Medical vs. surgical abortion: the importance of women's choice

Waiting to start abortion: A qualitative exploration of narratives of waiting shared in a Reddit community for abortion post-Dobbs leak in 2022

With the Dobbs leak introducing uncertainty about access and the Dobbs v. Jackson Women's Health Organization decision in June of 2022 overturning the US constitutional right to abortion, delays in accessing desired abortion care are likely growing longer and more common. Timely research on people's experiences waiting to access abortion care is needed. Using data from an abortion subreddit (r/abortion), we analyzed posts that described waiting after having decided to terminate the pregnancy, either by having an in-clinic appointment or ordering medication(s) online for self-managed abortion. Our analysis explored described 1) wait time length, 2) factors contributing to waiting, and 3) impacts of waiting. We used a hybrid inductive and deductive thematic qualitative coding approach to analyze a month-stratified 10% random sample of posts to the r/abortion community in 2022 surrounding the Dobbs leak and decision (May-December, n = 523 posts). Among posts to r/abortion that described waiting to start an abortion (n = 80), wait times ranged from one day to more than a month. Lack of appointment availability and waiting for mailed medications were commonly described as causing delays in accessing in-clinic abortion care and self-managed abortion, respectively. People shared challenges with pregnancy symptoms and feelings of anxiety, fear, isolation, and uncertainty. Posters also commonly described needing additional support while waiting. Overall, waiting to start an abortion was extremely stressful and isolating., with people often waiting weeks between ordering medication or scheduling an appointment and initiating the abortion process. Experiences of waiting to start an abortion and their impacts are of increasing concern as abortion access is further restricted. Additional targeted information and support are needed to mitigate these challenges. Providing timely access is imperative to quality care and overall abortion experiences.

Dantas PB, Trabach CB, Junqueira AA, Nunes CC, Baccaro LF. Analysis of uterine evacuation methods in postabortion care after implementation of a surveillance network (CLAP MUSA-Network) at a university hospital

BACKGROUND

Management of uterine evacuation is essential for increasing safe abortion care. Monitoring through surveillance systems tracks changes in clinical practice and provides information to improve equity in abortion care quality.

OBJECTIVE

This study aimed to evaluate the frequency of manual vacuum aspiration (MVA) and medical abortion (MA), and identify the factors associated with each uterine evacuation method after surveillance network installation at a Brazilian hospital.

METHODS

This cross-sectional study included women admitted for abortion or miscarriage to the University of Campinas Women's Hospital, Brazil, between July 2017 and November 2020. The dependent variables were the use of MVA and MA with misoprostol. The independent variables were the patients' clinical and sociodemographic data. The Cochran-Armitage, chi-square, and Mann-Whitney U tests, as well as multiple logistic regression analysis, were used to compare uterine evacuation methods.

RESULTS

We enrolled 474 women in the study, 91.35% of whom underwent uterine evacuation via uterine curettage (78.75%), MVA (9.46%), or MA (11.54%). MVA use increased during the study period (Z = 9.85, p < 0.001). Admission in 2020 (odds ratio [OR] 64.22; 95% confidence interval [CI] 3.79-1086.69) and lower gestational age (OR 0.837; 95% CI 0.724-0.967) were independently associated with MVA, whereas the only factor independently associated with MA was a higher education level (OR 2.66; 95% CI 1.30-5.46).

CONCLUSION

MVA use increased following the installation of a surveillance network for good clinical practice. Being part of a network that encourages the use of evidence-based methods provides an opportunity for healthcare facilities to increase access to safe abortions.

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.

Structural barriers or patient preference? A mixed methods appraisal of medical abortion use in England and Wales

Although patient choice of abortion method is a key component of quality care, medical abortion (MA) has become the most common method (87%) in England and Wales, as in many countries worldwide. This research aimed to critically examine factors influencing the growth in MA use in England and Wales. Mixed methods were used, combining multi-level regression analysis of national abortion statistics (2011-2020) and key informant interviews with abortion service managers, commissioners, and providers (n=27). Overall trends have been driven by growth in MA use for abortions under 10 weeks in the private non-profit sector. Variation in MA use between patient sub-groups and regions has narrowed over time. Qualitative findings highlight health system constraints that have influenced the shift towards MA, including workforce constraints, infrastructure requirements, provider policies, cost, and commissioning practices involving under-funding and competition, which have caused the private non-profit sector to limit method choice across their services to remain financially viable. While removal of legal restrictions on MA has expanded choice, similar policy progress has not been seen for surgical methods. The study concludes that abortion method choice has been constrained by structural health system factors, with potential negative consequences for service acceptability, inequalities, and patient-centredness.

