.

RESULTS

Pharmacy workers dispensed MA drugs in 35.7% of the visits while they refused to provide MA drugs to the mystery clients in 39.3% of visits. Lack of evidence of prior consultation with a physician (27.5%), referral to other health facilities (21.8%), unavailability of MA drugs in the pharmacy (21.3%) and lack of prescription (16.4%) were the main reasons for refusal. Seventy percent of the pharmacy workers inquired clients about last menstrual period/months of pregnancy while 38.1% asked whether the pregnancy status was confirmed. During 65.1% of the visits, mystery clients were told about when to take the MA drugs while in 66.4% of visits, they were told about the route of drug administration. Similarly, mystery clients were briefed about what to expect during the abortion process in half of the visits, and information about the possible side effects of the MA drug was provided in 55.9% of the visits. Pharmacy workers provided correct information on taking MA drugs to mystery clients in 70.7% of visits.

CONCLUSION

Despite legal provision of sale of MA drugs only on prescription, pharmacy workers dispensed MA drug in one out of three visits. As pharmacies are the initial contacts of women for abortion services in Nepal, correct supplementary information through pharmacy workers can be an effective strategy to expand access to quality safe abortion services.

Abortion Legalization in Uruguay: Effects on Adolescent Fertility

The Latin American and Caribbean adolescent fertility rates are among the highest in the world: about 1.7 million children are born to teen mothers every year, and most of them are declared unintended pregnancies. The region also has the highest rate of unintended pregnancy of any world region, and nearly half of such pregnancies end in abortion. However, fewer than 18 percent of the region's women live in countries where abortion is broadly legal. This paper estimates the causal effect of abortion legalization on adolescent fertility in Uruguay using official data on legal abortions provided after the 2012 reform. We employed a difference-in-differences strategy, classifying states by whether they are responsive or unresponsive to the reform. The results suggest that abortion reform had a negative impact on the adolescent birth rate by 2.5-2.8 births per thousand adolescents aged 15-19 (a 4 percent decrease from the preintervention average). Additionally, we exploited variation in reform implementation intensity through the estimation of fixed-effect linear regression models and found consistent results. Our findings are robust to controlling for a concurrent large-scale program of contraceptive implants. We conclude that legislation aimed at enhancing rights and reducing avoidable deaths and complications from unsafe abortions may also have spillover effects that help reduce adolescent fertility.

Medical methods for first trimester abortion

BACKGROUND

Medical abortion became an alternative method of pregnancy termination following the development of prostaglandins and antiprogesterone in the 1970s and 1980s. Recently, synthesis inhibitors of oestrogen (such as letrozole) have also been used to enhance efficacy. The most widely researched drugs are prostaglandins (such as misoprostol, which has a strong uterotonic effect), mifepristone, mifepristone with prostaglandins, and letrozole with prostaglandins. More evidence is needed to identify the best dosage, regimen, and route of administration to optimise patient outcomes. This is an update of a review last published in 2011.

