Experiences of Women With Medical Abortion Care Reflected in Social Media (VEILLE Study): Noninterventional Retrospective Exploratory Infodemiology Study

BACKGROUND

Abortion (also known as termination of pregnancy) is an essential element of women's reproductive health care. Feedback from women who underwent medical termination of pregnancy about their experience is crucial to help practitioners identify women's needs and develop necessary tools to improve the abortion care process. However, the collection of this feedback is quite challenging. Social media offer anonymity for women who share their abortion experience.

OBJECTIVE

This exploratory infodemiology study aimed to analyze, through French social media posts, personal medical symptoms and the different experiences and information dynamics associated with the medical abortion process.

METHODS

A retrospective study was performed by analyzing posts geolocated in France and published from January 1, 2017, to November 30, 2021. Posts were extracted from all French-language general and specialized publicly available web forums using specific keywords. Extracted messages were cleaned and pseudonymized. Automatic natural language processing methods were used to identify posts from women having experienced medical abortion. Biterm topic modeling was used to identify the main discussion themes and the Medical Dictionary for Regulatory Activities was used to identify medical terms. Encountered difficulties were explored using qualitative research methods until the saturation of concepts was reached.

RESULTS

Analysis of 5398 identified posts (3409 users) led to the identification of 9 major topics: personal experience (n=2413 posts, 44.7%), community support (n=1058, 19.6%), pain and bleeding (n=797, 14.8%), psychological experience (n=760, 14.1%), questioned efficacy (n=410, 7.6%), social pressure (n=373, 6.9%), positive experiences (n=257, 4.8%), menstrual cycle disorders (n=107, 2%), and reported inefficacy (n=104, 1.9%). Pain, which was mentioned in 1627 (30.1%) of the 5398 posts by 1024 (30.0%) of the 3409 users, was the most frequently reported medical term. Pain was considered severe to unbearable in 24.5% of the cases (399 of the 1627 posts). Lack of information was the most frequently reported difficulty during and after the process.

CONCLUSIONS

Our findings suggest that French women used social media to share their experiences, offer and find support, and provide and receive information regarding medical abortion. Infodemiology appears to be a useful tool to obtain women's feedback, therefore offering the opportunity to enhance care in women undergoing medical abortion.

Quality testing of mifepristone and misoprostol in 11 countries

OBJECTIVE

Previous studies have demonstrated quality concerns with misoprostol. Mifepristone, however, has not been extensively assessed for quality. Between 2020 and 2021, Concept Foundation and the International Planned Parenthood Federation conducted a study to determine the quality of these medical abortion drugs in low- and middle-income countries (LMIC).

METHODS

The collection of batch samples of misoprostol and mifepristone was carried out by trained sampling agents in selected LMIC. Single drug packs and combipacks were sampled. A World Health Organization prequalified laboratory conducted testing method verifications and subsequent sample analysis. Tests included identification, assay, related substances, and content uniformity for misoprostol, and identification, assay, related substances, and dissolution for mifepristone.

RESULTS

Samples were collected from Burkina Faso, Cambodia, Democratic Republic of Congo, India, Kyrgyzstan, Moldova, Nepal, Nigeria, Pakistan, Uganda and Vietnam. Sixty-four pooled batch samples were tested, consisting of 31 combipacks, 26 misoprostol-only and seven mifepristone-only products. Overall, 54.7% of samples were non-compliant with one or more of the specifications, representing 51.6% of combipack products, 57.1% of misoprostol tablets analyzed and 23.7% of mifepristone tablets. One falsified misoprostol-only product was found.

CONCLUSION

The present study confirms that a significant problem still exists in relation to the quality of medical abortion drugs in LMIC. For misoprostol, our findings suggest that historical concerns around primary packaging may have been largely resolved but that manufacturing processes for both finished product and active pharmaceutical ingredient need to be improved. The present study also provides evidence of mifepristone quality issues.

Can mid-level providers manage medical abortion after 12 weeks' gestation as safely and effectively as physicians? A non-inferiority, randomized controlled trial in Addis Ababa, Ethiopia

OBJECTIVE

To determine whether clinical outcomes among clients undergoing medical abortion after 12 weeks' gestation differ by provider cadre.

METHODS

Randomized controlled trial conducted among eligible clients seeking abortion between 13 and 20 weeks' gestation. Participants seeking in-facility abortion were randomized to receive care from a mid-level provider (nurse/midwife) or physician. The primary outcome was median time to expulsion with non-inferiority margin of -1.5 h between provider groups. Quantile median regression models assessed non-inferiority. Secondary outcomes included retained placenta, complications, and patient acceptability.

RESULTS

After randomization and eligibility assessment by the provider, 171 women participated in the study: 81 in the physician group and 90 in the mid-level provider group. Their average age was 24 years, the mean gestational age was 16 weeks, and 65% were nulliparous in both groups. The median time to expulsion did not differ significantly, being 8.1 h for the mid-level group and 6.6 h for the physician group. The adjusted median difference was 0.8 h (95% confidence interval [CI] -1.15 to 2.66), within the non-inferiority margin. Retained placenta occurred similarly: 30.0% (n = 24) of the physician group and 20.5% (n = 18) of the mid-level provider group (adjusted risk difference [ARD] 7.6%, 95% CI -2.81 to 18.06). Complications occurred in 7% of cases, including 5.0% (n = 4) of patients in the physician group and 8.9% (n = 8) in the mid-level provider group (ARD -4.7%, 95% CI -12.43 to 3.12). Patient acceptability did not differ by group.

CONCLUSIONS

Training mid-level providers to provide abortion services after 12 weeks' gestation independently of physicians is feasible and may result in comparable clinical outcomes.

Impact of approval of home use of misoprostol in England on access to medical abortion: An interrupted time series analysis

OBJECTIVE

In 2018, the Department of Health and Social Care in England approved the use of misoprostol at home for early medical abortions, following administration of mifepristone at clinic. The objective of the present study was to assess the impact of the approval of home administration of misoprostol in England on access to medical abortion, assessed through proxy measures of the proportion of all abortions that were medical and gestational age.

METHODS

This study uses the clinical data from the British Pregnancy Advisory Service on abortions in England in years 2018-2019, containing demographic and procedure characteristics of patients. We conducted an interrupted time series analysis to establish the differences before and after the approval in access to medical abortion, measured by the proportion of all abortions that were medical, and gestational age. The analysis also examined whether these changes were equitable, with focus on area-level deprivation.

RESULTS

The analysis of the data (145 529 abortions) suggested that there was an increase in the proportion of medical abortions and decrease in gestational age of abortions after the approval. Compared with the situation if former trends had continued, the actual proportion of early medical abortions was 4.2% higher in December 2019, and the mean gestational age 3.4 days lower. We found that the acceleration of existing trends in increase in proportion of medical abortions and decrease in gestational age were larger in the most deprived quintiles and in those reporting a disability, but not equal across ethnic groups, with Black and Black British women experiencing little change in trajectories post-approval.

CONCLUSION

The approval of home use of misoprostol as part of an early medical abortion regimen in England was associated with material and equitable improvements in abortion access. Pre-approval trends toward greater uptake of medical abortion and declining gestational age were accelerated post-approval and were greatest in the most deprived areas of England, but not across all racial/ethnic groups. The present findings strongly support the continuation or introduction of home management of medical abortions.

Telephone follow-up after early medical abortion using Australia's first low sensitivity urine pregnancy test

BACKGROUND

Follow-up after early medical abortion (EMA) in Australia often entails tracking serum human chorionic gonadotropin levels or performing ultrasonography in-clinic. In other countries, methods of follow-up such as using a low-sensitivity urine pregnancy test (LSUPT), telephone evaluation and a questionnaire have been demonstrated to be safe and acceptable.

AIMS

To evaluate the safety and efficacy of telephone follow-up after EMA using an LSUPT and questionnaire.

MATERIALS AND METHODS

A prospective observational cohort study of patients undergoing telephone follow-up after EMA using an LSUPT and questionnaire was conducted from March 26 to July 31, 2020. Outcomes of patients who returned to clinic because of a positive LSUPT were evaluated and adverse event rates were calculated. Routinely collected adverse event information was used to compare complication rates during the evaluation period with that prior to introduction of the LSUPT.

RESULTS

During the study period, 2223 patients underwent the new protocol. One hundred and ninety-seven patients had a positive LSUPT at their telephone follow-up. One hundred and thirty-two had an incomplete abortion, 11 had a continuing pregnancy, 53 had a complete abortion and one left the clinic before full assessment.

CONCLUSIONS

Introduction of telephone follow-up with an at-home LSUPT reduced the number of patients requiring unnecessary clinic appointments, with over 90% of patients completing their follow-up at home. Complication rates during the study period were found to be at least comparable with previously identified organisational adverse events.