Client perspectives on choice of abortion method in England and Wales

INTRODUCTION

The National Institute for Health and Care Excellence, the Royal College of Obstetricians and Gynaecologists and the World Health Organization recommend that services provide a choice between medical and surgical methods of abortion. We analysed qualitative study data to examine patient perspectives on abortion method choice and barriers to meeting them.

METHODS

In-depth interviews with 24 clients who had an abortion at British Pregnancy Advisory Service clinics were carried out between December 2018 and July 2019 to examine perspectives of quality of abortion care. In this article we focus on client perspectives on choice of abortion method. We performed thematic analysis of data relating to choice of abortion method, refined the analysis, interpreted the findings, and organised the data into themes.

RESULTS

Participants' preferences for abortion method were shaped by prior experience of abortion, accessibility and privacy, perceptions of risk and experiences of abortion method, and information gathering and counselling. Participants' ability to obtain their preferred method was impacted by intersecting constraints such as appointment availability, service location and gestational age.

CONCLUSIONS

Our findings show that many factors shape participants' preferences for abortion method. In response to the COVID-19 pandemic, some abortion services have constrained abortion method choices, with an emphasis on medical abortion and 'no-touch' care. Providers in the UK and beyond should aim to restore and expand more treatment options when the situation allows.

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.

Access experiences and attitudes toward abortion among youth experiencing homelessness in the United States: A systematic review

Objectives

We sought to review the literature on the access experiences and attitudes toward abortion among youth experiencing homelessness in the United States.

Methods

We conducted a systematic review of peer‐reviewed literature published from 2001 to 2019. We included qualitative studies involving US participants that focused on access experiences, views, or accounts of unintended pregnancy and/or abortion among youth experiencing homelessness. We excluded studies published before 2001 as that was the year mifepristone medication abortion was made available in the US and we aimed to investigate experiences of access to both medical and surgical abortion options.

Results

Our thematic analysis of the data resulted in five key themes that characterize the abortion attitudes and access experiences of youth experiencing homelessness: (1) engaging in survival sex and forced sex, (2) balancing relationships and autonomy, (3) availability does not equal access, (4) attempting self-induced abortions using harmful methods, and (5) feeling resilient despite traumatic unplanned pregnancy experiences.

Conclusions

Youth experiencing homelessness experience barriers to abortion access across the US, including in states with a supportive policy context and publicly funded abortion services. In the absence of accessible services, youth may consider harmful methods of self-induced abortion. Improved services should be designed to offer low-barrier abortion care with the qualities that youth identified as important to them, including privacy and autonomy.

Association of Medicaid Expansion With Access to Abortion Services for Women With Low Incomes in Oregon

BACKGROUND

The Affordable Care Act allowed states to expand Medicaid eligibility for women with low incomes before pregnancy. Women who experience an unintended pregnancy may encounter fewer delays in accessing abortion services if they are already enrolled in Medicaid. In states where the Medicaid program includes coverage for abortion services, Medicaid expansion may increase timely access to abortion services. Oregon has expanded Medicaid and is 1 of 16 states in which the Medicaid program covers abortion services. We explored how Medicaid expansion in Oregon was associated with Medicaid-financed abortion rates and receipt of medication abortion relative to surgical abortion.

METHODS

Using Medicaid claims and eligibility data we identified women ages 19 to 43 (n = 30,367) who had abortions before the expansion period (2008-2013) and after the expansion period (2014-2016). We used American Community Survey data to estimate the annual number of Oregon women aged 19 to 43 with incomes below 185% of the federal poverty level who would be eligible for a Medicaid-financed abortion. We conducted interrupted time series analyses using negative binomial and logistic regression models.

RESULTS

Incidence of Medicaid-financed abortion increased from 13.4 in 1,000 women in 2008 to 16.3 in 2016. Medication abortion receipt increased from 11.5% of abortions in 2008 to 31.7% in 2016. For both outcomes, we identified an increasing time trend after Medicaid expansion, followed by a subsequent leveling off of the trend. By the end of 2016, incidence of Medicaid-financed abortion was 4.5 abortions per 1,000 women-years (95% confidence interval, 3.3-5.7) higher than it would have been without expansion and medication abortions comprised a 7.4 percentage point (95% confidence interval, 4.4-10.4) greater share of all abortions.