OBJECTIVES

To compare the effectiveness and side effects of different medical methods for first trimester abortion.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Global Health, and LILACs on 28 February 2021. We also searched Clinicaltrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform, and reference lists of retrieved papers.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that compared different medical methods for abortion before the 12th week of gestation. The primary outcome is failure to achieve complete abortion. Secondary outcomes are mortality, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the method.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and evaluated studies for inclusion, and assessed the risk of bias. We processed data using Review Manager 5 software. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 99 studies in the review (58 from the original review and 41 new studies). 1. Combined regimen mifepristone/prostaglandin Mifepristone dose: high-dose (600 mg) compared to low-dose (200 mg) mifepristone probably has similar effectiveness in achieving complete abortion (RR 1.07, 95% CI 0.87 to 1.33; I2 = 0%; 4 RCTs, 3494 women; moderate-certainty evidence). Prostaglandin dose: 800 µg misoprostol probably reduces abortion failure compared to 400 µg (RR 0.63, 95% CI 0.51 to 0.78; I2= 0%; 3 RCTs, 4424 women; moderate-certainty evidence). Prostaglandin timing: misoprostol administered on day one probably achieves more success on complete abortion than on day three (RR 1.94, 95% CI 1.05 to 3.58; 1489 women; 1 RCT; moderate-certainty evidence). Administration strategy: there may be no difference in failure of complete abortion with self-administration at home compared with hospital administration (RR 1.63, 95% CI 0.68 to 3.94; I2 = 84%; 2263 women; 4 RCTs; low-certainty evidence), but failure may be higher when administered by nurses in hospital compared to by doctors in hospital (RR 2.69, 95% CI 1.39 to 5.22; I2 = 66%; 3 RCTs, 3056 women; low-certainty evidence). Administration route: oral misoprostol probably leads to more failures than the vaginal route (RR 2.38, 95% CI 1.46 to 3.87; I2 = 39%; 3 RCTs, 1704 women; moderate-certainty evidence) and may be associated with more frequent side effects such as nausea (RR 1.14, 95% CI 1.03 to 1.26; I2 = 0%; 2 RCTs, 1380 women; low-certainty evidence) and diarrhoea (RR 1.80 95% CI 1.49 to 2.17; I2 = 0%; 2 RCTs, 1379 women). Compared with the vaginal route, complete abortion failure is probably lower with sublingual (RR 0.68, 95% CI 0.22 to 2.11; I2 = 59%; 2 RCTs, 3229 women; moderate-certainty evidence) and may be lower with buccal administration (RR 0.71, 95% CI 0.34 to 1.46; I2 = 0%; 2 RCTs, 479 women; low-certainty evidence), but sublingual or buccal routes may lead to more side effects. Women may experience more vomiting with sublingual compared to buccal administration (RR 1.33, 95% CI 1.01 to 1.77; low-certainty evidence). 2. Mifepristone alone versus combined regimen The efficacy of mifepristone alone in achieving complete abortion compared to combined mifepristone/prostaglandin up to 12 weeks is unclear (RR of failure 3.25, 95% CI 0.81 to 13.09; I2 = 83%; 3 RCTs, 273 women; very low-certainty evidence). 3. Prostaglandin alone versus combined regimen Nineteen studies compared prostaglandin alone to a combined regimen (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate). Compared to any of the combination regimens, misoprostol alone may increase the risk for failure to achieve complete abortion (RR of failure 2.39, 95% CI 1.89 to 3.02; I2 = 64%; 18 RCTs, 3471 women; low-certainty evidence), and with more diarrhoea. 4. Prostaglandin alone (route of administration) Oral misoprostol alone may lead to more failures in complete abortion than the vaginal route (RR 3.68, 95% CI 1.56 to 8.71, 2 RCTs, 216 women; low-certainty evidence). Failure to achieve complete abortion may be slightly reduced with sublingual compared with vaginal (RR 0.69, 95% CI 0.37 to 1.28; I2 = 87%; 5 RCTs, 2705 women; low-certainty evidence) and oral administration (RR 0.58, 95% CI 0.11 to 2.99; I2 = 66%; 2 RCTs, 173 women). Failure to achieve complete abortion may be similar or slightly higher with sublingual administration compared to buccal administration (RR 1.11, 95% CI 0.71 to 1.74; 1 study, 401 women).

AUTHORS' CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate) may be more effective than single agents (prostaglandin alone or mifepristone alone). In the combined regimen, the dose of mifepristone can probably be lowered to 200 mg without significantly decreasing effectiveness. Vaginal misoprostol is probably more effective than oral administration, and may have fewer side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all studies were conducted in settings with good access to emergency services, which may limit the generalisability of these results.

Peri-abortion contraceptive counseling: A systematic review of randomized controlled trials

Objective

To assess the effects of peri-abortion contraceptive counseling interventions.

Methods

We performed a systematic review of randomized controlled trials (RCTs) that compared the effect of different types of peri-abortion contraceptive counseling interventions and were published as original papers in scientific journals. The literature search was performed in June 2021 in PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar; without restrictions in language or publication date. Two independent authors identified studies that met the inclusion and exclusion criteria and extracted the data. The risk of bias was assessed using the Cochrane tool, and evidence certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Whenever possible, meta-analyses were performed. The protocol was registered at PROSPERO (CRD42020187354).

Results

Eleven RCTs were eligible for inclusion (published from 2004 to 2017), from which nine compared enhanced versus standard counseling. Pooled estimates showed that, compared to standard counseling, enhanced counseling was associated with a higher incidence of effective contraceptive use (>3 months) (relative risk [RR], 1.12; 95% confidence interval [CI], 1.09–1.16), although no significant difference was found in the incidence of long-acting reversible contraceptive use (RR, 1.25; 95% CI, 0.68–2.29), contraceptive uptake (RR, 1.06; 95% CI, 0.98–1.15), and obstetric event occurrence (RR, 0.91; 95% CI, 0.57–1.47). Certainty of evidence was very low for all outcomes. In addition, two studies compared contraceptive counseling provided by physicians versus that provided by non-physicians, which did not show significant differences.