Revolution in abortion care? Perspectives of key informants on the importance of abortion method choice in the era of telemedicine

Patient choice of medical or surgical abortion is a standard of quality abortion care, but the choice of surgical abortion is constrained in England and Wales, particularly since the COVID-19 pandemic and introduction of telemedicine. This qualitative study explored the perspectives of abortion service providers, managers, and funders on the need to offer a choice of methods within early gestation abortion services in England and Wales. Twenty-seven key informant interviews were conducted between August and November 2021, and framework analysis methods were used. Participants presented arguments both for and against offering method choice. Most participants felt that it was important to maintain choice, although they recognised that medical abortion suits most patients, that both methods are very safe and acceptable, and that the priority for abortion services is to maintain timely access to respectful care. Their arguments related to practicalities around patient needs, the risk of reinforcing inequalities in access to patient-centred care, potential impacts on patients and providers, comparisons to other services, costs, and moral issues. Participants argued that constraining choice has a greater impact on those who are less able to advocate for themselves and there were concerns that patients may feel stigmatised or isolated when unable to choose their preferred method. In conclusion, although medical abortion suits most patients, this study highlights arguments for maintaining the option of surgical abortion in the era of telemedicine. More nuanced discussion of the potential benefits and impacts of self-management of medical abortion is needed.

Implementing medical abortion through telemedicine in Colombia: a qualitative study

The non-governmental organisation Profamilia developed and implemented medical abortion through telemedicine in response to the Covid-19 pandemic. This service is now integrated as an alternative to in-person care and available to abortion-seekers across Colombia. Previous research has emphasised bottlenecks in abortion provision, but less is known about implementation processes and experiences. We assessed the feasibility and acceptability of telemedicine for medical abortion from the perspectives of key informants involved in the implementation in Colombia. We conducted 15 in-depth interviews with healthcare professionals, coordinators and support staff implementing telemedicine for medical abortion in the early phase of implementation, between March and October 2021. We analysed the data using the framework method and applied the normalisation process theory in our analysis and interpretation of findings. Our findings show that strong leadership, organisational efforts on pre-implementation training, monitoring and evaluation, and collaboration between diversely skilled and experienced providers are essential for successful implementation. Participants were generally positive towards the use of telemedicine for medical abortion; concerns related to effectiveness, safety and safeguarding existed mainly among providers with less clinical experience. We identified contextual barriers, such as social opposition, regulatory barriers, providers' unavailability, and poor phone and internet connections in rural areas, which impacted the feasibility of the intervention negatively. In conclusion, to ensure stakeholders' buy-in and for the service to reach all abortion seekers in need, future implementation endeavours must address concerns about safety and effectiveness, and tackle identified contexual barriers.Plain Language SummaryIn telemedicine for medical abortion, all or some components of abortion care, such as initial consultations, home delivery of abortion medication, and post-abortion follow up are provided with the use of telecommunications. Telemedicine for medical abortion has been shown to be a safe and effective form of service delivery.In this study, we interviewed 15 healthcare providers and staff involved in the implementation of a telemedicine service for medical abortion in Colombia to determine whether they deemed the service to be acceptable and feasible. We found that collaboration between providers of different backgrounds and levels of experience, appropriate training and strong leadership were key factors for successfully implementing the service. However, some healthcare providers, especially those with less clinical experience, were concerned that telemedicine for medical abortion may not be safe and may risk the health and well-being of abortion-seekers. Further, social opposition to abortion, unclear regulation and limited access to technology were identified as barriers that need to be addressed to ensure the service reaches all abortion-seekers in need.In conclusion, despite contextual barriers and some provider's concerns about medical safety, telemedicine for medical abortion was viewed as a positive and feasible form of service delivery in Colombia.

Effects of medical abortion assisted by traditional Chinese medicine: A network meta-analysis of randomized controlled trials

BACKGROUND

To what extent traditional Chinese medicine (TCM) combined with mifepristone and misoprostol is beneficial for improving the complete abortion rate and duration of vaginal bleeding has been a subject of debate in the field of medical abortion.

OBJECTIVE

To assess the evidence regarding the complete abortion rate and duration of vaginal bleeding of medical abortion assisted by different kinds of TCM.

SEARCH STRATEGY

We searched electronic databases such as PubMed, Web of Science and Cochrane Library database, China National Knowledge Internet, Wan fang Database, VIP Database, and China Biology Medicine disc from 2000 to February 15, 2023.

SELECTION CRITERIA

The control group was medical abortion with mifepristone and misoprostol, and the experimental group was medical abortion assisted by TCM.

DATA COLLECTION AND ANALYSIS

Major data extraction included sample size, age, medicine used for abortion, outcome measures. RevMan 5.3 and Stata 15.1 software were used to assess the literature quality and perform network meta-analysis, respectively.

MAIN RESULTS

A total of 73 randomized controlled trials (RCTs) with 11 683 patients and nine kinds of TCM were included in this study. Compared with mifepristone and misoprostol, eight kinds of TCM had statistical significance in improving the complete abortion rate. The effect value of Sancao decoction was 5.86 (95% confidence interval [CI] 2.53-13.58). Seven kinds of TCM shortened the duration of vaginal bleeding. The effect value of comfrey and trichosanthin decoction was -8.75 (95% CI -10.86 to -6.64).

CONCLUSIONS

This network meta-analysis showed that Lenge Zhumo decoction and Sancao decoction could have a large beneficial effect on complete abortion rate in medical abortion during early pregnancy, and comfrey and trichosanthin decoction could be the best TCM for shortening the duration of vaginal bleeding.

Adaptations to comprehensive abortion care during the COVID-19 pandemic: case studies of provision in Bolivia, Mali, Nepal, and the occupied Palestinian territory

The COVID-19 pandemic impacted comprehensive abortion care provision. To maintain access to services while keeping individuals safe from infection, many organisations adapted their programmes. We conducted a programme evaluation to examine service adaptations implemented in Bolivia, Mali, Nepal, and the occupied Palestinian territory. Our programme evaluation used a case study approach to explore four programme adaptations through 14 group and individual interviews among 16 service providers, facility managers and representatives from supporting organisations. Data collection took place between October 2021 and January 2022. We identified adaptations to comprehensive abortion care services in relation to provision, health information systems and counselling, and referrals. Four overarching strategies emerged: (1) the use of digital technologies, (2) home and community outreach, (3) health worker optimisation, and (4) further consideration of groups in vulnerable situations. In Bolivia, the use of a messaging application increased access to confidential gender-based violence support and comprehensive abortion care. In Mali, the adoption of digital approaches created timely and complete data reporting and trained members of the community served as "interlocutors" between the communities and providers. In Nepal, an interim law expanded medical abortion provision to pharmacies, and home visits complemented facility-based services. In the occupied Palestinian territory, the use of a hotline and social media expanded access to quick and reliable information, counselling, referrals, and post-abortion care. Adaptations to comprehensive abortion care service delivery to mitigate disruptions to services during the COVID-19 pandemic may continue to benefit service quality of care, access to care, routine monitoring, as well as inclusivity and communication in the longer term.

Reach, experience, and acceptability of an abortion self-care intervention in Bolivia: a mixed-methods evaluation

In 2018, Ipas Bolivia launched an abortion self-care (ASC) community intervention with the goal of increasing access to supportive, well-informed abortion support provided by community agents (CAs). Between September 2019 and July 2020, Ipas conducted a mixed-methods evaluation to assess the reach, outcomes, and acceptability of the intervention. We used logbook data maintained by CAs to capture demographic characteristics and ASC outcomes of people supported. We also conducted in-depth interviews with 25 women who had received support and 22 CAs who had provided support. 530 people accessed ASC support through the intervention, most of whom were young, single, educated women accessing abortion in the first trimester. Among the 302 people who self-managed their abortions, 99% reported having a successful abortion. No women reported adverse events. All women interviewed expressed satisfaction with the support provided by the CA and, in particular, with the information, lack of judgement, and respect they felt from CAs. CAs spoke highly about their experience and viewed their participation as a way to increase people's ability to exercise their reproductive rights. Obstacles included experiences of stigma, fears of legal repercussions, and difficulties dispelling misconceptions around abortion. Legal restrictions and abortion stigma continue to complicate access to safe abortion, and findings from this evaluation highlight important avenues for the effectiveness and expansion of ASC interventions, including legal support to people who have abortions and those who provide abortion support, building capacity of people as informed buyers, and ensuring that interventions reach rural and other often under-served people.

Approved but Unavailable: A Mystery-Caller Survey of Mifepristone Access in a Large Ontario City

OBJECTIVES

Mifepristone/misoprostol (mife/miso) has been approved in Canada since 2017, and is available since 2018. Mife/miso does not require witnessed administration in Canada, and therefore most patients obtain a prescription for home use. We sought to determine the proportion of pharmacies in Hamilton, Ontario, Canada, a city of over 500 000, that had combination mife/miso in stock at any given time.

METHODS

A mystery-caller approach was used to survey all pharmacies (n = 218) in Hamilton, Ontario, Canada between June 2022 and September 2022.

RESULTS

Of the 208 pharmacies that were successfully contacted, only 13 (6%) pharmacies had mife/miso in stock. The most commonly cited reasons for the medication being unavailable were low patient demand (38%), cost (22%), lack of familiarity with medication (13%), supplier issues (9%), training requirements (8%), and medication expiry (7%).