CONCLUSIONS

Medicaid expansion was associated with increased receipt of Medicaid-financed abortions and may have reduced out-of-pocket payment among women with low incomes. Increased receipt of medication abortion may indicate that expansion enhanced earlier access to services, possibly as a result of increased prepregnancy Medicaid enrollment, and this earlier access may increase reproductive autonomy and safety.

A Retrospective Cost-Effectiveness Analysis of Mifepristone-Misoprostol Medical Abortions in the First Year at the Regina General Hospital

Objective

In July 2017, mifepristone–misoprostol (mife/miso) became available for medical abortion at the Regina General Hospital's Women's Health Centre (RGH WHC). We investigated whether the proportion of abortions performed medically changed as a result of the introduction of mife/miso, whether using mife/miso instead of the surgical alternative would result in cost savings to the health care system, and whether abortion type differed between patients residing in and outside of Regina.

Methods

We conducted a retrospective chart review of all 306 medical abortions from the RGH WHC between July 1, 2017 and June 30, 2018. We obtained medical and surgical abortion information from that year and the preceding one from an administrative database. Statistical methods were used to calculate the costs of mife/miso, methotrexate-misoprostol (MTX/miso) and surgical abortion, as well as cost-effectiveness ratios.

Results

The proportion of medical abortions increased from 15.4% in 2016/2017 to 28.7% in 2017/2018 (χ²₁ = 54.629; P < 0.001). Calculated costs for mife/miso, with and without complications were CAD $1173.70 and CAD $1708.90, respectively, versus CAD $871.10 and CAD $1204.10, respectively, for MTX/miso, and CAD $1445.95 and CAD $2261.95, respectively, for hospital-based vacuum aspiration. At a willingness-to-pay threshold of CAD $318 (the cost of mife/miso), statistical modelling showed a 61.3% chance that mife/miso was more cost-effective than surgical abortion and a 90.8% chance that it was more cost-effective than MTX/miso. Patients from Regina were significantly more likely (χ²₁ = 29.406; P < 0.001) to receive a medical abortion (34.9% of abortions) than those living outside of Regina (19.6% of abortions).

Conclusion

The proportion of abortions completed medically increased significantly over the period studied. Patients from Regina were more likely to receive medical abortion during both time periods. Mife/miso had a >50% probability of cost-effectiveness over both surgical and MTX/miso options.

Counselling before first trimester abortion and acceptability of the procedure: results from a Slovenian cross-sectional study

Objectives: In Slovenia, first-trimester abortion is performed at the woman's request, either surgically under general anaesthesia or medically with mifepristone and misoprostol, in a public hospital. Our study aimed to evaluate pre-abortion counselling and to reveal differences in acceptability and satisfaction with the two abortion methods.Methods: A cross-sectional study was carried out at Ljubljana University Medical Centre between January and June 2015. Women requesting termination of a pregnancy up to 10 weeks' gestation voluntarily completed an anonymous questionnaire after the procedure and were divided into a surgical and a medical abortion group.Results: Of the 266 women who were invited to take part, 229 accepted; 16.6% chose a surgical abortion, 83.4% a medical abortion. The most frequent reason cited for requesting an abortion was economic/housing problems. Most women who chose a surgical abortion did so because it was faster, whereas most women who chose a medical abortion did so on the advice of a primary care gynaecologist. Women choosing a surgical abortion had more previous pregnancies and presented with a higher gestational age pregnancy. The choice of method was not related to the woman's age. There were no differences in acceptability of the two procedures. Pain during the procedure was, however, more severe in the medical abortion group (p = .026), along with bleeding, nausea and chills; there were no differences in severity of vomiting, diarrhoea, dizziness or headache between the groups. Women in the surgical abortion group reported higher satisfaction with the method (p < .001). The study revealed a low frequency of pre-abortion contraceptive counselling.Conclusion: The most common reason given for choosing a surgical abortion was the speed of the procedure; for a medical abortion, it was on the advice of a primary care gynaecologist. Satisfaction was higher with the surgical abortion method. There were no differences in general acceptability of the methods.

Trends in the method and gestational age of abortion in high-income countries

BACKGROUND

Examining the distribution of abortions by method of abortion and gestational age at time of termination provides insight about the options women may have to terminate their pregnancies. Comparing these distributions across countries and over time is an important step toward understanding the factors that can drive these distributions, including regulations and practices related to the provision of abortion services, and women's preferences and needs.