Conclusions

Enhanced contraceptive counseling may favor effective contraceptive use but may not affect the rate of obstetric event occurrence. Also, the studies did not find a difference in the effects of counseling interventions given by different providers. Since evidence certainty was very low, future well-designed RCTs are needed to make informed decisions.

Registration

The study protocol was registered at PROSPERO (CRD42020187354).

Medical abortion offered in pharmacy versus clinic-based settings

BACKGROUND

Medical abortion is usually offered in a clinic or hospital, but could potentially be offered in other settings such as pharmacies. In many countries, pharmacies are a common first point of access for women seeking reproductive health information and services. Offering medical abortion through pharmacies is a potential strategy to improve access to abortion.

OBJECTIVES

To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, two trials registries and grey literature websites in November 2020. We also handsearched key references and contacted authors to locate unpublished studies or studies not identified in the database searches.

SELECTION CRITERIA

We identified studies that compared women receiving the same regimen of medical abortion or post-abortion care in either a clinic or pharmacy setting. Studies published in any language employing the following designs were included: randomized trials and non-randomized studies including a comparative group.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed both retrieved abstracts and full-text publications. A third author was consulted in case of disagreement. We intended to use the Cochrane risk of bias tool, RoB 2, for randomized studies and used the ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions) to assess risk of bias in non-randomized studies. GRADE methodology was used to assess the certainty of the evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion.

MAIN RESULTS

Our search yielded 2030 records. We assessed a total of 89 full-text articles for eligibility. One prospective cohort study met our inclusion criteria. The included study collected data on outcomes from 605 women who obtained a medical abortion in Nepal from either a clinic or pharmacy setting. Both sites of care were staffed by the same auxiliary nurse midwives. Over all domains, the risk of bias was judged to be low for our primary outcome. During the pre-intervention period, the study's investigators identified a priori appropriate confounders, which were clearly measured and adjusted for in the final analysis. For women who received medical abortion in a pharmacy setting, compared to a clinic setting, there may be little or no difference in complete abortion rates (adjusted risk difference (RD)) 1.5, 95% confidence interval (CI) -0.8 to 3.8; 1 study, 600 participants; low certainty evidence). The study reported no cases of blood transfusion, and a composite outcome, comprised mainly of infection complications, showed there may be little or no difference between settings (adjusted RD 0.8, 95% CI -1.0 to 2.8; 1 study, 600 participants; very low certainty evidence). The study reported no events for hospital admission for an abortion-related event or need for surgical intervention, and there may be no difference in women reporting being highly satisfied with the facility where they were seen (38% pharmacy versus 34% clinic, P = 0.87; 1 study, 600 participants; low certainty evidence).

AUTHORS' CONCLUSIONS

Conclusions about the effectiveness and safety of pharmacy provision of medical abortion are limited by the lack of comparative studies. One study, judged to provide low certainty evidence, suggests that the effectiveness of medical abortion may not be different between the pharmacy and clinic settings. However, evidence for safety is insufficient to draw any conclusions, and more research on factors contributing to potential differences in quality of care is needed. It is important to note that this study included a care model where a clinician provided services in a pharmacy, not direct provision of care by pharmacists or pharmacy staff. Three ongoing studies are potentially eligible for inclusion in review updates. More research is needed because pharmacy provision could expand timely access to medical abortion, especially in settings where clinic services may be more difficult to obtain. Evidence is particularly limited on the patient experience and how the care process and quality of services may differ across different types of settings.

Access to and sustainability of abortion services: a systematic review and meta-analysis for the National Institute of Health and Care Excellence-new clinical guidelines for England

BACKGROUND

Induced abortion is a common procedure. However, there is marked variation in accessibility of services across England. Accessing abortion services may be difficult, particularly for women who live in remote areas, are in the second trimester of pregnancy, have complex pre-existing conditions or have difficult social circumstances.

OBJECTIVE AND RATIONALE

This article presents a two-part review undertaken for a new National Institute of Health and Care Excellence guideline on abortion care, and aiming to determine: the factors that help or hinder accessibility and sustainability of abortion services in England (qualitative review), and strategies that improve these factors, and/or other factors identified by stakeholders (quantitative review). Economic modelling was undertaken to estimate cost savings associated with reducing waiting times.