CONCLUSIONS

These findings suggest that while mife/miso has been available in Canada since 2017, significant barriers remain to patients accessing this medication. This study clearly demonstrates a need for further advocacy and clinician education to ensure mife/miso is accessible to the patients who require it.

Midwives Safeguarding Abortion Access: Establishing Medication Abortion Services

The abortion access landscape for patients has changed dramatically in the wake of the US Supreme Court Dobbs v. Jackson Women's Health Organization decision in June of 2022. In response, the Division of Midwifery at Baystate Medical Center in Springfield, Massachusetts, began a medication abortion service for both established patients and those who may seek care from out of state. This service increases access to abortion care now while also providing the clinical experience needed for student nurse-midwives to become future abortion providers. This article outlines the steps taken to implement a medication abortion service and ways it can be adopted by other midwifery practices. Strategies to address possible clinical, administrative, and logistical challenges are addressed. Finally, this article is a call to action because midwives are well qualified to provide high quality, safe, and comprehensive medication abortion within the midwifery model of care.

The serum lipidomics reveal the action mechanism of Danggui-Yimucao herbal pair in abortion mice

Medical abortion is a common medical procedure that women choose to terminate an unwanted pregnancy, but it often brings post-abortion complications. Danggui (Angelica sinensis Radix)-Yimucao (Leonuri Herba), as a herbal pair (DY) in clinical prescriptions of traditional Chinese medicine, is often used in the treatment of gynecological diseases and has the traditional functions of tonifying the blood, promoting blood circulation, removing blood stasis and regulating menstruation. In this study, serum lipidomics were adopted to dissect the mechanism of DY in promoting recovery after medical abortion. A total of 152 differential metabolites were screened by lipidomics. All metabolites were imported into MetaboAnalyst for analysis, and finally key metabolic pathways such as glycerophospholipid metabolism, linoleic acid metabolism and pentose and glucuronate interconversions were enriched. Our results indicated that metabolic disorders in abortion mice were alleviated by DY through glycerophospholipid metabolism, while prostaglandin and leukotriene metabolites might be the key targets of DY to promote post-abortion recovery.

Delayed presentation of placenta accreta following a first-trimester medical abortion

Placenta accreta can rarely present as a uterine mass on imaging months after a first trimester medical abortion, even in patients at low-risk for abnormal placentation. Early and accurate diagnosis can be crucial to reduce morbidity and mortality associated with this disease, particularly for those desiring fertility preservation.

Effectiveness and acceptability of home use of misoprostol for medical abortion up to 10 weeks of pregnancy

INTRODUCTION

The administration of mifepristone, followed by misoprostol, is widely used for medical abortion. Many studies have demonstrated home abortion to be safe in pregnancies up to 63 days of gestation, and recent data support its safety when extended to more advanced pregnancies. We studied the efficacy and acceptability of home use of misoprostol up to 70 days of gestation in a Swedish setting and compared the outcomes between pregnancies with a gestational age of up to 63 days and pregnancies with gestational age 64-70 days.

MATERIAL AND METHODS

This prospective cohort study was performed between November 2014 and November 2021 at Södersjukhuset and Karolinska University Hospital, Stockholm, and some patients were also recruited from Sahlgrenska University Hospital, Göteborg and Helsingborg Hospital. The primary outcome was the rate of complete abortions and was defined as complete abortion without any need for surgical or medical intervention and assessed by clinical assessment, pregnancy test and/or vaginal ultrasound. Secondary objectives were assessed by daily self-reporting in a diary and included pain, bleeding, side effects and women's satisfaction and perception of home use of misoprostol. A comparison of categorical variables was made with Fisher's exact test. The significance level was set to a p-value ≤0.05. The study was registered at Clinicaltrials.gov on July 14, 2014 (NCT02191774).

RESULTS

During the study period we enrolled 273 women opting for medical abortion with home use of misoprostol. In the early group, up to 63 days of gestation, 112 women were included with a mean gestational length of 45 days and in the late group, 64-70 days of gestation, 161 women with a mean gestations length of 66.3 days were included. Complete abortion occurred in 95% (95% CI 89-98) of women in the early group and in 96% (95% CI 92-99) in the late group. No differences were found regarding side effects and acceptability was similarly high in both groups.

CONCLUSIONS

Our results show high efficacy and acceptability of medical abortion when misoprostol is administered at home up to 70 days of gestation. This supports previous findings about maintained safety when misoprostol is administered at home even past a very early pregnancy.

Mifepristone priming and subsequent misoprostol for second trimester medical abortion in women with previous caesarean delivery

AIMS

To assess clinical outcomes and complications in women with ≥1 prior caesarean delivery (CS) during mid-pregnancy medical abortion with misoprostol following mifepristone priming.

MATERIALS AND METHODS

Retrospective analysis of abortions at 13-28 weeks gestation using sequential mifepristone and misoprostol at a single centre from 1/2008-12/2018. Procedural outcomes were compared between cases with no prior CS, one prior and ≥2 prior CS.

RESULTS

There were 1399 consecutive women who underwent a medical abortion, with 304 (21.7%) having ≥1 prior lower segment CS (241 one, 49 two, 12 three, one four) and one a prior classical CS. Median gestation was 19 weeks (interquartile range (IQR) 17-21) among nulliparas, multiparas with no prior CS and multiparas with prior CS, P = 0.505. Compared with nulliparas (median procedural duration 10.8 h, IQR 7.5-16.5; adjusted hazards ratio (aHR) = 1.20 95%CI 1.04-1.40, P = 0.015), multiparas with prior CS had a shorter procedural duration (9.5 h, IQR 6.5-13.5) while multiparas with no CS had the shortest duration (7.0 h, IQR 5.0-9.8; aHR = 2.28 95%CI 2.01-2.58, P < 0.001). Complications were more frequent with prior CS: estimated blood loss (medians: 100 cc no CS vs 150 cc ≥1 CS, P = 0.002), blood loss >1000 cc (3.6% no CS vs 7.2% ≥1 CS; odds ratio (OR) = 2.11 95%CI 1.23-3.62, P = 0.007) and placental retention (17.3% no CS vs 25.3% ≥1 CS; adjusted OR = 1.44 95%CI 1.05-1.99, P = 0.024). Uterine rupture occurred in 4/304 women with ≥1 prior CS (1.3%).

CONCLUSIONS

Mifepristone-misoprostol abortion in women with prior CS is generally safe but associated with an increased risk of procedural complications. Lowering of the misoprostol dosage with prior CS may reduce uterine rupture, although this hypothesis requires ongoing research.

Telemedicine medical abortion service in Georgia: an evaluation of a strategy with reduced number of in-Clinic visits

PURPOSE

To evaluate feasibility and acceptability of a medical abortion service that offers: a telemedicine visit (in place of an in-person visit) during a mandatory waiting period, and at-home follow-up with the use of multi-level pregnancy tests (MLPT).

METHODS

Participants were screened for eligibility in clinic, and during the waiting period, received a telephone call to confirm desire to proceed with the service. Participants were mailed a study package containing mifepristone, misoprostol, two multi-level pregnancy tests, and instructions for their use. Follow-up consultation took place by phone to evaluate abortion completeness. The analysis was descriptive.

RESULTS

One-hundred twenty-two participants were enrolled in the study, and 120 chose to proceed with the abortion after the waiting period and were sent a study package. One participant was lost to follow up. The majority of participants did not experience problems receiving the study package (94.1%, n = 112), took mifepristone (100%, n = 119), misoprostol (99.2%, n = 118), and MLPTs (99.1%, n = 116) as instructed, and forwent additional clinic visits (91.6%, n = 109). All participants were satisfied with the service. Most participants had a complete abortion without a procedure (95.8%, n = 114).

CONCLUSIONS

The adapted telemedicine medical abortion service was feasible and satisfactory to participants and has the potential to make medical abortion more patient-centered where waiting periods are mandated.

The diagnostic value of transvaginal color Doppler ultrasonography plus serum β-HCG dynamic monitoring in intrauterine residue after medical abortion

To probe the diagnostic value of transvaginal color Doppler ultrasonography plus serum β-human chorionic gonadotropin (β-HCG) dynamic monitoring in intrauterine residue after medical abortion.In total, 200 pregnant women undergoing medical abortion in our institution from January 2017 to December 2019 were picked, and assigned to either group A (n = 75, with residue) or group B (n = 125, without residue). We detected serum β-HCG, progesterone (P), follicle stimulating estrogen (FSH) levels and ultrasonic indicators endometrial thickness (ET), peak systolic velocity (PSV), resistance index (RI) values, dissected correlation of indicators using logistic linear regression analysis, and prospected the diagnostic value of relevant indicators in intrauterine residue after medical abortion utilizingreceiver operating characteristic curve.At 7 days after abortion (T3), total vaginal bleeding and visual analogue scalescore in group A were saliently higher in contrast to group B ( P < .05). At 72 hours after abortion (T2) and T3, serum β-HCG, P and FSH levels declined strikingly in both groups, but group B held plainly higher decrease rate than group A ( P HC.05). At T3, ET and PSV levels in both groups considerably waned, whereas RI levels notedly waxed, and group B owned markedly higher decrease/increase than group A ( P wa.05). At T3, serum β-HCG in group A possessed positive association with serum P, FSH, intrauterine ET, PSV levels separately ( P HC.05), whereas negative link with RI levels ( P , .05). The specificity and sensitivity of β-HCG, P, FSH, β-HCG/ET, β-HCG/PSV and β-HCG/RI in the diagnosis of intrauterine residue after medical abortion were high ( P < .05).Serum β-HCG dynamic monitoring plus transvaginal color Doppler ultrasonography is of great value in diagnosing intrauterine residue after medical abortion. Serum β-HCG, P, FSH levels can be combined with the results of intrauterine ET, PSV, RI values, so as to boost the diagnostic accuracy of the intrauterine residue after medical abortion.