METHODS

We sought official statistics on gestational age and method of abortion for all high-income countries with liberal abortion laws. For the 24 high-income countries with available data, we calculated percentage distributions of abortions by gestational age of pregnancy and method of abortion for 2017 or the most recent year for which data were available, and assessed trends in the preceding 10 years whenever possible.

RESULTS

Medication (or medical) abortion accounts for at least half of all abortions in the majority of countries. In the majority of countries over 90% of all abortions were completed before 13 weeks, and more than two-thirds of abortions occurred before the first 9 weeks of gestation. Over the past 10 years there has been an increase in both the proportion of abortions that were medication abortions and the proportion that were obtained before 9 weeks gestation.

CONCLUSIONS

These findings highlight changes in abortion provision in the past decade. More research is needed to understand whether the observed distributions are a function of women's preferences or of barriers to the timing and type of care they would prefer.

Adapting the Interpersonal Quality in Family Planning care scale to assess patient perspectives on abortion care

Background

Women value receiving quality interpersonal care during abortion services, yet no measure exists to assess this outcome from patients’ perspectives. We sought to adapt the Interpersonal Quality in Family Planning care scale (Dehlendorf et al., American Journal of Obstetrics Gynaecology 10.1016/j.ajog.2016.01.173, 2016) for use in abortion care.

Methods

We adapted items from the original scale for the abortion context, and conducted cognitive interviews to explore the acceptability, understandability, and importance of the adapted items. Adults who spoke English and/or Spanish, had an abortion in the past year, and lived in the US were eligible to participate. Interview memos were analyzed concurrently with data collection to refine the measure in stages.

Results

We interviewed 26 participants. Items were tested over seven stages and led to four main changes. First, we revised three items to reflect concepts perceived as important to the specific decision-making context of abortion. Second, we removed two items that emerged as potentially inappropriate for this context. Third, we modified language in four items to improve their appropriateness for this context (e.g., ‘telling me’ to ‘explaining’; ‘letting me say’ to ‘listening to’). Fourth, we modified language in three items to improve their clarity. Three items remained unchanged, as there was consistent agreement on their importance, understandability, and relevance.

Conclusions

The resulting 10-item measure, the Interpersonal Quality in Abortion Care scale, was perceived to be highly important, understandable, and feasible to complete. Future psychometric evaluation can prepare it for use in clinical practice to ensure women feel adequately informed and supported during abortion care.

Sociodemographic Characteristics of Women Able to Obtain Medication Abortion Before and After Ohio's Law Requiring Use of the Food and Drug Administration Protocol

Purpose: In 2011, a law went into effect in Ohio that regulates how abortion care providers can offer medication abortion to their patients. We sought to evaluate changes in sociodemographic characteristics of Ohio medication abortion patients before and after the implementation of this law. Methods: We used a retrospective cohort design, comparing characteristics of women obtaining a medication abortion at four abortion facilities before and after the law. We used chart data from January 2010 to January 2011 and February 2011 to October 2014. For any significant changes in sociodemographics found before and after the law, we used stratified cross-tabulations to disentangle whether they were likely related to the restricted gestational limit imposed by the law (lowered from 9 to 7 weeks gestation), or whether they were likely related to other burdens brought on by the law, such as increased costs and visits. Results: Women obtaining a medication abortion after the law were more likely to be older (p=0.01), have higher levels of education (p<0.001), be of white race (p<0.001), have private insurance (p=0.001), have no children (p=0.002), and reside in a higher income zip code (p=0.03). Both the reduced gestational limit and the increased costs and visits likely contributed to declines among black women and women with lower levels of education. The reduced gestational limit for medication abortion likely contributed to a decline among younger women and Medicaid recipient groups. The increased costs and visits imposed by the law likely contributed to the decline in medication abortion among women with no insurance and women with children. Conclusion: The lower gestational limit, higher cost, and time and travel burdens exacted by Ohio's medication abortion law were associated with disproportionate reductions in medication abortion among the most disadvantaged groups. The law was associated with reduced access among women who were younger, of black race, less educated, and in lower socioeconomic groups.

Cervical preparation prior to surgical abortion in real-life conditions and factors driving the prescription: A national observational study

INTRODUCTION

Few data exist to document the real-life practices regarding surgical abortion for first trimester abortion, in particular regarding the cervical preparation. Using a large national sample of French hospitals practicing surgical abortion, we explore actual practices and described drugs used for cervical preparation and factors that influence the prescription.