SEARCH METHODS

Ovid Embase Classic and Embase, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), PsycINFO, Cochrane Library via Wiley Online, Cinahl Plus and Web of Science Core Collection were searched for articles published up to November 2018. Studies were included if they were published in English after 2001, conducted in Organization for Economic Co-operation and Development (OECD) countries and were: qualitative studies reporting views of patients and/or staff on factors that help or hinder the accessibility and sustainability of a safe abortion service, or randomized or non-randomized studies that compared strategies to improve factors identified by the qualitative review and/or stakeholders. Studies were excluded if they were conducted in OECD countries where abortion is prohibited altogether or only performed to save the woman's life. One author assessed risk of bias of included studies using the following checklists: Critical Appraisal Skills Programme checklist for qualitative studies, Cochrane Collaboration quality checklist for randomized controlled trials, Newcastle-Ottawa scale for cohort studies, and Effective Practice and Organization of Care risk of bias tool for before-and-after studies.Qualitative evidence was combined using thematic analysis and overall quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual). Quantitative evidence was analysed in Review Manager 5.3 and overall quality of evidence was assessed using GRADE.

OUTCOMES

Eight themes (service level barriers; financial barriers; logistical barriers; personal barriers; legal and policy barriers; privacy and confidentiality concerns; training and education; community prescribing and telemedicine introduce greater flexibility) and 18 subthemes were identified from 23 papers (n = 1016) included in the qualitative review. The quality of evidence ranged from very low to high, with evidence for one theme and seven subthemes rated as high quality. Nine studies (n = 7061) were included in the quantitative review which showed that satisfaction was better (low to high quality evidence) and women were seen sooner (very low quality evidence) when care was led by nurses or midwives compared with physician-led services, women were seen sooner when they could self-refer (very low quality evidence), and clinicians were more likely to provide abortions if training used an opt-out model (very low quality evidence). Economic modelling showed that even small reductions in waiting times could result in large cost savings for services.

WIDER IMPLICATIONS

Self-referral, funding for travel and accommodation, reducing waiting times, remote assessment, community services, maximizing the role of nurses and midwives and including practical experience of performing abortion in core curriculums, unless the trainee opts out, should improve access to and sustainability of abortion services.

Medical management of induced and incomplete first-trimester abortion by non-physicians in low- and middle-income countries: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Unsafe abortion is the cause of a substantial number of maternal mortalities and morbidities globally, but specifically in low- and middle-income countries. Medical abortion methods provided by non-physicians may be a way to reduce the burden of unsafe abortions. Currently, only one systematic review comparing non-physicians with physicians for medical abortion exists. However, the review does not have any setting restrictions and newer evidence has since been published. Therefore, this review aims to evaluate the effectiveness, acceptability, and safety of first-trimester abortion managed by non-physicians compared with physicians in low- and middle-income countries.

MATERIAL AND METHODS

The databases PubMed, Cochrane Library, Global Health Library, and EMBASE were searched using a structured search strategy. Further, the trial registries clinicaltrials.gov and The International Clinical Trial Registry Platform were searched for published and unpublished trials. Randomized controlled trials comparing provision of medical abortion by non-physicians with that by physicians in low- or middle-income countries were included. Risk of bias was assessed using the Cochrane Risk of Bias tool. Trials that reported effect estimates on the effectiveness of medical methods on complete abortion were included in the meta-analysis. The protocol was prospectively registered in the PROSPERO database, ID: CRD42020176811.

RESULTS

Six papers from four different randomized controlled trials with a total of 4021 participants were included. Two of the four included trials were assessed to have overall low risk of bias. Four papers had outcome data on complete abortion and were included in the meta-analyses. Medical management of first-trimester abortion and medical treatment of incomplete abortion were found to be equally effective when provided by a non-physician as when provided by a physician (risk ratio 1.00; 95% CI 0.99-1.01). Further, the treatment was equally safe, and women were equally satisfied when a non-physician provided the treatment compared with a physician.

CONCLUSIONS

Provision of medical abortion or medical treatment for incomplete abortion in the first trimester is equally effective, safe, and acceptable when provided by non-physicians compared with physicians in low- and middle-income countries. We recommend that the task of providing medical abortion and medical treatment for incomplete abortion in low- and middle-income countries should be shared with non-physicians.

Inequalities in access to and quality of abortion services in Mexico: Can task-sharing be an opportunity to increase legal and safe abortion care?

