A prospective, non-randomized study of home use of mifepristone for medical abortion in the U.S

Home use of mifepristone for medical abortion: a systematic review

BACKGROUND

In many countries, persons seeking medical abortion with mifepristone followed by misoprostol can self-administer the second drug, misoprostol, at home, but self-administration of the first drug, mifepristone, is not allowed to the same extent.

OBJECTIVES

This systematic review aims to evaluate whether the efficacy, safety and women's satisfaction with abortion treatment are affected when mifepristone is self-administered at home instead of in a clinic.

SEARCH STRATEGY

A literature search covered CINAHL, Cochrane Library, Embase, Ovid MEDLINE and APA PsycInfo in October 2022.

SELECTION CRITERIA

Eligible studies focused on persons undergoing medical abortion comparing home and in-clinic mifepristone intake. Outcomes included abortion effectiveness, compliance, acceptability, and practical consequences for women.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and risk of bias. Meta-analysis included similar studies while those differing in design were synthesised without meta-analysis.

RESULTS

Six studies (54 233 women) of medical abortions up to 10 weeks were included. One randomised controlled trial and one retrospective register study had moderate risk of bias, and four non-randomised clinical trials where women could choose the place for intake of mifepristone had serious risk of bias. There was no difference in abortion effectiveness (high confidence) or compliance (moderate confidence) between mifepristone administered at home or in-clinic. No differences in complications were detected between groups and most women who chose home administration of mifepristone expressed a preference for this approach.

CONCLUSIONS

Our systematic review demonstrates that the effectiveness of medical abortion is comparable regardless of mifepristone administration and intake, at home or in the clinic.

Should COVID-specific arrangements for abortion continue? The views of women experiencing abortion in Britain during the pandemic

BACKGROUND

During the COVID-19 pandemic, the British governments issued temporary approvals enabling the use of both medical abortion pills, mifepristone and misoprostol, at home. This permitted the introduction of a fully telemedical model of abortion care with consultations taking place via telephone or video call and medications delivered to women's homes. The decision was taken by the governments in England and Wales to continue this model of care beyond the original end date of April 2022, while at time of writing the approval in Scotland remains under consultation.

METHODS

We interviewed 30 women who had undergone an abortion in England, Scotland or Wales between August and December 2021. We explored their views on the changes in abortion service configuration during the pandemic and whether abortion via telemedicine and use of abortion medications at home should continue.

RESULTS

Support for continuation of the permission to use mifepristone and misoprostol at home was overwhelmingly positive. Reasons cited included convenience, comfort, reduced stigma, privacy and respect for autonomy. A telemedical model was also highly regarded for similar reasons, but for some its necessity was linked to safety measures during the pandemic, and an option to have an in-person interaction with a health professional at some point in the care pathway was endorsed.

CONCLUSIONS

The approval to use abortion pills at home via telemedicine is supported by women having abortions in Britain. The voices of patients are essential to shaping acceptable and appropriate abortion service provision.

A telemedicine model for abortion in South Africa: a randomised, controlled, non-inferiority trial

BACKGROUND

Telemedicine for medical abortion increases access to safe abortion but its use has not been described in a controlled trial. We aimed to investigate the effectiveness, adherence, safety, and acceptability of a modified telemedicine protocol for abortion compared with standard care in a low-resource setting.

METHODS

In this randomised, controlled, non-inferiority trial we recruited women seeking medical abortion at or before 9 gestational weeks at four public health clinics in South Africa. Participants were randomly allocated (1:1) by computer-generated blocks of varying sizes to telemedicine or standard care. The telemedicine group received asynchronous online abortion consultation and instruction, self-assessed gestational duration, and had a uterine palpation as a safety measure. Participants in this group took 200 mg mifepristone and 800 μg misoprostol at home. The standard care group received in-person consultation and instruction together with an ultrasound, took 200 mg mifepristone in clinic and 800 μg misoprostol at home. Our primary outcome was complete abortion after initial treatment, assessed at a 6-week interview. Our non-inferiority margin was 4%. Group differences were assessed by modified intention-to-treat (mITT) analysis and per protocol. The trial is registered at ClinicalTrials.gov, NCT04336358, and the Pan African Clinical Trials Registry, PACTR202004661941593.