METHODS

From December 2013 to July 2014, a longitudinal, prospective, multicenter, non-interventional study was undertaken with the main objective of assessing in real-life conditions the modalities of cervical preparation prior surgical abortion in women with less than 14 weeks of amenorrhea.

RESULTS

A total of 542 patients agreed to participate and were included by 36 French private or public hospitals. Among 36 active centers, 31 (86.1%) implemented cervical preparation prior surgical abortion, in line with French and international clinical guidelines. For the 510 patients who underwent surgical abortions, the most frequent prescribed treatment was misoprostol only (224/510, 43.9% of patients), following by mifepristone only (167/510, 32.8%) and a combination of misoprostol and mifepristone (99/510, 19.4%). Finally, four factors were identified as independent contributor to guide the treatment prescribed for cervical preparation: woman work situation, gestational age intensity of center's activity regarding the number of abortions yearly and mode of anesthesia.

CONCLUSIONS

Our study showed an almost systematic implementation of cervical preparation before surgical abortion in France. Misoprostol only was the most commonly prescribed treatment for the cervix preparation, followed by mifepristone only. Several factors may have a significant influence on the type of cervical preparation chosen by physicians.

Quantity over quality-Findings from a systematic review and environmental scan of patient decision aids on early abortion methods

Background

The availability and effectiveness of decision aids (DAs) on early abortion methods remain unknown, despite their potential for supporting women's decision making.

Objective

To describe the availability, impact and quality of DAs on surgical and medical early abortion methods for women seeking induced abortion.

Search strategy

For the systematic review, we searched MEDLINE, Cochrane Library, CINAHL, EMBASE and PsycINFO. For the environmental scan, we searched Google and App Stores and consulted key informants.

Inclusion criteria

For the systematic review, we included studies evaluating an early abortion method DA (any format and language) vs a comparison group on women's decision making. DAs must have met the Stacey et al (2014). Cochrane review definition of DAs. For the environmental scan, we included English DAs developed for the US context.

Data extraction and synthesis

We extracted study and DA characteristics, assessed study quality using the Effective Practice and Organization of Care risk of bias tool and assessed DA quality using International Patient Decision Aid Standards (IPDAS).

Results

The systematic review identified one study, which found that the DA group had higher knowledge and felt more informed. The evaluated DA met few IPDAS criteria. In contrast, the environmental scan identified 49 DAs created by non‐specialists. On average, these met 28% of IPDAS criteria for Content, 22% for Development and 0% for Effectiveness.

Conclusions

Research evaluating DAs on early abortion methods is lacking, and although many tools are accessible, they demonstrate suboptimal quality. Efforts to revise existing or develop new DAs, support patients to identify high‐quality DAs and facilitate non‐specialist developers' adoption of best practices for DA development are needed.

Access, equity and costs of induced abortion services in Australia: a cross-sectional study

OBJECTIVES

To examine access and equity to induced abortion services in Australia, including factors associated with presenting beyond nine weeks gestation.

METHODS

Cross-sectional survey of 2,326 women aged 16+ years attending for an abortion at 14 Dr Marie clinics. Associations with later presentation assessed using multivariate logistic regression.

RESULTS

Over a third of eligible women opted for a medical abortion. More than one in 10 (11.2%) stayed overnight. The median Medicare rebated upfront cost of a medical abortion was $560, compared to $470 for a surgical abortion at ≤9 weeks. Beyond 12 weeks, costs rose considerably. More than two-thirds (68.1%) received financial assistance from one or more sources. Women who travelled ≥4 hours (AdjOR: 3.0, 95%CI 1.2-7.3), had no prior knowledge of the medical option (AdjOR: 2.1, 95%CI 1.4-3.1), had difficulty paying (AdjOR: 1.5, 95%CI 1.2-1.9) and identified as Aboriginal and/or Torres Strait Islander (AdjOR: 2.1, 95%CI 1.2-3.4) were more likely to present ≥9 weeks.

CONCLUSIONS

Abortion costs are substantial, increase at later gestations, and are a financial strain for many women. Poor knowledge, geographical and financial barriers restrict method choice. Implications for public health: Policy reform should focus on reducing costs and enhancing early access.

Quality of Care in a Safe-Abortion Hotline in Indonesia: Beyond Harm Reduction

OBJECTIVES

To examine services offered by safe-abortion hotlines in contexts in which abortion is legally restricted and to document the experiences of women contacting a safe-abortion hotline in Indonesia.