First-trimester abortion became legal in Mexico City in April 2007. Since then, 216 755 abortions have been provided, initially in hospitals, by specialized physicians using surgical techniques. With time and experience, services were provided increasingly in health centers, by general physicians using medical therapies. Meanwhile, abortion remains legally restricted in the remaining 31/32 Mexican states. Demand and need for abortion care have increased throughout the country, while overall abortion-specific mortality rates have declined. In an effort to ensure universal access to and improved quality of reproductive and maternal health services, including abortion, Mexico recently expanded its cadres of health professionals. While initial advances are evident in pregnancy and delivery care, many obstacles and barriers impair the task-sharing/shifting process in abortion care. Efforts to expand the provider base for legal abortion and postabortion care to include midlevel professionals should be pursued by authorities in the new Mexican administration to further reduce abortion mortality and complications.

Medication Abortion Up to 70 Days of Gestation

Medication abortion, also referred to as medical abortion, is a safe and effective method of providing abortion. Medication abortion involves the use of medicines rather than uterine aspiration to induce an abortion. The U.S. Food and Drug Administration (FDA)-approved medication abortion regimen includes mifepristone and misoprostol. The purpose of this document is to provide updated evidence-based guidance on the provision of medication abortion up to 70 days (or 10 weeks) of gestation. Information about medication abortion after 70 days of gestation is provided in other ACOG publications [1].

A repeat dose of misoprostol 800 mcg following mifepristone for outpatient medical abortion at 64-70 and 71-77 days of gestation: A retrospective chart review

OBJECTIVE

To compare the effectiveness of outpatient medical abortion with mifepristone 200 mg and two misoprostol 800 mcg doses at 64-70 and 71-77 days of gestation.

STUDY DESIGN

We conducted a retrospective chart review of medical abortion outcomes among clients with 64-77 day gestations at a Mexico City public clinic between February 2014 and November 2016 who took mifepristone 200 mg followed 24-48 h later by two doses of misoprostol 800 mcg four hours apart (first dose buccally, second dose sublingually). The primary outcome was successful medical abortion, defined as pregnancy expulsion without surgical intervention. We also assessed additional management and visits to other facilities. We compared outcomes by gestational age (64-70 vs 71-77 days).

RESULTS

Of 602 charts reviewed, we analyzed 232 and 218 in the respective groups for effectiveness; nearly 25% of clients were lost to follow up. Treatment success occurred in 231 (99.6%, 95% CI 97.6-100%) clients at 64-70 days and 213 (97.7%, 95% CI 94.7-99.3%) clients at 71-77 days (p = 0.11). Ongoing pregnancy occurred in 1 (0.4%, 95% CI 0-2.4%) and 3 (1.4%, 95% CI 0.3-4.0%) clients, respectively (p = 0.36). Two charts from the 71-77 days group documented visits to other facilities: one bleeding concern prior to scheduled follow up and a hemorrhage during an aspiration intervention.

CONCLUSIONS

Regimen effectiveness was high at 64-70 and 71-77 days among clients who attended follow up. However, with 25% attrition, it is difficult to draw definitive conclusions about effectiveness and associated safety.

IMPLICATIONS

Mifepristone 200 mg followed by two doses of misoprostol 800 mcg four hours apart is a promising medical abortion regimen to improve efficacy in pregnancies from 64-77 days of gestation as compared to regimens with an initial single misoprostol dose. Prospective research is recommended to achieve more robust efficacy estimates.

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.

Twelve years after abortion decriminalization in Mexico City: Can we still remain an island of liberties?

Latin America hosts the most restrictive abortion legislation globally. In 2007, Mexico, the second largest Catholic country in the world, decriminalized elective abortion within the first twelve weeks of pregnancy in the capital: Mexico City (also known as Federal District of Mexico). Following the reform, the Mexico City Ministry of Health (MX-MOH) implemented safe and legal services. Free services are provided to Mexico City residents and a sliding fee of up to $100 is applied to women from other Mexican states. Conscientious objection (CO) was addressed and included in service provision guidelines. Since 2007, 18 of 32 states amended their penal codes to restrict abortion. The road toward increasing access to abortion services at the MX-MOH included a shift from dilation and curettage (D&C) to medical abortion (MA), first with the misoprostol-alone regimen, followed by the combined mifepristone-misoprostol regimen. Manual vacuum aspiration is offered to out-of-state-women or to those beyond the gestational age where MA is less effective. Contraceptive uptake among abortion seekers is high (up to 95% of them prefer a free method of their choice). The Legal Interruption of Pregnancy program at the MX-MOH continues to provide effective, safe, reliable, and free services. However, women from indigenous groups residing in rural areas, those with low schooling, and adolescents with an unintended pregnancy who live in rural, urban, peri-urban districts, and at the state level are underserved despite being legally eligible to receive abortion services. Therefore, information and services for the disadvantaged groups need to be strengthened.