Trend of serum beta-human chorionic gonadotropin levels after medical abortion in the early first trimester of pregnancy

AIM

This study aimed to study serum beta-human chorionic gonadotropin level trends after medical abortion using mifepristone and misoprostol in the early first trimester.

METHODS

We enrolled women at ≤63 days of gestation who were indicated for pregnancy termination. We excluded women with incomplete abortions, nonviable pregnancies, extrauterine pregnancies, and contraindications for mifepristone/misoprostol use. Women received oral mifepristone (200 mg), followed by vaginal misoprostol (800 mcg) after 48 h. Serum beta-human chorionic gonadotropin levels were monitored pre-mifepristone administration (day 1); 48 h post-mifepristone, pre-misoprostol administration (day 3); day 10; and weekly after day 10, until negative beta-human chorionic gonadotropin levels (<25 mIU/mL) were achieved.

RESULTS

Among 39 enrolled women, 36 (92.3%) who underwent complete abortion without further interventions were included. The median gestational age was 51 (32-61) days. Three phases of beta-human chorionic gonadotropin levels were observed: an increase of up to 5.1% within 48 h of taking mifepristone, before misoprostol administration; a rapid decline on day 10 (by 98.5% compared with initial levels); and a slow decline after day 10 until negative results were attained within 7 weeks.

CONCLUSION

Serum beta-human chorionic gonadotropin levels minimally increased 48 h after taking mifepristone, rapidly declined within 1 week of misoprostol administration, and slowly declined until negative within 7 weeks post-abortion.

Improving safe post-abortion care practices: A study on interventions implemented by Ipas Pakistan

An estimated 50 million induced abortions occur in developing countries annually, and an estimated 7 million women are treated for complications associated with unsafe abortions. According to a 2012 estimate, 15 per 1,000 women aged 15-49 years seek treatment for abortion-related health complications in both private and public sectors. A high unmet need for family planning in Pakistan and a low percentage of women adopting a contraceptive method in the post-partum period led to unwanted pregnancy becoming one of the reasons for unsafe abortion. Post-abortion care (PAC) is an integrated service delivery model that includes both maternal health and family planning interventions. The study aims to examine improvement in abortion-related practices through the implementation of the PAC model at all tiers of public health service delivery systems in the two most populous provinces-Punjab, Sindh, Khyber Pakhtunkhwa, and Islamabad Capital Territory (ICT) region-of Pakistan. The improvement model comprises clinical training of healthcare providers, community engagement, and counseling of community women on safe post-abortion practices. It was a descriptive study utilizing data of 27,616 PAC clients recorded and reported by the service providers on the logbooks from 104 selected public health facilities from March 2018 to December 2021 in ICT, Punjab, Sindh, and Khyber Pakhtunkhwa provinces of Pakistan. Women who received PAC services were older than 25 years, 22,652 (82%), with a mean age of 29 years. Most of these women were in their first trimester, 26,110 (95%), and the majority diagnosed with PAC (incomplete, missed, or threatened abortion), 26,838 (97%). The majority of women, 25,324 (92%), received safe methods for post-abortion care that included the use of misoprostol, 15,804 (58%), and manual vacuum aspiration, 8,898 (32%). In total, 17,105 (72%) of women opted for a contraceptive method that included long-acting reversible contraceptives, 2,313 (10%); short-term excluding condoms, 3,436 (27%); and condoms, 8,113 (34%). The key predictors identified for uptake of the post-abortion family planning method indicated that women more than 25 years of age, in the early second trimester, and who were counseled on post-abortion family planning were more likely to adopt the contraceptive method than others. Increased access to post-abortion care and family planning could potentially reduce the incidence of unsafe abortion, unintended pregnancies, and associated maternal mortality. The experience of Pakistan suggests that the integrated post-abortion care service delivery model can be effectively implemented across the public health systems.

Cost Analysis of Surgical and Medical Uterine Evacuation Methods for First-Trimester Abortion Used in Public Hospitals in Mexico

Background:

Data on abortion procedures costs are scarce in low- and middle-income countries. In Mexico, the only known study was conducted more than a decade ago, with data from years before the abortion legislation. This study estimated the costs, from the health system’s perspective, of surgical and medical abortion methods commonly used by women who undergo first-trimester abortion in Mexico.

Methods:

Data were collected on staff time, salaries, medications, consumables, equipment, imaging, and lab studies, at 5 public general hospitals. A bottom-up micro-costing approach was used.

Results:

Surgical abortion costs were US$201 for manual vacuum aspiration and US$298 for sharp curettage. The cost of medical abortion with misoprostol was US$85. The use of cervical ripening increases the costs by up to 18%. Staff comprised up to 72% of total costs in surgical abortions. Hospitalization was the area where most of the spending occurred, due to the staff and post-surgical surveillance required.

Conclusions:

Our estimates reflect the costs of “real-life” implementation and highlight the impact on costs of the overuse of resources not routinely recommended by clinical guidelines, such as cervical ripening for surgical abortion. This information will help decision-makers to generate policies that contribute to more efficient use of resources.

Medical abortion in India - An imperative need for task sharing

Background

Over-the-counter (OTC) sale of medical abortion (MA) inducing drugs is a common practice. Exploring its impact on women's health and the barriers to avail free MA services at hospital by these women is essential to improve upon policy decision.

Methods

A prospective observational study included 112 women following ingestion of MA drugs from nonformal providers. Demography, clinical details, and reasons for not availing free abortion services at hospital were recorded.

Results

Among 112 women, mean age was 28.63 (SD 4.7) years. Seventy one (63.39%) women were from rural region; 70.54% were educated below high school; 44 (39.28%) had prior induced abortion; 62.5% had never used any contraception. Majority (101; 90%) took two drugs (Mifepristone and Misoprostol), 28 (25%) used correct dosage. Drugs were consumed beyond 9 weeks of gestation by 25 (22.4%) women. Abnormal vaginal bleeding was commonest 105 (93.75%) presentation. Haemorrhagic shock was noted in 21 (18.75%) women, while 21 (18.7%) women required blood transfusion. "Easy and quick availability of these drugs OTC" was the commonest statement for not attending hospital.

Conclusion

Easy and quick availability of OTC drugs, distance to hospital were major barriers. Incorrect dosage and lack of gestational age calculation were two most common errors in the risk assessment protocol. Expanding provider base, by training midlevel providers, can overcome these and unmask the full potential of MA to make abortion safer.

Policy surveillance for a global analysis of national abortion laws

Policy surveillance offers a novel and important method for comparing law across jurisdictions. We used policy surveillance to examine abortion laws across the globe. Self-managed abortion, which generally takes place outside formal healthcare settings, is increasing in prevalence and can be safe. We analysed provisions that do not account for the prevalence of self-managed abortion and evidence of its safety. Such provisions require that abortion take place in a formal healthcare setting. We also analysed criminal penalties for non-compliance. Our method included development of a legal framework, an iterative process of refining coding schemes and procedures, and rigorous quality control. We limited our analysis to liberal abortion laws for two reasons. Abortion laws globally trend towards less restrictive. In addition, we aimed to focus on how laws relate to abortion outside a formal healthcare setting specifically and excluded laws that prohibit abortion more broadly. We found that in all countries with liberal national abortion laws, the law permits only healthcare professionals or trained health workers to perform legal abortion and the majority require the abortion to take place in a specified health facility. With policy surveillance methods we can illuminate characteristics of law across many jurisdictions and the need for widespread reform, toward laws that reflect scientific evidence and the way people have abortions.

A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization

Introduction

Previous research indicates that an increasing number of women who go to an emergency room for complications following an induced abortion are treated for a miscarriage, meaning their abortion is miscoded or concealed.

Objective

To determine if the failure to identify a prior induced abortion during an ER visit is a risk factor for higher rates of subsequent hospitalization.

Methods

Post hoc analysis of hospital admissions following an induced abortion and ER visit within 30 days: 4273 following surgical abortion and 408 following chemical abortion; abortion not miscoded versus miscoded or concealed at prior ER visit.