METHODS

We analyzed 1829 first-time contacts to a safe-abortion hotline in Indonesia as a part of routine service provision between January 1, 2012 and December 31, 2014.

RESULTS

Nearly one third (29.9%) of initial contacts reported their age as between 18 and 24 years, and most (51.2%) reported being unmarried. When asked about their reason for calling the hotline, the majority of initial contacts stated that they were pregnant and not ready to have a child. More than one third reported gestational ages below 12 weeks, and nearly one fifth (18.3%) reported a gestation of 13 weeks or greater.

CONCLUSIONS

These unique data provide a window of understanding into who contacts safe-abortion hotlines and why, and enable exploration of future directions for research on the role of safe-abortion hotlines in women's access to safe abortion. Public Health Implications. Safe-abortion hotlines should be evaluated not only for reducing harm but also for providing high-quality abortion care.

"In patient" medical abortion versus surgical abortion: patient's satisfaction

OBJECTIVE

To compare patients' satisfaction with medical and surgical abortion, implementing the Italian guidelines on medical abortion entailing an "in patient" procedure.

METHODS

A total of 1832 pregnant chose between surgical (vacuum aspiration) or medical abortion (mifepristone p.o. followed after 3 days by sublingual misoprostol) and expressed their expected satisfaction on a visual analog scale (VAS). A total of 885 women chose surgical and 947 medical abortion. The primary end-point was satisfaction VAS score 20 days after the procedure. Secondary end-points were: difference between pre- and post-abortion VAS score; difference in satisfaction VAS scores according to parity and previous abortion; incidence of side effects.

RESULTS

VAS score was high in each group but significantly higher for the 1-day surgical than for the 3-day medical abortion procedure (7.9 ± 1.0 versus 7.2 ± 1.2; p < 0.0001). In the surgical group the VAS score increased after the treatment (6.9 ± 1.6 versus 7.9 ± 1.0, p < 0.0001), while it decreased in the medical group (7.5 ± 1.0 versus 7.2 ± 1.2; p < 0.0001). Multiparous women reported higher satisfaction with medical abortion; women with a previous abortion preferred surgical abortion.

CONCLUSIONS

Both procedures are considered satisfactory by the patients. Performing medical abortion as a 3-day "in patient" procedure, decreased women's satisfaction scores from their baseline expectations.

Improving access to safe abortion in a rural primary care setting in India: experience of a service delivery intervention

Background

Abortion services were legalized in India in 1972, however, the access to safe abortion services is restricted, especially in rural areas. In 2002, medical abortion using mifepristone- misoprostol was approved for termination of pregnancy, however, its use has been limited in primary care settings.

Methods

This paper describes a service delivery intervention for women attending with unwanted pregnancies over 14 years in four primary care clinics of Rajasthan, India. Prospective data was collected to document the profile of women, method of abortion provided, contraceptive use and follow-up rates after abortion. This analysis includes data collected during August 2001-March 2015.

Results

A total of 9076 women with unwanted pregnancies sought care from these clinics, and abortion services were provided to 70 % of these. Most abortion seekers were married, had one or more children. After 2003, the use of medical abortion increased over the years and ultimately accounted for 99 % of all abortions in 2014. About half the women returned for a follow-up visit, while the proportion using contraceptives declined from 74 % to 52 % from 2001 to 2014.

Conclusions

The results of our intervention indicate that integrating medical abortion into primary care settings is feasible and has a potential to improve access to safe abortion services in rural areas. Our experience can be used to guide program managers and service providers about reducing barriers and making abortion services more accessible to women.

Medical versus surgical methods of early abortion: protocol for a systematic review and environmental scan of patient decision aids

INTRODUCTION

Currently, we lack understanding of the content, quality and impact of patient decision aids to support decision-making between medical and surgical methods of early abortion. We plan to undertake a systematic review of peer-reviewed literature to identify, appraise and describe the impact of early abortion method decision aids evaluated quantitatively (Part I), and an environmental scan to identify and appraise other early abortion method decision aids developed in the US (Part II).

METHODS AND ANALYSIS

For the systematic review, we will search PubMed, Cochrane Library, CINAHL, EMBASE and PsycINFO databases for articles describing experimental and observational studies evaluating the impact of an early abortion method decision aid on women's decision-making processes and outcomes. For the environmental scan, we will identify decision aids by supplementing the systematic review search with Internet-based searches and key informant consultation. The primary reviewer will assess all studies and decision aids for eligibility, and a second reviewer will also assess a subset of these. Both reviewers will independently assess risk of bias in the studies and abstract data using a piloted form. Finally, both reviewers will assess decision aid quality using the International Patient Decision Aid Standards criteria, ease of readability using Flesch/Flesch-Kincaid tests, and informational content using directed content analysis.