WHO guidelines and the role of the physician in task sharing in safe abortion care

Globally, many women undergo unsafe abortion, although abortion is extremely safe when done in accordance with recommended guidelines. Hence, many women suffer from abortion-related complications, and unsafe abortion remains a major cause of maternal mortality. The high percentage of unsafe abortion is attributed to the inability of women to access safe abortion services. A critical barrier to access is the lack of trained providers. To address this problem, task sharing and the expansion of health worker roles in abortion care have become a public health strategy to mitigate health worker shortages and reduce unsafe abortion. This chapter provides an overview of the WHO guidance on task sharing in safe abortion care, discusses the special role of physicians, and highlights the complexity of implementing task sharing by analyzing the findings from six country case studies.

Medical abortion in Nepal: a qualitative study on women's experiences at safe abortion services and pharmacies

Background

Although Nepal legalised abortion in 2002, a significant number of women continue to access unsafe abortions. An estimated 60% of all abortions performed in 2014 were unsafe, with unsafe abortion continuing to be a leading contributor to maternal mortality. Despite medical abortion access being solely permitted through government accredited safe abortion services, medical abortion pills are readily available for illegal purchase at pharmacies throughout the country.

Methods

Utilising an Assets Focused Rapid Participatory Appraisal (AFRPA) research methodology, underpinned by a health information pyramid conceptual framework, this qualitative exploratory study collected data from in-depth, open-ended interviews. The study explored the medical abortion and sexual and reproductive health experiences of ten women who accessed medical abortion through an accredited safe abortion service, and ten women who accessed unsafe medical abortion through pharmacies.

Results

Thematic content analysis revealed emerging themes relating to decision-making processes in accessing safe or unsafe medical abortion; knowledge of safe abortion services; and SRH information access and post-abortion contraceptive counselling. Findings emphasised the interconnectivity of sexual and reproductive health and rights; reproductive coercion; education; poverty; spousal separation; and women’s personal, social and economic empowerment.

Conclusions

While barriers to safe abortion services persist, so will the continued demand for medical abortion provision through pharmacies. Innovated and effective harm reduction implementations combined with access and information expansion strategies offer the potential to increase access to safe medical abortion while decreasing adverse health outcomes for women.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0755-0) contains supplementary material, which is available to authorized users.

Pharmacy access to medical abortion from trained providers and post-abortion contraception in Nepal

OBJECTIVE

To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies was associated with reduced post-abortion contraceptive use in Nepal.

METHODS

The present prospective observational study compared contraceptive use among women aged 16-45 years and up to 63 days of pregnancy, who presented at one of six privately-owned pharmacies or six public health facilities in the Chitwan and Jhapa districts of Nepal for medical abortion between October 16, 2014, and September 1, 2015. Participants obtained medical abortions per Nepali protocol and completed a follow-up visit and interview at 14-21 days. Effective contraceptive use was compared between abortion care settings using multivariable mixed effects logistic regression.

RESULTS

Of 605 participants, 600 completed follow-up at 14-21 days; 474 (79.0%) were using a contraceptive method, most commonly pills (180 [30.0%]) and injectables (175 [29.2%]), followed by condoms (82 [13.7%]), long-acting reversible methods (33 [5.5%]), and sterilization (4 [0.7%]). Receipt of care from a private pharmacy was not associated with a difference in the use of hormonal or long-acting methods (adjusted odd ratio 0.89, 95% confidence interval 0.60-1.33).

CONCLUSION

Medical abortion provision from pharmacies by qualified providers can provide women with necessary induced-abortion care while not compromising longer-term pregnancy prevention.

Effectiveness and safety of early medication abortion provided in pharmacies by auxiliary nurse-midwives: A non-inferiority study in Nepal

BACKGROUND

Expanding access to medication abortion through pharmacies is a promising avenue to reach women with safe and convenient care, yet no pharmacy provision interventions have been evaluated. This observational non-inferiority study investigated the effectiveness and safety of mifepristone-misoprostol medication abortion provided at pharmacies, compared to government-certified public health facilities, by trained auxiliary nurse-midwives in Nepal.

METHODS

Auxiliary nurse-midwives were trained to provide medication abortion through twelve pharmacies and public facilities as part of a demonstration project in two districts. Eligible women were ≤63 days pregnant, aged 16-45, and had no medical contraindications. Between 2014-2015, participants (n = 605) obtained 200 mg mifepristone orally and 800 μg misoprostol sublingually or intravaginally 24 hours later, and followed-up 14-21 days later. The primary outcome was complete abortion without manual vacuum aspiration; the secondary outcome was complication requiring treatment. We assessed risk differences by facility type with multivariable logistic mixed-effects regression.