FINDINGS

Between Feb 28, 2020, and Oct 5, 2021, we enrolled 900 women, 153 (17·0%) of whom were discontinued before the abortion and were not included in the analysis. By mITT analysis, 355 (95·4%) of 372 women in the telemedicine group had a complete abortion compared with 338 (96·6%) of 350 in the standard care group (odds ratio 0·74 [95% CI 0·35 to 1·57]). The risk difference was -1·1% (-4·0 to 1·7). Among women who completed treatment as allocated (per protocol), 327 (95·6%) of 342 women in telemedicine group had complete abortion, compared with 338 (96·6%) of 350 in the standard care group (0·77 [0·36 to 1·68]), with a risk difference of -1·0% (-3·8 to 1·9). One participant (in the telemedicine group) had a ruptured ectopic pregnancy, and a further four participants were admitted to hospital (two in each group), of whom two had blood transfusions (one in each group).

INTERPRETATION

Asynchronous online consultation and instruction for medical abortion and home self-medication, with uterine palpation as the only in-person component, was non-inferior to standard care with respect to rates of complete abortion, and did not affect safety, adherence, or satisfaction.

FUNDING

Grand Challenges Canada and the Swedish Research Council.

Medication Abortion With Pharmacist Dispensing of Mifepristone

Medication abortion with pharmacist-dispensed mifepristone is effective, with a low prevalence of adverse events, and patients are satisfied with the model of care.

To estimate effectiveness and acceptability of medication abortion with mifepristone dispensed by pharmacists.

Women's experiences of self-administration of misoprostol at home as part of early medical abortion: a qualitative evaluation

BACKGROUND

Between 2017 and 2019, legislation was introduced in the UK that approved the home as a place for self-administration of misoprostol for early medical abortion. While research has shown that early medical abortion at home is as safe as in a clinical setting, women's experiences in the UK in the light of this change have not yet been investigated. This qualitative research explored the experiences of women in one region of Scotland, UK who accessed early medical abortion with home self-administration of misoprostol.

METHODS

Qualitative interviews were conducted with 20 women who had recently undergone early medical abortion (≤69 days' gestation) with home self-administration of misoprostol. The data were analysed thematically using an approach informed by the Framework analytic approach.

RESULTS

Women appreciated the flexibility that home administration of misoprostol offered, including the opportunity to control the timing of the abortion. This was particularly important for women who sought not to disclose the abortion to others. Most women valued being in the comfort and privacy of the home when preparing for self-administration, although a small number highlighted some concerns about being at home. Most women reported that self-administration of misoprostol was straightforward; however, some expressed concerns around assessing whether their experiences were 'normal'.

CONCLUSIONS

Women welcomed the opportunity for home self-administration of misoprostol. To further improve women's early medical abortion experience we suggest that the legislation be amended so that women can self-administer in an appropriate non-clinical setting, not just their home.

Perspectives on self-managed abortion among providers in hospitals along the Texas-Mexico border

BACKGROUND

Following self-managed abortion (SMA), or a pregnancy termination attempt outside of the formal health system, some patients may seek care in an emergency department. Information about provider experiences treating these patients in hospital settings on the Texas-Mexico border is lacking.

METHODS

The study team conducted semi-structured interviews with physicians, advanced practice clinicians, and nurses who had experience with patients presenting with early pregnancy complications in emergency and/or labor and delivery departments in five hospitals near the Texas-Mexico border. Interview questions focused on respondents' roles at the hospital, knowledge of abortion services and laws, perspectives on SMA trends, experiences treating patients presenting after SMA, and potential gaps in training related to abortion. Researchers conducted interviews in person between October 2017 and January 2018, and analyzed transcripts using a thematic analysis approach.

RESULTS

Most of the 54 participants interviewed said that the care provided to SMA patients was, and should be, the same as for patients presenting after miscarriage. The majority had treated a patient they suspected or confirmed had attempted SMA; typically, these cases required only expectant management and confirmation of pregnancy termination, or treatment for incomplete abortion. In rare cases, further clinical intervention was required. Many providers lacked clinical and legal knowledge about abortion, including local resources available.

CONCLUSIONS

Treatment provided to SMA patients is similar to that provided to patients presenting after early pregnancy loss. Lack of provider knowledge about abortion and SMA, despite their involvement with SMA patients, highlights a need for improved training.