ETHICS AND DISSEMINATION

As this study does not involve human subjects, ethical approval will not be sought. We aim to disseminate the findings in a scientific journal, via academic and/or professional conferences and among the broader community to contribute knowledge about current early abortion method decision-making support.

TRIAL REGISTRATION NUMBER

This protocol is registered in the International Prospective Register of Systematic Reviews (CRD42015016717).

Non-invasive prenatal testing: a review of international implementation and challenges

Noninvasive prenatal genetic testing (NIPT) is an advance in the detection of fetal chromosomal aneuploidies that analyzes cell-free fetal DNA in the blood of a pregnant woman. Since its introduction to clinical practice in Hong Kong in 2011, NIPT has quickly spread across the globe. While many professional societies currently recommend that NIPT be used as a screening method, not a diagnostic test, its high sensitivity (true positive rate) and specificity (true negative rate) make it an attractive alternative to the serum screens and invasive tests currently in use. Professional societies also recommend that NIPT be accompanied by genetic counseling so that families can make informed reproductive choices. If NIPT becomes more widely adopted, States will have to implement regulation and oversight to ensure it fits into existing legal frameworks, with particular attention to returning fetal sex information in areas where sex-based abortions are prevalent. Although there are additional challenges for NIPT uptake in the developing world, including the lack of health care professionals and infrastructure, the use of NIPT in low-resource settings could potentially reduce the need for skilled clinicians who perform invasive testing. Future advances in NIPT technology promise to expand the range of conditions that can be detected, including single gene disorders. With these advances come questions of how to handle incidental findings and variants of unknown significance. Moving forward, it is essential that all stakeholders have a voice in crafting policies to ensure the ethical and equitable use of NIPT across the world.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acceptability and feasibility of medical abortion with mifepristone and misoprostol in Nigeria

OBJECTIVE

To examine the acceptability and feasibility of medical abortion in Nigeria.

METHODS

In total, 250 women who were eligible for legal pregnancy termination with a gestational age of up to 63 days since last menstrual period were enrolled in Benin City and Zaria between May 2005 and October 2006. Participants received 200 mg of oral mifepristone in the clinic and then took 400 μg of oral misoprostol 2 days later-choosing to either return to the clinic or take it at home. Women returned 2 weeks later for an assessment of abortion status.

RESULTS

The vast majority (96.3%) of women had successful complete abortions. Ultrasound was used to determine outcome in less than one-third (28.9%) of participants. Most women (83.2%) took the misoprostol at home. Almost all (96.2%) participants were satisfied or very satisfied with the abortion method.

CONCLUSION

The introduction of medical abortion with mifepristone and misoprostol could greatly expand current method options and improve the quality of reproductive health care in Nigeria and other settings in which access to legal abortion services is limited.

Patient viewing of the ultrasound image prior to abortion

BACKGROUND

Little research has investigated women's interest in and factors associated with viewing their ultrasound image in abortion care.

STUDY DESIGN

Using medical records for all abortion care visits in 2011 (n = 15,575) at an urban abortion provider, we determined the proportion of women who chose to view by sociodemographic and pregnancy-related characteristics. We used bivariate and multivariable mixed-effects logistic regression models to examine associations between individual-level factors and the decision to view.

RESULTS

A total of 42.6% of women chose to view. Identifying as nonwhite, being under age 25, being at or below the federal poverty level, and having medium or low decision certainty about the abortion were associated with increased odds of viewing. Being age 30 and over, having previously been pregnant and being more than 9 weeks gestation were associated with decreased odds of viewing.

CONCLUSIONS

Many women seeking abortion care want to view their ultrasound image when offered the opportunity.

Results from a study using misoprostol for management of incomplete abortion in Vietnamese hospitals: implications for task shifting

Background

Complications following spontaneous or induced abortion are a major cause of maternal morbidity. To manage these complications, post-abortion care (PAC) services should be readily available and easy to access. Standard PAC treatment includes surgical interventions that are highly effective but require surgical providers and medical centers that have the necessary space and equipment. Misoprostol has been shown to be an effective alternative to surgical evacuation and can be offered by lower level clinicians. This study sought to assess whether 400 mcg sublingual misoprostol could effectively evacuate the uterus after incomplete abortion and to confirm its applicability for use at lower level settings.