Results

Chemical abortion patients whose abortions are misclassified as miscarriages during an ER visit subsequently experience on average 3.2 hospital admissions within 30 days. 86% of the patients ultimately have surgical removal of retained products of conception (RPOC). Chemical abortions are more likely than surgical abortions (OR 1.80, CL 1.38-2.35) to result in an RPOC admission, and chemical abortions concealed are more likely to result (OR 2.18, CL 1.65-2.88) in a subsequent RPOC admission than abortions without miscoding. Surgical abortions miscoded/concealed are similarly twice as likely to result in hospital admission than those without miscoding.

Conclusion

Patient concealment and/or physician failure to identify a prior abortion during an ER visit is a significant risk factor for a subsequent hospital admission. Patients and ER personnel should be made aware of this risk.

In-person later abortion accompaniment: a feminist collective-facilitated self-care practice in Latin America

In Argentina, Chile and Ecuador, abortion at later durations of pregnancy is legally restricted. Feminist collectives in these contexts support people through self-managed medical abortion outside the healthcare system. The model of in-person abortion accompaniment represents an opportunity to examine a self-care practice that challenges and reimagines abortion provision. We formed a collaborative partnership built on a commitment to shared power and decision-making between researchers and partners. We conducted 28 key informant interviews with accompaniers in Argentina, Chile and Ecuador in 2019 about their model of in-person abortion accompaniment at later durations of pregnancy. We iteratively coded transcripts using a thematic analysis approach. Accompaniers premised their work in a feminist activist framework that understands accompaniment as addressing inequalities and expanding rights, especially for the historically marginalised. Through a detailed description of the process of in-person accompaniment, we show that the model, including the logistical considerations and security mechanisms put in place to ensure favourable abortion outcomes, emphasises peer-to-peer provision of supportive physical and emotional care of the accompanied person. In this way, it represents supported self-care through which individuals are centred as the protagonists of their own abortion, while being accompanied by feminist peers. This model of supported self-care challenges the idea that “self-care” necessarily means “solo care”, or care that happens alone. The model’s focus on peer-to-peer transfer of knowledge, providing emotional support, and centring the accompanied person not only expands access to abortion, but represents person-centred practices that could be scaled and replicated across contexts.

Easing of Regulatory Barriers to Telemedicine Abortion in Response to COVID-19

For many people seeking abortion during the continuing COVID-19 pandemic, telemedicine abortion is the safest and most acceptable method, posing lower risk of exposure to the virus. In addition, by reducing in-person visits with health care providers, increased use of telemedicine for abortion can reduce pressure on overburdened health systems. Given the benefits of telemedicine during the pandemic, government agencies in several countries took measures to temporarily allow telemedicine abortion. We conducted key-word English-language searches to identify examples of government action to remove regulatory barriers to the practice of telemedicine abortion in response to the pandemic. We found instances of government agencies in eight countries taking steps to ease regulatory barriers to telemedicine abortion. Telemedicine abortion is safe, cost-effective, and may be the preferred method of abortion during acute periods of COVID-19 transmission, as well as after the pandemic has abated. As one step to expanding access to abortion with medicine where abortion is legal, health agencies and other regulatory bodies can take steps to remove barriers specific to telemedicine abortion.

Danggui-Yimucao Herb Pair Can Protect Mice From the Immune Imbalance Caused by Medical Abortion and Stabilize the Level of Serum Metabolites

Unintended pregnancy is a situation that every woman may encounter, and medical abortion is the first choice for women, but abortion often brings many sequelae. Angelica sinensis Radix (Danggui) and Leonuri Herba (Yimucao) are widely used in the treatment of gynecological diseases, which can regulate menstrual disorders, amenorrhea, dysmenorrhea, and promote blood circulation and remove blood stasis, but the mechanism for the treatment of abortion is not clear. We determined the ability of Danggui and Yimucao herb pair (DY) to regulate the Th1/Th2 paradigm by detecting the level of progesterone in the serum and the expression of T-bet and GATA-3 in the spleen and uterus. Then, we detected the level of metabolites in the serum and enriched multiple metabolic pathways. The arachidonic acid pathway can directly regulate the differentiation of Th1/Th2 cells. This may be one of the potential mechanisms of DY in the treatment of abortion.

Medical abortion ratios and gender equality in Europe: an ecological correlation study

Medical abortion (MA) is recommended by the WHO as a safe and effective pregnancy termination method in the first trimester. From a feminist perspective, it is a non-medicalised, self-managed, emancipating procedure allowing persons seeking abortion to be more in control of their abortion, as opposed to surgical procedures. In European countries where MA is legal, the proportion of MA (relative to surgical abortions) varies greatly. We hypothesised that this ratio may be partly explained by country-level dimensions of gender equality. We assessed the association between MA ratios and gender equality in Europe in correlation and regression analyses, using several country-level gender equality indices. The relevance of other factors, i.e. date of introduction of MA and pregnancy week until which MA is permitted, was also investigated. MA ratios ranged from 24.4% (Italy) to 97.7% (Finland). MA was more frequent relative to surgical abortion in countries with higher levels of gender equality. All gender equality indices were associated with MA ratios (e.g. Global Gender Gap Index corr. coeff: 0.761, p < 0.0001). Specifically, markers of economic and political gender equality seemed to drive the correlations. The pregnancy week until which MA is permitted was associated with both gender equality and MA ratios. Our study suggests that women’s participation in the economic and political sphere may have repercussions on the methods offered and used through abortion services. It highlights the link between feminist perspectives, reproductive health policies and practices, and gender equality, especially in terms of access to economic resources and political representation.

A descriptive analysis of medical abortion commodity availability and pricing at retail outlets in 44 countries across four regions globally

Pharmacies in low- and middle-income countries play an important role in increasing the availability of medical abortion to individuals for self-use. We aimed to document the costs to users of medical abortion products at outlets across geographies and understand the diversity of available products, primarily in low- and middle-income countries or in places where access to abortion is restricted. A descriptive analysis of price data was completed for identified medical abortion products at retail outlets visited in 44 countries from November 2017 to February 2018. Median prices and ranges are reported in $US for mifepristone 200 mg tablets, misoprostol 200 mcg tablets, and combipacks. Misoprostol, mifepristone, and combipacks were found in 44, 19, and 16 countries, respectively. Nearly two-thirds of products (321/508) required a prescription. The median price of misoprostol was $0.63 per tablet (range $0.09–$27.63) based on 304 price points. Mifepristone and combipacks had fewer price points available (n = 59 and n = 44, respectively). Median prices were $11.78 per mifepristone tablet (range $1.77–$37.83) and $11.18 per combipack (range $3.50–$35.86). Overall, prices were highest in Latin America and lowest in South/Southeast Asia. Only 11.5% (7/61) of the total unique misoprostol brands were quality-assured (i.e. approved by a stringent regulatory authority or pre-qualified by the World Health Organization), compared to 25.0% (4/16) of unique combipack products. There was wide variation in product pricing and availability across settings. The infrequent availability of mifepristone and combipacks, in addition to the limited availability of quality-assured medicines and high cost of abortion medications, are important factors affecting access to high-quality abortion care.

Effect of mifepristone and lithospermum combination regimen on medical abortion in early pregnancy rats

OBJECTIVE

To investigate the optimal dose of mifepristone and lithospermum combination regimen on medical abortion in early pregnancy rats without increasing side effects.

STUDY DESIGN

Sixty sexually mature female Sprague Dawley (SD) rats with early pregnancy were randomly allocated into 10 groups, including a control group (treated with 0.5% CMC-Na) and nine experiments (treated with 1 mg/kg mifepristone, and 90, 180, 270, and 540 mg/kg lithospermum, and 90/180/270/540 mg/kg lithospermum +1 mg/kg mifepristone, respectively). The hormone levels, factors associated with endometrial bleeding, oxidative stress, and apoptotic proteins in the endometrium, were then investigated.

RESULTS

The results demonstrated that 540 mg/kg lithospermum plus 1 mg/kg mifepristone treatment significantly improved the abortion rate when compared with the control group. Compared with the 1 mg/kg mifepristone, 540 mg/kg lithospermum plus 1 mg/kg mifepristone treatment did not induce significant increase in factors associated with abnormal endometrial bleeding, such as matrix metalloproteinase-9 (MMP9). However, mifepristone and lithospermum combination regimen promoted the expression level of malondialdehyde (MDA), activated caspase 3, caspase 9 and Bax, meanwhile, reduced the expression of superoxide dismutase (SOD) and Bcl-2.

CONCLUSION

These findings provided strong evidence that mifepristone and lithospermum combination regimen can obtain satisfactory abortion effect without increasing the expression level of bleeding-related factors.