Effectiveness, safety and acceptability of medical abortion at home versus in the clinic: a systematic review and meta-analysis in response to COVID-19

BACKGROUND

Increased access to home-based medical abortion may offer women a convenient, safe and effective abortion method, reduce burdens on healthcare systems and support social distancing during the COVID-19 pandemic. Home-based medical abortion is defined as any abortion where mifepristone, misoprostol or both medications are taken at home.

METHODS

A systematic review and meta-analysis of randomised controlled trials (RCTs) and non-randomised studies (NRSs) were conducted. We searched databases from inception to 10 July 2019 and 14 June 2020. Successful abortion was the main outcome of interest. Eligible studies were RCTs and NRSs studies with a concurrent comparison group comparing home versus clinic-based medical abortion. Risk ratios (RRs) and their 95% CIs were calculated. Estimates were calculated using a random-effects model. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess risk of bias by outcome and to evaluate the overall quality of the evidence.

RESULTS

We identified 6277 potentially eligible published studies. Nineteen studies (3 RCTs and 16 NRSs) were included with 11 576 women seeking abortion up to 9 weeks gestation. Neither the RCTs nor the NRS found any difference between home-based and clinic-based administration of medical abortion in having a successful abortion (RR 0.99, 95% CI 0.98 to 1.01, I2=0%; RR 0.99, 95% CI 0.97 to 1.01, I2=52%, respectively). The certainty of the evidence for the 16 NRSs was downgraded from low to very low due to high risk of bias and publication bias. The certainty of the evidence for the three RCTs was downgraded from high to moderate by one level for high risk of bias.

CONCLUSION

Home-based medical abortion is effective, safe and acceptable to women. This evidence should be used to expand women's abortion options and ensure access to abortion for women during COVID-19 and beyond.

PROSPERO REGISTRATION NUMBER

CRD42020183171.

Medication Abortion Up to 70 Days of Gestation

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

Women's voices and medical abortions: A review of the literature

Globally, a growing proportion of induced abortions are medical abortions. The procedure has been hailed as a revolutionary technology, which, according to experts, has the potential to transform women's experiences of abortion and the way abortion services are accessed. Noticeably absent in the discourse, however, are women's voices. More specifically, there is a lack of understanding about what shapes women's preferences for medical abortion and the challenges they experience in accessing the drugs for the procedure. We conducted a systematic review of the literature to draw attention to these important issues which exist, but are often embedded within research highlighting other dominating aspects of medical abortions. A comprehensive search of four databases - supplemented by searching reference sections of selected articles, tracking their citations, and hand searching special editions on medical abortion - was conducted. A total of 45 peer-reviewed studies met our inclusion criteria. The studies were assessed for quality and analyzed using a critical interpretive synthesis approach. The findings revealed significant variations in women's preferences for surgical versus medical abortions. Country-specific abortion laws, implementing protocols, side-effects, rates of failures, and the need to verify the abortion shaped women's preference for abortion methods. Overall, women who preferred medical abortions did so because they perceived it as a 'natural' and safe procedure that can be self-conducted at home, thereby reducing their dependency on the health system. However, women face significant barriers to medical abortion care. These include legal requirements around type of provider, site of service, need for follow-up, providers' limited knowledge of the procedure, and preferences for surgical abortions. Borderless internet-based services have enabled some women to circumvent these barriers. Our review suggests that medical abortions are used by women either in countries where the health system is fully supportive or where the health system is completely disengaged, usually due to restricted abortion laws. In those countries where abortions are legal but often difficult to access due to health system barriers, women tend to prefer surgical abortions.

Self-administered versus provider-administered medical abortion

BACKGROUND

The advent of medical abortion has improved access to safe abortion procedures. Medical abortion procedures involve either administering mifepristone followed by misoprostol or a misoprostol-only regimen. The drugs are commonly administered in the presence of clinicians, which is known as provider-administered medical abortion. In self-administered medical abortion, drugs are administered by the woman herself without the supervision of a healthcare provider during at least one stage of the drug protocol. Self-administration of medical abortion has the potential to provide women with control over the abortion process. In settings where there is a shortage of healthcare providers, self-administration may reduce the burden on the health system. However, it remains unclear whether self-administration of medical abortion is effective and safe. It is important to understand whether women can safely and effectively terminate their own pregnancies when having access to accurate and adequate information, high-quality drugs, and facility-based care in case of complications.