Methods

All women presenting with incomplete abortion at one of three hospitals in Vietnam were enrolled. Providers were not asked to record if the abortion was spontaneous or induced. It is likely that all were spontaneous given the legal status and easy access to abortion services in Vietnam. Participants were given 400 mcg sublingual misoprostol and instructed to hold the pills under their tongue for 30 minutes and then swallow any remaining fragments. They were then asked to return one week later to confirm their clinical status. Study clinicians were instructed to confirm a complete expulsion clinically. All women were asked to complete a questionnaire regarding satisfaction with the treatment.

Results

Three hundred and two women were enrolled between September 2009 and May 2010. Almost all participants (96.3%) had successful completions using a single dose of 400 mcg misoprostol. The majority of women (87.2%) found the side effects to be tolerable or easily tolerable. Most women (84.3%) were satisfied or very satisfied with the treatment they received; only one was dissatisfied (0.3%). Nine out of ten women would select this method again and recommend it to a friend (91.0% and 90.0%, respectively).

Conclusions

This study confirms that 400 mcg sublingual misoprostol effectively evacuates the uterus for most women experiencing incomplete abortion. The high levels of satisfaction and side effect tolerability also attest to the ease of use of this method. From these data and given the international consensus around the effectiveness of misoprostol for incomplete abortion care, it seems timely that use of the drug for this indication be widely expanded both throughout Vietnam and wherever access to abortion care is limited.

Trial registration

ClinicalTrials.gov, NCT00670761

Medical abortion service in rural areas of Henan Province, China: a provider survey

AIM

The aim of this study was to explore the knowledge, attitudes and practices on medical abortion of abortion service providers in rural areas of China.

MATERIAL AND METHODS

A cross-sectional study via self-administered questionnaire was conducted among 362 abortion service providers from family planning service centers (FPSC) and hospitals in rural areas of Henan Province, China, between November 2009 and May 2010.

RESULTS

Most of the providers were female (99.4%) and obstetricians/gynecologists (63.3%). The knowledge score achieved ranged from 9.4 to 78.1 points, with both the median and the mode of 56.3 points. Of the 52.2% (189/362) of providers having a preference on abortion method, 30.2% (57/189) preferred medical abortion, while 69.8% (132/189) preferred surgical abortion. In total, 50.7% (174/343) of the providers indicated the provision of medical abortion should be expanded, with the three biggest challenges in its further expansion being increased complications/failures, poor client knowledge/awareness, and problems with drug/equipment supplies. Of all the providers, 81.7% and 92.2% reported they had experience in providing medical abortion and surgical abortion, respectively. Medical abortion providers were mainly experienced in misoprostol with oral (81.8%)/vaginal (79.6%) prostaglandin (misoprostol/gemeprost).

CONCLUSION

Knowledge on medical abortion of providers working in rural China was at a moderate level. Providers preferred surgical abortion to medical abortion. Providers have more experience in providing surgical abortion than medical abortion. Efforts should be made to overcome the perceived challenges in future expansion of medical abortion.

Contraceptive paths of adolescent women undergoing an abortion in France

PURPOSE

Although more than 30,000 teenagers had an induced abortion in France in 2007 (14.3% of all abortions), little is known about their abortion experience. We explore young women's decisions related to their abortion and the patterns of abortion care among teenagers in France, and draw particular attention to the contraceptive circumstances surrounding the abortion.

METHODS

The data are drawn from the French National Survey of Abortion Patients conducted in 2007, comprising 1,525 women aged 13-19 years.

RESULTS

A majority of French teens (82%) reported their pregnancy was unplanned and took on the responsibility of having an abortion: 45% made the decision alone, 46% shared the decision with their family or partner, and 9% reported the decision was made on their family's or partner's request alone. Sixty-nine percent of teenagers were eligible for both medical and surgical abortions, but only 43% thought they were given a choice of methods. Two-thirds of pregnancies were caused by contraceptive misuse or failure, mostly due to condom slippage or breakage (26%) or inconsistent pill use (20%). In 68% of cases, teenagers were prescribed a more effective method than the one they were using before, although only 11% received a prescription for a long-acting method. One in five teenagers reported not receiving a prescription for contraception.

CONCLUSIONS

Our results reveal varying degrees of young women's autonomy in the decisions regarding their abortion. Although most teens switch to more effective methods of contraception after an abortion, only a minority receives a prescription for a long-acting method.