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

Factors associated with severe pain during medication abortion at ≤9 weeks' gestation: A secondary analysis of a multicenter, randomized, placebo-controlled trial

OBJECTIVES

This study aimed to identify covariates other than pain management regimen associated with severe pain during medication abortion at ≤9 weeks' gestation.

STUDY DESIGN

This is a secondary analysis of a randomized trial in Vietnam, Nepal, and South Africa investigating two prophylactic pain management regimens during medication abortion. We used multivariable logistic regression models to identify factors associated with severe pain within 8 hours after taking misoprostol.

RESULTS

During June 2016 to October 2017, 273 of 556 (49.1%) participants experienced severe pain (score ≥8 out of 10). In multivariable analyses, controlling for study center and prophylactic treatment arm, multiparity (odds ratio [OR] 0.35, 95% CI 0.23-0.53) was associated with reduced odds of severe pain, while dysmenorrhea (OR 1.16, 95% CI 1.07-1.26) and higher gestational duration (OR 1.05, 95% CI 1.01-1.09) were associated with increased odds of pain. Higher anticipated pain score (OR 1.10, 95% CI 0.99-1.23) was marginally associated with severe pain. Among multiparous patients, history of cesarean delivery (OR 3.49, 95% CI 1.24-9.77), severe pain in childbirth (OR 2.36, 95% CI 1.03-5.42), and dysmenorrhea (OR 1.22, 95% CI 1.08-1.39) were significantly associated with severe pain. Higher gestational duration (OR 1.05, 95% CI 0.99-1.11) trended toward an association with severe pain. Sociodemographic variables, including younger age, marital status, financial stability, and anxiety or depression, were not associated with pain.

CONCLUSIONS

Beyond known risk factors of nulliparity, dysmenorrhea, and gestational duration, this analysis demonstrates that severe pain during medication abortion is significantly associated with history of cesarean delivery and severe pain in childbirth. Depression and anxiety were not associated with severe pain. These findings can inform counseling for patients seeking medication abortion.

IMPLICATIONS

Education and counseling prior to medication abortion should include information about the range of factors associated with increased pain. This information can help individuals make informed decisions about their abortion method and, for those choosing medication abortion, better prepare for and optimize their pain management.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN126130 0 0 017729.

Patients' experiences with pain and bleeding in first-trimester abortion care

BACKGROUND

Abortion care is safe and commonly needed. While pain and bleeding are expected, patients' experience of pain and bleeding at the time of abortion can affect patient satisfaction and the abortion experience. There is limited research characterizing factors associated with patient-reported severe pain and heavy bleeding with contemporary abortion methods.

OBJECTIVE

To assess clinical predictors of patient-reported heavy bleeding and pain among first-trimester abortion patients.

STUDY DESIGN

We conducted a secondary analysis of a multicenter prospective cohort study of 644 participants undergoing medication or procedural abortion up to 11w6d. The primary outcome was participant-reported severe postabortion pain; secondary outcomes included bleeding severity and discordance between expected and experienced pain and bleeding. We developed logistic regression models assessing clinical factors associated with severe pain, heavy bleeding, more than expected pain, and heavier than expected bleeding.

RESULTS

Of 644 eligible participants, 516 (80%) responded, 347 (67%) of whom had medication abortion and 169 (33%) of whom had procedural abortion. One-fourth reported severe pain, 35.0% heavy bleeding, 31.6% more than expected pain, and 33.5% heavier than expected bleeding. Factors most strongly associated with participant-reported severe pain included medication abortion (odds ratio=4.69 [95% confidence interval: 2.56-8.58]), history of severe menstrual pain (odds ratio=2.60 [95% confidence interval: 1.38-4.89]), and screening positive for depression at baseline (odds ratio=2.13 [95% confidence interval: 1.18-3.85]). Independent risk factors for pain discordance included first abortion experience (adjusted odds ratio=2.03 [95% confidence interval: 1.18-3.48]), nulliparity (adjusted odds ratio=2.21 [95% confidence interval: 1.26-3.85]), history of a prior cesarean delivery (adjusted odds ratio=2.06 [95% confidence interval: 1.14-3.72]), and baseline depression (adjusted odds ratio=1.72 [95% confidence interval: 1.05-2.82), adjusted for gravidity, abortion method, and location of care. Self-reported heavy bleeding was most strongly associated with medication abortion regimen (adjusted odds ratio=9.19 [95% confidence interval: 5.09-16.61]) and screening positive for depression at baseline (adjusted odds ratio=2.15 [95% confidence interval: 1.28-3.61]). Abortion method and gestational length were the only significant predictors of discordance between bleeding expectations and experience.

CONCLUSION

While most patients were prepared for the pain and bleeding experienced after abortion, the patient experience may be improved by anticipatory guidance that incorporates risk factors for severe pain and heavy bleeding.