RESULTS

Over 99% of enrolled women completed follow-up (n = 600). Complete abortions occurred in 588 (98·0%) cases, with ten incomplete abortions and two continuing pregnancies. 293/297 (98·7%) pharmacy participants and 295/303 (97·4%) public facility participants had complete abortions, with an adjusted risk difference falling within the pre-specified 5 percentage-point non-inferiority margin (1·5% [-0·8%, 3·8%]). No serious adverse events occurred. Five (1.7%) pharmacy and two (0.7%) public facility participants experienced a complication warranting treatment (aRD, 0.8% [-1.0%-2.7%]).

CONCLUSIONS

Early mifepristone-misoprostol abortion was as effective and safe when provided by trained auxiliary nurse-midwives at pharmacies as at government-certified health facilities. Findings support policy expanding provision through registered pharmacies by trained auxiliary nurse-midwives to improve access to safe care.

Comparative satisfaction of receiving medical abortion service from nurses and auxiliary nurse-midwives or doctors in Nepal: results of a randomized trial

Background

Early first-trimester medical abortion (MA) service (≤ 63 days) has been provided by doctors and nurses under doctors’ supervision since 2009 in Nepal. This paper assesses whether MA services provided by specifically trained and certified nurses and auxiliary nurse-midwives independently from doctors’ supervision, is considered as satisfactory by women as those provided by doctors.

Methods

The data come from a multi-center, randomized, controlled equivalence trial conducted between April 2009 and March 2010 in five district hospitals in Nepal. Women seeking MA were randomly assigned to doctors or nurses and auxiliary nurse-midwives(ANMs).Eligible women were administered 200 mg mifepristone orally followed by 800 μg misoprostol vaginally two days later by their assigned providers and followed up 10–14 days later. At the follow-up visit women’s reported satisfaction with MA service they received was measured.

Results

Of 1295 women screened for eligibility, 535 were randomly assigned to a doctor and 542 to a nurse or ANM. Nineteen women were lost-to-follow up in the former group and 27 were lost-to-follow up or did not complete the acceptability interview in the latter group. This study is, therefore, based on516womenin the doctor’s group and 515 women in the nurse or ANM group. All women in the nurse or ANM group reported being satisfied or highly satisfied by MA compared to 99% in the doctor’s group. Satisfaction was similar regardless of the type of provider; 38% among nurse or ANM and 35% among the doctor group were “highly satisfied”, and 62% and 64%, respectively, were “satisfied”. Women’s experiences such as ‘less than expected amount or duration of bleeding following MA’, ‘shorter than expected duration of the abortion process’, and ‘able to manage symptoms’, were found to be associated with women’s higher satisfaction with MA. Counseling and information on the method, potential complications of MA and post-abortion contraception was nearly universal. No statistically significant differences were found in the level of satisfaction by age, parity, marital status, education or occupation of women.

Conclusions

Women’s satisfaction with MA service provided by trained nurses or auxiliary nurse-midwives was similar to that provided by doctors. The findings, therefore, provide support for extending safe and accessible medical abortion services by government-trained nurses and auxiliary nurse midwives to women seeking early first trimester pregnancy termination.

Trial registration

The trial was retrospectively registered with ClinicalTrials.gov (identifier: NCT01186302). Registered August 20, 2010.

Effectiveness, safety, and acceptability of first-trimester medical termination of pregnancy performed by non-doctor providers: a systematic review

BACKGROUND

Previous systematic reviews have concluded that medical termination of pregnancy (TOP) performed by non-doctor providers may be as effective and safe as when provided by doctors. Medical treatment of incomplete miscarriage by non-doctor providers and the treated women's acceptance of non-doctor providers of TOP has not previously been reviewed.

OBJECTIVES

To review the effectiveness, safety, and acceptability of first-trimester medical TOP, including medical treatment for incomplete miscarriage, by trained non-doctor providers.

SEARCH STRATEGY AND SELECTION CRITERIA

A search strategy using appropriate medical subject headings was developed. Electronic databases (PubMed, Popline, Cochrane, CINAHL, Embase, and ClinicalTrials.gov) were searched from inception through April 2016. Randomised controlled trials and comparative observational studies were included.

DATA COLLECTION AND ANALYSIS

Meta-analyses were performed for included randomised controlled trials regarding the outcomes of effectiveness and acceptability to women. Certainty of evidence was established using the GRADE approach assessing study limitations, consistency of effect, imprecision, indirectness and publication bias.