[Systematic review and Meta-analysis on efficacy and safety of Gongxuening Capsules in treatment of abnormal vaginal bleeding after medical abortion]

To systematically evaluate the efficacy and safety of Gongxuening Capsules in the treatment of abnormal vaginal bleeding after medical abortion. CNKI, Wanfang, SinoMed, VIP, PubMed, Cochrane Library and EMbase databases were retrieved to comprehensively collect the clinical randomized controlled trials(RCTs) of Gongxuening Capsules for treatment of abnormal vaginal bleeding after medical abortion from the establishment of the databases to October 10, 2020. Literature screening, data extraction and quality evaluation were conducted independently by two system reviewers according to the inclusion and exclusion criteria. Cochrane Handbook bias risk assessment tool was used for the literature methodology quality evaluation, RevMan 5.3 software was used for Meta-analysis, and the evidence quality of outcomes was evaluated by the evidence quality grading system(GRADE). A total of 16 RCTs were inclu-ded. The results of Meta-analysis showed that as compared with the western medicine treatment alone, the addition of Gongxuening Capsules to the western medicine treatment can reduce the amount of vaginal bleeding(RR=1.23, 95%CI[1.19, 1.27], P&lt;0.000 01), shorten vaginal bleeding time(RR_(≤15 d number of people)=1.39, 95%CI[1.31, 1.48], P&lt;0.000 01; MD_(number ofdays)=-1.20, 95%CI[-1.66,-0.74],P&lt;0.000 01). However, there was no obvious advantage in abortion effect(RR=1.02, 95%CI[0.99, 1.06], P=0.14) and menstrual recovery(MD=-0.35, 95%CI[-0.96, 0.25], P=0.25). The results of GRADE showed that the grading level was low for vaginal bleeding volume and vaginal bleeding time, and extremely low for abortion effect and mens-trual recovery. In terms of safety, 16 studies reported adverse events. Only one study showed no adverse events and the rest showed transient nausea, vomiting, stomach burning, upper abdominal discomfort and other gastrointestinal symptoms. The results show that the addition of Gongxuening Capsules to the application of western medicine in treatment of drug abortion can reduce the amount of vaginal bleeding and shorten vaginal bleeding time, but the abortion effect and menstrual recovery have no obvious advantages. The use of Gongxuening Capsules helps to achieve less adverse reactions and higher safety. Due to the small sample size of the included studies and many methodological quality problems, no conclusions with clinical guidance value can be obtained. Large sample-zise, high-qua-lity randomized controlled trials are still needed for further verification.

"Better dead than being mocked": an anthropological study on perceptions and attitudes towards unwanted pregnancy and abortion in the Democratic Republic of Congo

Unwanted pregnancy and unsafe abortion contribute significantly to the burden of maternal suffering, ill health and death in the Democratic Republic of Congo (DRC). This qualitative study examines the vulnerabilities of women and girls regarding unwanted pregnancy and abortion, to better understand their health-seeking behaviour and to identify barriers that hinder them from accessing care. Data were collected in three different areas in eastern DRC, using in-depth individual interviews, group interviews and focus group discussions. Respondents were purposively sampled. All interviews were audio recorded and transcribed verbatim. Transcriptions were screened for relevant information, manually coded and analysed using qualitative content analysis. Perceptions and attitudes towards unwanted pregnancy and abortion varied across the three study areas. In North Kivu, interviews predominantly reflected the view that abortions are morally reprehensible, which contrasts the widespread practice of abortion. In Ituri many perceive abortions as an appropriate solution for reducing maternal mortality. Legal constraints were cited as a barrier for health professionals to providing adequate medical care. In South Kivu, the general view was one of opposition to abortion, with some tolerance towards breastfeeding women. The main reasons women have abortions are related to stigma and shame, socio-demographics and finances, transactional sex and rape. Contrary to the prevailing critical narrative on abortion, this study highlights a significant need for safe abortion care services. The proverb "Better dead than being mocked" shows that women and girls prefer to risk dying through unsafe abortion, rather than staying pregnant and facing stigma for an unwanted pregnancy.

Different dosing intervals of mifepristone-misoprostol for second-trimester termination of pregnancy: A meta-analysis and systematic review

OBJECTIVE

To compare 1- and 2-day drug administration interval between mifepristone and misoprostol for second-trimester pregnancy termination and provide evidence-based recommendations.

METHODS

Search strategy: the search was performed in Pubmed, EMBASE, and Cochrane Library for the relevant published studies from their establishment to March 2020.

SELECTION CRITERIA

randomized controlled trials (RCTs) comparing 1- and 2-day time interval of mifepristone-misoprostol for termination of pregnancy during second-trimester pregnancy were considered. Data were processed using Revman 5.3 software.

RESULTS

Meta-analyses of three RCTs showed no significant difference was reported in the induction-to-abortion time and successful abortion rate between 1- and 2-day mifepristone and misoprostol intervals. Statistical difference was not identified in the induction-to-abortion time between the two drug administration intervals in nulliparous or parous women.

CONCLUSIONS

Both 1- and 2-day dosing intervals between mifepristone and misoprostol are suitable for clinical use for second-trimester medical termination of pregnancy.

10-year evaluation of the use of medical abortion through telemedicine: a retrospective cohort study

OBJECTIVE

To provide a descriptive overview and evaluate changes in the use and outcome of abortions provided worldwide by telemedicine in the past 10 years.

DESIGN

Retrospective cohort study.

SETTING

Multi-country.

POPULATION/SAMPLE

30 344 women who completed the follow-up survey of the telemedical abortion service Women on Web from January 2009 till January 2020.

METHODS

Analyses of follow-up surveys, binary logistic regressions to test the association between year and outcomes.

MAIN OUTCOME MEASURES

Rate of complete abortions, surgical interventions, ongoing pregnancies, blood transfusions per year, socio-economic situation, knowledge on medical abortion, acceptability of receiving service, appropriateness of method and the likelihood of recommending the service to a friend.

RESULTS

Medical abortions were provided to 81 683 women, of whom 30 344 (37.2%) completed the follow-up survey. In total, 26 076 women reported doing the medical abortion, of whom 1.5% reported an ongoing pregnancy, 10.2% a surgical intervention and 0.6% a blood transfusion. Acceptability of the service was 99%, and 59.2% of the users reported previous knowledge of medical abortion. We found a significant increase in complete abortions in 2019 (odds ratio 1.92; 95% CI 1.59-2.31) and decrease in surgical interventions (odds ratio 0.49; 95% CI 0.40-0.60) compared with 2009.

CONCLUSION

Low follow-up rates present a limitation in analysing trends in telemedical abortion usage. However, our findings suggest that it is a highly acceptable method around the world and that there has been an increase in complete abortions by telemedical abortions and a decrease in surgical interventions in the last 10 years.

TWEETABLE ABSTRACT

In the last 10 years, there has been an increase in complete abortions and decrease in surgical interventions of telemedical abortion.

Fear of childbirth after medical vs surgical abortion. Population-based register study from Finland

INTRODUCTION

To evaluate the effect of method of induced abortion and other abortion-associated variables on the incidence of fear of childbirth in subsequent pregnancy.

MATERIAL AND METHODS

This population-based register study cohort includes all nulliparous women with their first pregnancy ending in an induced abortion in 2000-2015 and subsequent pregnancy with live singleton delivery between 2000 and 2017 (n = 21 479). Data were derived from three national registers maintained by the Finnish Institute for Health and Welfare. We divided the study population in three cohorts: (a) medical and (b) surgical abortion during first trimester (≤84 days of gestation), and (c) medical abortion during second trimester (85-168 days of gestation). Primary outcome measures were the incidence of registry-identified fear of childbirth and cesarean delivery related to it.

RESULTS

The overall incidence of fear of childbirth was 5.6% (n = 1209). Altogether, 19.2% (n = 4121) of women underwent cesarean delivery. The odds were elevated especially for elective cesarean delivery (odds ratio [OR] 9.30, 95% CI 7.95-10.88, P < .001) in women with fear of childbirth. In multivariable analysis, the odds for fear of childbirth (adjusted OR [aOR] 0.80, 95% CI 0.68-0.94) and cesarean delivery (aOR 0.66, 95% CI 0.84-0.90) were decreased in women with a history of first-trimester medical abortion compared with those with first-trimester surgical abortion. Second-trimester medical abortion had no effect on the odds for fear of childbirth (aOR 1.04, 95% CI 0.71-1.50). Maternal age of 30-39 years and interpregnancy interval over 2 years were additional risk factors for both fear of childbirth and cesarean delivery, but surgical evacuation of uterus after the abortion was not.

CONCLUSIONS

One first- or second-trimester medical abortion does not increase the odds for fear of childbirth, and cesarean delivery related to it in subsequent pregnancy when compared with first-trimester surgical abortion. Older maternal age and longer interpregnancy interval emerged as risk factors for fear of childbirth.

A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015

INTRODUCTION

Existing research on postabortion emergency room visits is sparse and limited by methods which underestimate the incidence of adverse events following abortion. Postabortion emergency room (ER) use since Food and Drug Administration approval of chemical abortion in 2000 can identify trends in the relative morbidity burden of chemical versus surgical procedures.

OBJECTIVE

To complete the first longitudinal cohort study of postabortion emergency room use following chemical and surgical abortions.

METHODS

A population-based longitudinal cohort study of 423 000 confirmed induced abortions and 121,283 subsequent ER visits occurring within 30 days of the procedure, in the years 1999-2015, to Medicaid-eligible women over 13 years of age with at least one pregnancy outcome, in the 17 states which provided public funding for abortion.