How integrated knowledge translation worked to reduce federal policy barriers to the implementation of medication abortion in Canada: a realist evaluation

BACKGROUND

Initial Canadian federal regulations for the abortion pill, mifepristone, had the potential to impede safe and equitable access to this medication. To catalyze evidence-based regulatory change, we engaged health policy, health system, and health services decision makers, and health professional organizations in integrated knowledge translation (iKT), a research approach that engages the users of research as equal partners.

METHODS

We conducted a realist evaluation of what iKT strategies worked, for whom, and in what context to impact federal mifepristone regulations. We constructed initial program theories (if-then statements about how iKT worked). We tested the initial program theories using interviews with researchers and knowledge partners and triangulated with analysis of research programme documents. We configured the evidence in relation to the initial program theories, and refined program theories into causal explanatory configurations.

RESULTS

We analyzed 38 interviews with researchers, health professional leaders, advocacy group leaders, and administrative government policy makers, as well as 49 program documents. Our results indicated that researcher partnerships with stakeholders had a meaningful impact on the removal of restrictions. We found key components of the causal explanatory configurations included: researcher motivation to move evidence into action, trusted reputations as credible sources of evidence, strategic partnerships, understanding of health policy processes, and researcher roles as a trusted convenor between key groups and decision makers.

CONCLUSIONS

Our study identifies several practical and transferable approaches to impactful iKT. The findings may be of relevance to researchers focused on public health topics subject to stigma.

Obstetric infections and clinical characteristics of maternal sepsis: a hospital-based retrospective cohort study

Sepsis is responsible for 50% of intrahospital maternal deaths worldwide. Incidence is increasing in both low and middle-, and high-income countries. There is little data on incidence and clinical outcomes of obstetric infections including maternal sepsis in the Nordic countries. The aims of this study are to give estimates of the occurrence of obstetric infections and maternal sepsis in a Norwegian hospital cohort, assess the quality of management of maternal sepsis cases, and evaluate the usefulness of diagnostic codes to identify maternal sepsis retrospectively. We conducted a retrospective cohort study of pregnant, labouring, post-abortion, and postpartum women. We assessed the accuracy of the diagnostic code most frequently applied for maternal sepsis, O85. We found 7.8% (95% confidence interval 7.1-8.5) infection amongst pregnant, labouring, and postpartum women. The incidence of maternal sepsis was 0.3% (95% confidence interval 0.2-0.5), and the majority of sepsis cases were recorded in the postpartum period. Two thirds of women were given broad-spectrum antibiotics at the time sepsis was diagnosed, but only 15.4% of women with puerperal sepsis were given antimicrobials in accordance with national guidelines. When used retrospectively, obstetric infection codes are insufficient in identifying both maternal and puerperal sepsis, with only 20.3% positive predictive value for both conditions. In conclusion, obstetric infections contribute significantly to maternal morbidity in Norway's second largest maternity hospital. This study provides incidences of maternal infections for hospitalised patients in temporal relation to pregnancy, labour, abortion and the postpartum period, knowledge which is valuable for planning of health care services and allocation of resources. In addition, the study highlights areas where improvement is needed in clinical handling of maternal sepsis. There is need for studies on the management quality and use of correct diagnostic codes in this patient category.

How can patient experience of abortion care be improved? Evidence from the SACHA study

BACKGROUND

Models of abortion care have changed significantly in the last decade, most markedly during the COVID-19 pandemic, when home management of early medical abortion with telemedical support was approved in Britain.

OBJECTIVE

Our study aimed to examine women's satisfaction with abortion care and their suggestions for improvements.

DESIGN

Qualitative, in-depth, semi-structured interviews.

METHODS

A purposive sample of 48 women with recent experience of abortion was recruited between July 2021 and August 2022 from independent sector and National Health Service abortion services in Scotland, Wales and England. Interviews were conducted by phone or via video call. Women were asked about their abortion experience and for suggestions for any improvements that could be made along their patient journey - from help-seeking, the initial consultation, referral, treatment, to aftercare. Data were analyzed using the Framework Method.

RESULTS

Participants were aged 16-43 years; 39 had had a medical abortion, 8 a surgical abortion, and 1 both. The majority were satisfied with their clinical care. The supportive, kind and non-judgmental attitudes of abortion providers were highly valued, as was the convenience afforded by remotely supported home management of medical abortion. Suggestions for improvement across the patient journey centred around the need for timely care; greater correspondence between expectations and reality; the importance of choice; and the need for greater personal and emotional support.

CONCLUSION

Recent changes in models of care present both opportunities and challenges for quality of care. The perspectives of patients highlight further opportunities for improving care and support. The principles of timely care, choice, management of expectations, and emotional support should inform further service configuration.

[Pain assessment during medical abortion up to 14 weeks: A 1-year prospective comparative study]

OBJECTIVES

Pain assessment of patients requesting a medical abortion according to the term, up to 14 weeks, by a numerical rating scale (NRS).