MAIN RESULTS

Six papers were included. Medical TOP and medical treatment of incomplete miscarriage is probably equally effective when performed by non-doctor providers as when performed by doctors (RR 1.00; 95% CI 0.99-1.01). Women's acceptance, reported as overall satisfaction with the allocated provider, is probably equally high between groups (RR 1.00; 95% CI 1.00-1.01).

CONCLUSION

Medical TOP and medical treatment of incomplete miscarriage provided by trained non-doctor providers is probably equally as effective and acceptable to women as when provided by doctors.

TWEETABLE ABSTRACT

Medical termination of pregnancy performed by doctors and non-doctors can be equally effective and acceptable.

Building Bridges: A Case for Community Health Worker Provision of Misoprostol-Only Abortion in the First Trimester

INTRODUCTION

The consequences of unsafe abortion are devastating to women, their families, and their communities. Medication abortion presents an important alternative to harmful self-induction practices and surgical intervention under questionable circumstances. In settings where mifepristone is unavailable, the use of misoprostol alone is a safe and effective option for terminating an unwanted pregnancy. Studies have demonstrated the safety and efficacy of administration of misoprostol by community health workers (CHW) for indications such as postpartum hemorrhage and treatment of incomplete abortion.

OBJECTIVES

The current study assesses the safety and efficacy of CHW managing misoprostol-only abortion in the first trimester.

METHODS

A retrospective review of clinical files of women who received abortion services in three countries in Latin America between April 2009 and December 2015 included analysis of 173 cases.

RESULTS

In 94% of cases, the pregnancy was terminated without any further intervention. In the remaining cases, clients were referred for manual vacuum aspiration. In four cases, a complication was reported by the provider. In one, the complication was promptly resolved through referral to a higher level of care; in the remaining three, the complication was resolved directly by the provider. In 98% of cases, women reported being satisfied with the treatment they received.

CONCLUSION

This study demonstrates that CHW are able to provide misoprostol-only abortion services to women effectively and safely. The benefits of this model of care also extend beyond the abortion service: CHW are able to offer women a comprehensive range of quality health services, including contraceptive services, increasing access to vital healthcare in areas with few other options.

Post-abortion care with misoprostol - equally effective, safe and accepted when administered by midwives compared to physicians: a randomised controlled equivalence trial in a low-resource setting in Kenya

OBJECTIVE

To assess the effectiveness of midwives administering misoprostol to women with incomplete abortion seeking post-abortion care (PAC), compared with physicians.

DESIGN

A multicentre randomised controlled equivalence trial. The study was not masked.

SETTINGS

Gynaecological departments in two hospitals in a low-resource setting, Kenya.

POPULATION

Women (n=1094) with incomplete abortion in the first trimester, seeking PAC between 1 June 2013 to 31 May 2016. Participants were randomly assigned to receive treatment from midwives or physicians. 409 and 401 women in the midwife and physician groups, respectively, were included in the per-protocol analysis.

INTERVENTIONS

600 µg misoprostol orally, and contraceptive counselling by a physician or midwife.

MAIN OUTCOME MEASURES

Complete abortion not needing surgical intervention within 7-10 days. The main outcome was analysed on the per-protocol population with a generalised estimating equation model. The predefined equivalence range was -4% to 4%. Secondary outcomes were analysed descriptively.

RESULTS

The proportion of complete abortion was 94.8% (768/810): 390 (95.4%) in the midwife group and 378 (94.3%) in the physician group. The proportion of incomplete abortion was 5.2% (42/810), similarly distributed between midwives and physicians. The model-based risk difference for midwives versus physicians was 1.0% (-4.1 to 2.2). Most women felt safe (97%; 779/799), and 93% (748/801) perceived the treatment as expected/easier than expected. After contraceptive counselling the uptake of a contraceptive method after 7-10 days occurred in 76% (613/810). No serious adverse events were recorded.

CONCLUSIONS

Treatment of incomplete abortion with misoprostol provided by midwives is equally effective, safe and accepted by women as when administered by physicians in a low-resource setting. Systematically provided contraceptive counselling in PAC is effective to mitigate unmet need for contraception.

TRIAL REGISTRATION NUMBER

NCT01865136; Results.

Determination of medical abortion eligibility by women and community health volunteers in Nepal: A toolkit evaluation

Objective

To determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman’s eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers.

Study design

We conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman’s eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care.

Results

Both women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women’s assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers’ (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women’s difficulty using the checklist. PPV of FCHVs’ determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively.

Conclusion

Although a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use.