RESULTS

ER visits are at greater risk to occur following a chemical rather than a surgical abortion: all ER visits (OR 1.22, CL 1.19-1.24); miscoded spontaneous (OR 1.88, CL 1.81-1.96); and abortion-related (OR 1.53, CL 1.49-1.58). ER visit rates per 1000 abortions grew faster for chemical abortions, and by 2015, chemical versus surgical rates were 354.8 versus 357.9 for all ER visits; 31.5 versus 8.6 for miscoded spontaneous abortion visits; and 51.7 versus 22.0 for abortion-related visits. Abortion-related visits as a percent of total visits are twice as high for chemical abortions, reaching 14.6% by 2015. Miscoded spontaneous abortion visits as a percent of total visits are nearly 4 times as high for chemical abortions, reaching 8.9% of total visits and 60.9% of abortion-related visits by 2015.

CONCLUSION

The incidence and per-abortion rate of ER visits following any induced abortion are growing, but chemical abortion is consistently and progressively associated with more postabortion ER visit morbidity than surgical abortion. There is also a distinct trend of a growing number of women miscoded as receiving treatment for spontaneous abortion in the ER following a chemical abortion.

Does prior ultrasonography affect the safety of induced abortion at or after 13 weeks' gestation? A retrospective study

Introduction

We aimed to assess whether ultrasonography prior to dilation and evacuation or medical abortion ≥13 weeks was correlated with safety.

Material and methods

We conducted a retrospective chart review of patients undergoing abortion ≥13 weeks at eight sites in Nepal from 2015 to 2019.

Results

We included 2294 women undergoing abortion ≥13 weeks (no upper gestational age limit); 593 underwent dilation and evacuation and 1701 had a medical abortion. Demographics differed by procedure for parity (19% vs 33% nulliparous, dilation and evacuation, and medical abortion) and gestational age (90% vs 52% were 13‐15 weeks, dilation and evacuation, and medical abortion). Ultrasonography was performed in 81% of cases overall. Complications were rare (<1% of dilations and evacuations, 1.4% of medical abortions). The most common adverse events with dilation and evacuation were hemorrhage and cervical laceration; three women required re‐aspiration. Following medical abortion, 13.5% had retained products, 12.9% with prior ultrasound and 16.3% who had not had an ultrasound. Hemorrhage and severe side‐effects occurred at similarly low rates regardless of whether ultrasonography was performed. In a logistic regression model where patient characteristics and case clustering within facilities were controlled for, we found a correlation between ultrasonography and complications when retained placenta was included in the model, but there was no correlation between ultrasonography and complications when retained placenta was excluded.

Conclusions

This study confirms low complication rates among women having an abortion ≥13 weeks’ gestation in healthcare facilities. Settings without universal availability of ultrasound may still maintain low, comparable complication rates.

Chemical Fingerprint Analysis and Ultra-Performance Liquid Chromatography Quadrupole Time-of-Flight Mass Spectrometry-Based Metabolomics Study of the Protective Effect of Buxue Yimu Granule in Medical-Induced Incomplete Abortion Rats

Medical abortion is a common method to terminate an early pregnancy and often causes serious complications such as abnormal uterine bleeding and endometritis. Buxue Yimu granule (BYG) is a well-known traditional Chinese medicine prescription composed of five kinds of drugs and is widely used in gynecology and obstetrics. The aim of the present study was to establish the quality standard of BYG and investigate its protective effect on incomplete abortion. The chemical fingerprint of BYG was established by high performance liquid chromatography (HPLC). The major compounds of BYG were determined by ultra-performance liquid chromatography with triple quadrupole mass spectrometry. An incomplete abortion rat model was induced by intragastric administration of mifepristone (8.3 mg·kg^-1) combined with misoprostol (100.0 μg·kg^-1) during early pregnancy. The serum levels of human chorionic gonadotrophin (HCG), estradiol (E₂), and progesterone (PG) were determined. The serum endogenous metabolites were analyzed by ultra-performance liquid chromatography quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF/MS). Multivariate analysis, including partial least squares discriminant analysis (PLS-DA) and orthogonal partial least squares discriminant analysis (OPLS-DA), was employed to analyze the metabolic profiles, and MetaboAnalyst was used to investigate the metabolic pathways. Furthermore, hematoxylin-eosin staining (HE) was used to evaluate the histopathological changes in uterine tissue. The expression levels of VEGFA and NF-κB were detected by immunohistochemistry. The results indicated that HPLC fingerprint analysis can be successfully used to assess the quality of BYG. The medical-induced incomplete abortion rats were clearly separated from control rats, and the biochemical changes were gradually restored to normal after administration of BYG. Moreover, 19 potential biomarkers, including N-lactoylleucine, 2-piperidinone, isobutyryl-l-carnitine, eicosapentaenoylcholine, LysoPC(14:0), LysoPC(20:5), physagulin C, LysoPC(18:3), leukotriene D5, deoxycholic acid 3-glucuronide, glycine, pregnanediol 3-O-glucuronide, LysoPC(18:2), LysoPC(17:0/0:0), N-acetyl-leukotriene E4, LysoPC(18:0), platelet-activating factor, LysoPA(24:1), and LysoPC(18:1), which were mainly related to the amino acids metabolism, lipids metabolism, and bile acid biosynthesis, were identified. Consequently, BYG exerts a potential protective role in the intervention of incomplete abortion by anti-inflammatory, promote endometrial repair, and regulate the metabolic disorders.

An examination of the characteristics and contraceptive acceptance of post-abortion clients in Ethiopia

This national study examined the socio-demographic, health facility, and provider characteristics associated with the use of postabortion contraception in Ethiopia in 2014. We used data from a Prospective Morbidity Survey (PMS) conducted in Ethiopia in 2014 to measure abortion incidence and morbidity nationally. Data were collected on the presentation, care and treatment of 5,604 women who sought abortion services in 365 health facilities over 30 days. Descriptive and multivariate logistic regression analysis were used to examine postabortion contraceptive uptake. Nearly 75% of abortion clients received postabortion contraception. The majority received short-acting methods, around one-third chose a long-acting or permanent method. Most women sought abortion services at public health centers (61.8%) and were cared for by midlevel providers (82.5%). Multivariate regression results showed that women who sought services during the first trimester (odds ratio/OR = 1.44; 95% confidence interval/CI 1.06, 1.95), for induced abortions (OR = 3.55; 95% CI 2.52, 4.99), from public sector facilities, and those served by midlevel providers, had greater odds of receiving postabortion contraception. We conclude that providing strong contraceptive services postabortion in government facilities, including long-acting methods in the method mix, and providing this care by midlevel providers could further reduce unmet need for contraception and repeat abortions.

Effect of herbal medicine Shenghua decoction on uterine bleeding after early medical abortion: A protocol for a systematic review and meta-analysis

BACKGROUND

Excessive and prolonged uterine bleeding is an important obstacle for medical abortion to get popularized. Shenghua decoction (SHD) is widely used for treating uterine bleeding after early medical abortion. However, the clinical evidence is unclear.

METHODS

Two researchers will dependently search literatures of SHD for the treatment of uterine bleeding after medical abortion from Web of Science, PubMed, Embase, and The Cochrane Library; traditional Chinese medicine databases; China National Knowledge Infrastructure (CNKI); Chinese Scientific Journal Database (VIP database); and Wan-Fang Database. These inclusive data of included studies will be conducted by RevMan V5.3 software.

RESULTS

This systematic review and meta-analysis will provide a detailed summary of the current evidence related to the efficacy of SHD in treating uterine bleeding after early medical abortion, including the duration and volume of uterine bleeding, the medical abortion pain.

CONCLUSION

This systematic review and meta-analysis will provide a detailed summary of the current evidence related to the efficacy of SHD in treating uterine bleeding after early medical abortion, REGISTRATION NUMBER:: PROSPERO CRD42020184465.

Medical Abortion Care During a Pandemic

In keeping with federal policy, our state’s laws do not permit medical abortion via telemedicine, not even during the coronavirus disease 2019 (COVID-19) outbreak, a decision that endangers the lives of women, clinical staff, nurses, and doctors. It also ties dedicated professionals to the clinic instead of being available to emergency rooms, bedsides, and intensive care units, knowing if their clinic doors close vulnerable women may be driven to desperate acts. Instead of 6 feet we could have been 3000 miles apart. Nearly 39% of abortions in the United States are medical abortions. Instructions, medication prescriptions, and routine follow-up can all be safely done remotely. When an examination or ultrasound are necessary, it can be accomplished with minimal staff and patient exposure. Instead, I am caught in a Kafkaesque moment in an already surreal time. Making medical abortion part of telemedicine during the COVID-19 pandemic could save the lives of women, nurses, staff, and doctors. Maybe yours, maybe even mine.