OBJECTIVES

To compare the effectiveness, safety, and acceptability of self-administered versus provider-administered medical abortion in any setting.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE in process and other non-indexed citations, Embase, CINAHL, POPLINE, LILACS, ClinicalTrials.gov, WHO ICTRP, and Google Scholar from inception to 10 July 2019.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and prospective cohort studies with a concurrent comparison group, using study designs that compared medical abortion by self-administered versus provider-administered methods.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted the data, and we performed a meta-analysis where appropriate using Review Manager 5. Our primary outcome was successful abortion (effectiveness), defined as complete uterine evacuation without the need for surgical intervention. Ongoing pregnancy (the presence of an intact gestational sac) was our secondary outcome measuring success or effectiveness. We assessed statistical heterogeneity with Chi² tests and I² statistics using a cut-off point of P < 0.10 to indicate statistical heterogeneity. Quality assessment of the data used the GRADE approach. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified 18 studies (two RCTs and 16 non-randomized studies (NRSs)) comprising 11,043 women undergoing early medical abortion (≤ 9 weeks gestation) in 10 countries. Sixteen studies took place in low-to-middle income resource settings and two studies were in high-resource settings. One NRS study received analgesics from a pharmaceutical company. Five NRSs and one RCT did not report on funding; nine NRSs received all or partial funding from an anonymous donor. Five NRSs and one RCT received funding from government agencies, private foundations, or non-profit bodies. The intervention in the evidence is predominantly from women taking mifepristone in the presence of a healthcare provider, and subsequently taking misoprostol without healthcare provider supervision (e.g. at home). There is no evidence of a difference in rates of successful abortions between self-administered and provider-administered groups: for two RCTs, risk ratio (RR) 0.99, 95% confidence interval (CI) 0.97 to 1.01; 919 participants; moderate certainty of evidence. There is very low certainty of evidence from 16 NRSs: RR 0.99, 95% CI 0.97 to 1.01; 10,124 participants. For the outcome of ongoing pregnancy there may be little or no difference between the two groups: for one RCT: RR 1.69, 95% CI 0.41 to 7.02; 735 participants; low certainty of evidence; and very low certainty evidence for 11 NRSs: RR 1.28, 95% CI 0.65 to 2.49; 6691 participants. We are uncertain whether there are any differences in complications requiring surgical intervention, since we found no RCTs and evidence from three NRSs was of very low certainty: for three NRSs: RR 2.14, 95% CI 0.80 to 5.71; 2452 participants.

AUTHORS' CONCLUSIONS

This review shows that self-administering the second stage of early medical abortion procedures is as effective as provider-administered procedures for the outcome of abortion success. There may be no difference for the outcome of ongoing pregnancy, although the evidence for this is uncertain for this outcome. There is very low-certainty evidence for the risk of complications requiring surgical intervention. Data are limited by the scarcity of high-quality research study designs and the presence of risks of bias. This review provides insufficient evidence to determine the safety of self-administration when compared with administering medication in the presence of healthcare provider supervision. Future research should investigate the effectiveness and safety of self-administered medical abortion in the absence of healthcare provider supervision through the entirety of the medical abortion protocol (e.g. during administration of mifepristone or as part of a misoprostol-only regimen) and at later gestational ages (i.e. more than nine weeks). In the absence of any supervision from medical personnel, research is needed to understand how best to inform and support women who choose to self-administer, including when to seek clinical care.

Promoting or Undermining Quality Decision Making? A Qualitative Content Analysis of Patient Decision Aids Comparing Surgical and Medication Abortion

OBJECTIVES

To understand, describe, and compare the content of patient decision aids on surgical and medication abortion, including 1) attributes used to describe each method, 2) approaches to clarify patients' values, 3) language used to describe each method, and 4) language used to frame women's decision-making role.

STUDY DESIGN

We analyzed 49 decision aids identified through a previous systematic review and environmental scan. We used summative content analysis for objectives 1 and 2 and directed content analysis for objectives 3 and 4.

RESULTS

We identified 37 method attributes. Overall, the attributes privileged medical over practical and emotional information. One decision aid included an explicit values clarification approach, and others included implicit approaches, which varied in length, information consistency, and organization. We identified four themes-information consistency, subjective claims, emotive or ambiguous descriptions, and medication abortion as not a real abortion-related to the methods' descriptions. We identified three themes-agency in choice, unclear emphasis on women's preferences, and endorsement of clinic services-related to women's decision-making role. Of the nine tools that listed factors influencing women's decision making, patient preferences was often listed last.

CONCLUSIONS

Early abortion method decision aids presented a broad range of information and typically framed the method choice as the woman's. However, their emphasis on medical attributes, use of inconsistent information, and, at times, biased presentation of methods may undermine quality decision making. We recommend adapting an existing decision aid or designing a novel tool based on the content and language that women find most acceptable.

Support for and interest in alternative models of medication abortion provision among a national probability sample of U.S. women

OBJECTIVE

The objective was to assess women's personal interest in and support for three alternative models of medication abortion (MA) provision.

STUDY DESIGN

Using an online survey of a U.S. national, probability-based representative sample of women ages 18-49, we gauged personal interest in and general support for three alternative models for accessing abortion pills: (1) in advance from a doctor for future use, (2) over-the-counter (OTC) from a drugstore and (3) online without a prescription. We conducted multivariable analyses to identify characteristics associated with support for these provision models.

RESULTS

Fifty percent (n=7022) of eligible women invited completed the survey. Nearly half (49%) supported and 30% were personally interested in one or more of the three access models; 44% supported advance provision, 37% supported OTC access, and 29% supported online access. Common advantages reported for advance provision, OTC and online access included privacy (49%, 29% and 46%, respectively), convenience (38%, 44% and 38%) and being able to end the pregnancy earlier (48%, 40% and 29%). Common disadvantages included concern that women might take the pills incorrectly (55%, 53% and 57%), not seeing a clinician before the abortion (52%, 54% and 53%) and safety (42%, 43% and 60%). History of abortion and experiencing barriers accessing reproductive health services were associated with greater support for the alternative models.

CONCLUSION

Women are interested in and support alternative models of MA provision, in particular, advance provision. However, they also reported concerns about incorrect pill use and not seeing a clinician beforehand.

IMPLICATIONS

Offering women more choices in how they access medication abortion, including options where they can safely self-manage their own care, has the potential to expand access to care.

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

OBJECTIVE

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

DESIGN

Qualitative interview study.

SETTING

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

POPULATION OR SAMPLE

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TWEETABLE ABSTRACT

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

A research agenda for moving early medical pregnancy termination over the counter

Given the overall safety profile and increasing availability of medical pregnancy termination drugs, we asked: would the mifepristone-misoprostol regimen for medical termination at ≤10 weeks of gestation meet US Food and Drug Administration regulatory criteria for over-the-counter (OTC) approval, and if not, what are the present research gaps? We conducted a literature review of consumer behaviours necessary for a successful OTC application for medical termination at ≤10 weeks of gestation and identified crucial research gaps. If we were to embark on a development programme for OTC or more generally, self-use of medical termination, the critical elements missing are the label comprehension, self-selection and actual use studies.

TWEETABLE ABSTRACT

Considering medical pregnancy termination through the over-the-counter regulatory lens clarifies critical evidence gaps.

Self-management of medical abortion: a qualitative evidence synthesis

Medical abortion is a method of pregnancy termination that by its nature enables more active involvement of women in the process of managing, and sometimes even administering the medications for, their abortions. This qualitative evidence synthesis reviewed the global evidence on experiences with, preferences for, and concerns about greater self-management of medical abortion with lesser health professional involvement. We focused on qualitative research from multiple perspectives on women's experiences of self-management of first trimester medical abortion (<12weeks gestation). We included research from both legal and legally-restricted contexts whether medical abortion was accessed through formal or informal systems. A review team of four identified 36 studies meeting inclusion criteria, extracted data from these studies, and synthesized review findings. Review findings were organized under the following themes: general perceptions of self-management, preparation for self-management, logistical considerations, issues of choice and control, and meaning and experience. The synthesis highlights that the qualitative evidence base is still small, but that the available evidence points to the overall acceptability of self-administration of medical abortion. We highlight particular considerations when offering self-management options, and identify key areas for future research. Further qualitative research is needed to strengthen this important evidence base.