Regulation of the Abortion Drug RU 486: The Collision of Politics, Ethics and Morals in Australia

The abortion drug RU 486 is widely available across the developed world, and its benefits and efficacy for women have been well established over the 40 years since its development. However, access to RU 486 for women in Australia has been a vexed issue since the mid-1990s. Because of pro-life politics under the Howard Government, importation of the drug into Australia was severely hampered, resulting in Australia lagging behind the rest of the developed world in access to medical abortions. This article highlights the history of RU 486, the current state of abortion laws in Australia and the issues that the politics of the 1990s still cause for Australian women who seek a medical abortion (especially those living remotely). Finally, it proposes some options that could alleviate some of the difficulties faced by those who seek access to RU 486.

Follow-up strategies to confirm the success of medical abortion of pregnancies up to 10 weeks' gestation: a systematic review with meta-analyses

OBJECTIVE

To compare the effectiveness, safety, and acceptability of in-clinic and remote/self-assessment, as well as different remote/self-assessments, for confirming the success of medical abortion at ≤10⁺⁰ weeks' gestation.

DATA SOURCES

Ovid Embase Classic and Embase; Ovid MEDLINE(R) and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations and Daily; and the Cochrane Library. We also consulted experts in this field for any ongoing or missed trials.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials published in English from 2000 onward, comparing in-clinic assessment with ultrasound to remote or self-assessment or comparing different remote or self-assessment strategies to confirm the success of medical abortion of pregnancies up to and including 10⁺⁰ weeks gestation, reporting any of the following outcomes: "missed ongoing pregnancy," "correct implementation of the follow-up strategy," patient satisfaction/preference, "adherence to follow-up strategy," "unscheduled visits/telephone calls to the abortion service," and surgical intervention.

STUDY APPRAISAL AND SYNTHESIS METHODS

One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for randomized controlled trials. All outcomes were analyzed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel-Haenszel statistical method and a fixed effect model. The overall quality of the evidence was assessed using GRADE.

RESULTS

Four randomized controlled trials (n = 5761) compared in-clinic to remote self-assessment and found no clinically significant differences apart from higher preference rates for remote follow-up, especially in the remote follow-up groups. The quality of this evidence was compromised by attrition, no blinding, inconsistency, indirectness, and low event rates. Two randomized controlled trials (n = 1125) compared different remote assessment strategies (using urine pregnancy tests) and also found no clinically significant differences apart from a clinically significantly lower rate of unscheduled visits to the abortion service in the remote follow-up group using a multilevel urine pregnancy test compared to remote follow-up using a high-sensitivity urine pregnancy test. The quality of this evidence was compromised by small event rates, lack of blinding, indirectness and high attrition rates.

CONCLUSION

The published data support offering women who have had a medical abortion up to and including 10⁺⁰ weeks' gestation the choice of self-assessment, remote assessment, or clinic follow-up.

Prevalence, attitudes and knowledge of misoprostol for self-induction of abortion in women presenting for abortion at Midwestern reproductive health clinics

In the setting of increasing restrictions to legal abortion in the United States, reports have emerged of self-induced termination of pregnancies with misoprostol, obtained without a prescription or provider. This study seeks to describe the prevalence of women seeking or employing misoprostol for self-induced abortion, and how they access information. In a cross-sectional study of women immediately following their abortion at three reproductive health clinics in the Midwestern United States, an anonymous survey queried gestational age, barriers, online investigation about self-induction and opinions concerning the availability of medical abortion. From June to September 2016, 276 women participated out of 437 presenting to the clinics during the study period. One hundred and ninety-one (74.6%) women had investigated abortion options online, and of those, 58 (30.9%) investigated misoprostol online, for home use. Women who investigated online options were less likely to have had a prior abortion than those who did not investigate online (29.3% vs. 63.1%, p < .01). They were also more likely to report prior home attempts to end this pregnancy (8.6% vs. 0%, p = .05). Overall, four (1.6%) of the respondents purchased misoprostol and three (1.2%) used it. A majority of women seeking an abortion sought online information prior to their clinic appointment, and almost a third of those had investigated misoprostol for home use. Women are accessing information regarding misoprostol for self-induction of abortion on the Internet. As barriers to legal abortion increase, women may be more likely to self-induce abortion.

Expression of HLA-G and KIR2DL4 receptor in chorionic villous in missed abortion

OBJECTIVE

Human leukocyte antigen-G (HLA-G) is a molecule that was first known to confer protection to the fetus from destruction by the immune system of its mother. HLA-G expression is mainly restricted to the fetal-maternal interface on the extravillous cytotrophoblast, placenta, amnion.

Methods: The purpose of this study is to investigate the HLA-G and KIR2DL4 expression in chorionic villous among 2 groups with missed abortion: group 1 - 27cases with normal karyotype and group 2 - 22 with fetal polyploidy. Criteria of inclusion: abortive material from two groups of women with missed abortion; 6-12 weeks gestational age, singleton pregnancy, cytogenetic of chorionic villous was obligatory - normal fetal karyotype and polyploidy of fetus.

Results: During IHC investigations the average relative area of HLA-G expression in trophoblast was counted (in 1st group 33.9 ± 3.5 and in 2nd group 38.6 ± 2.8). Expression of HLA-G the most verified in extravillous chorion stroma. The average relative area of KIR2DL4 receptor was not statistically different among two groups (31.6 ± 2.4 and 32.2 ± 1.7).

CONCLUSIONS

These results suggest the role of HLA-G for the progression in early reproductive losses. Low expression of HLA-G is associated with pregnancy complications and can be one of the reasons for spontaneous abortion.

From stigma to pride: health professionals and abortion policies in the Metropolitan Area of Buenos Aires

Abortion stigma is experienced not only by women but also by providers and health professionals in a wide range of legal contexts. This paper analyses interviews with providers who work in the public health system in the Metropolitan Area of Buenos Aires, Argentina. A court ruling in 2012, FAL/12, changed the interpretation of abortion’s legal status, clarifying the decriminalisation of abortion in cases of rape, and also requiring public policies and procedures to speed up access to legal abortion. Between 2014 and 2017, we conducted 27 in-depth, semi-structured interviews with abortion providers in public facilities across healthcare services in the Metropolitan Area of Buenos Aires. We found the way that health providers dealt with abortion stigma evolved over the course of time, as the abortion debate moved from the margins to the heart of political debate and public policies in Argentina between 2007 and 2017. Providers’ experiences changed as the social and legal context changed. FAL/12 – as a clear, legal ruling – was a landmark and turning point in the way health professionals in public health facilities conduct their activities, making it possible for them to move from providing silent and hidden abortion care, to acknowledging it with pride.

Misoprostol knowledge and distribution in Mexico City after the change in abortion law: a survey of pharmacy staff

OBJECTIVE

First-trimester abortion is widely available in Mexico City since legalisation in 2007, but few data exist surrounding pharmacy staff knowledge and sales practices. We describe misoprostol availability, whether a prescription is required, and knowledge of the legal status of abortion and uses for misoprostol among pharmacy staff in Mexico City.

METHODS

Data were collected from 174 pharmacies in Mexico City. One employee at each pharmacy was asked about availability, need for prescription, indications for misoprostol, and sociodemographic information. Our primary outcome was availability of misoprostol. We used descriptive and bivariate statistics to compare knowledge and practices by type of pharmacy and staff gender.

PATIENTS AND PUBLIC INVOLVEMENT

No patients were involved in this study.

RESULTS

Of the 174 pharmacies, 65 were chain and 109 small independent. Misoprostol was available at 61% of sites. Only 49% of independent pharmacies sold misoprostol, compared with 81.5% of chain pharmacies (p<0.05). Knowledge of indications for misoprostol use was similar. The majority (80%) of respondents knew that abortion was legal in Mexico City, and 44% reported requiring a prescription for sale of misoprostol, with no significant difference between male and female staff or by pharmacy type.

CONCLUSIONS

Availability, requirement of a prescription, and knowledge of indications for use of misoprostol varies among pharmacies, resulting in differential access to medical abortion. Pharmacies may be a good place to target education for pharmacy staff and women about safe and effective use of misoprostol for abortion.

The abstract versus the concrete: differing opinions of medical residents in obstetrics and gynaecology about abortion and punishment of abortion

Purpose: To investigate the opinions of Brazilian medical residents in Obstetrics and Gynaecology on abortion legislation according to their personal beliefs.Material and methods: A multicentre cross-sectional study. Residents at 21 university teaching hospitals completed a self-report questionnaire on their opinions in abstract terms, and about punishing women who abort in general and women they know.Results: In abstract terms, 8% favoured allowing abortion under any circumstances (fully liberal); 36% under socioeconomic or psychological constraints (broadly liberal); 75.3% opposed punishing a woman who has aborted (liberal in general practice); and 90.2% opposed punishing women they knew personally (liberal in personal practice). Not having a stable partner and not being influenced by religion were factors associated with liberal opinions. In personal practice, however, 80% of those who are influenced by religion were liberal. The percentage of respondents whose opinions were liberal was significantly greater among those who believed that abortion rates would remain the same or decrease following liberalisation.Conclusions: Judgements regarding the penalisation of women who abort are strongly influenced by how close the respondent is to the problem. Accurate information on abortion needs to be provided. Although about one third of the respondents were broadly liberal, the majority oppose punishment.