METHODS

This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020.

RESULTS

There was no significant difference in pain assessed by the NRS for medical abortion performed between 7-9 weeks and those performed between 9-14 weeks (6.5±2.5 vs. 6.6±2.2, P=0.85). Regardless of the term (before 7 weeks, between 7-9 weeks and between 9-14 weeks), patients felt relieved by taking painkillers in the case of medical abortion in 88.9%, 80.3% and 87.3% of cases respectively (P=0.18). The use of analgesics allowed a decrease of 3 points of the NRS in the 3 groups (P=0.67). Patients were more painful in case of medical protocol vs. surgical (maximum pain at 6.0±2.6 vs. 1.4±2.0, P<0.01), but declared to be relieved by analgesics in 85.1 and 94.3% of cases (P=0.24).

CONCLUSIONS

As pain is similar whatever the term in the case of medical abortion, and its management by analgesics seems to be effective, this criterion should not guide the professional in the choice of method, particularly between 9 and 14 weeks. This choice must be made by the patient.

[Single dose of misoprostol for abortion until 9 weeks of gestation]

OBJECTIVES

The primary objective was to compare the efficacy of a single-dose misoprostol for abortion before 7 weeks of gestation and between 7 and 9 weeks of gestation. The secondary objectives were to compare the amount of misoprostol required for complete expulsion, the need for endo-uterine aspiration, and to assess pain and patient experience in these two groups.

METHODS

This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020.

RESULTS

A total of 306 patients were included, 150 in the group before 7 weeks of gestation and 156 in the group between 7 and 9 weeks of gestation. There was no significant difference in the success rate of the single dose of misoprostol between the two groups with 34.7 and 37.8% respectively (P=0.63). After taking painkillers, there is no difference in terms of pain relief (EN ≤ 4 for 92 et 95% of patients P=0.37).

CONCLUSION

The single dose of misoprostol for in-hospital abortion is as effective between 7 and 9 weeks of gestation as it is before 7. By extension, therefore, we would suggest that there should be no difference in efficacy between home abortions before 7 weeks of gestation and between 7 and 9 weeks of gestation and therefore suggest that home abortions can be performed up to 9 weeks of gestation without fear of a decrease in the rate of complete expulsion and the efficacy of analgesia, with potentially less use of misoprostol compared with the hospital setting.

Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review

OBJECTIVE

To inform UK service development to support medical abortion at home, appropriate for person and context.

DESIGN

Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion.

INTERVENTIONS

Interventions and new models of abortion care relevant to the UK.

OUTCOME MEASURES

Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory.

RESULTS

We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception.

CONCLUSIONS

Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.

Abortion services and providers in Canada in 2019: results of a national survey

BACKGROUND

Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion.

METHODS

We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics.

RESULTS

Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (n = 2334) of all abortions in rural areas, as opposed to 25.6% (n = 11 067) in urban areas.

INTERPRETATION

The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.

Pain management for medical abortion before 14 weeks' gestation

BACKGROUND

Abortion is common worldwide and increasingly abortions are performed at less than 14 weeks' gestation using medical methods, specifically using a combination of mifepristone and misoprostol. Medical abortion is known to be a painful process, but the optimal method of pain management is unclear. We sought to identify and compare pain management regimens for medical abortion before 14 weeks' gestation.  OBJECTIVES: Primary objective To determine if there is evidence of superiority of any particular pain relief regimen in the management of combination medical abortion (mifepristone + misoprostol) under 14 weeks' gestation (i.e. up to 13 + 6 weeks or 97 days). Secondary objectives To compare the rate of gastrointestinal side effects resulting from different methods of analgesia To compare the rate of complete abortion resulting from different methods of analgesia during medical abortion To determine if the induction-to-abortion interval is associated with different methods of analgesia To determine if any method of analgesia is associated with unscheduled contact with the care provider in relation to pain.

SEARCH METHODS

On 21 August 2019 we searched CENTRAL, MEDLINE, Embase, CINAHL, LILACs, PsycINFO, the World Health Organization International Clinical Trials Registry and ClinicalTrials.gov together with reference checking and handsearching of conference abstracts of relevant learned societies and professional organisations to identify further studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and observational studies (non-randomised studies of interventions (NRSIs)) of any pain relief intervention (pharmacological and non-pharmacological) for mifepristone-misoprostol combination medical abortion of pregnancies less than 14 weeks' gestation.

DATA COLLECTION AND ANALYSIS

Two review authors (JRW and MA) independently assessed all identified papers for inclusion and risks of bias, resolving any discrepancies through discussion with a third and fourth author as required (CM and SC). Two review authors independently conducted data extraction, including calculations of pain relief scores, and checked for accuracy. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included four RCTs and one NRSI. Due to the heterogeneity of study designs, interventions and outcome reporting, we were unable to perform meta-analysis for any of the primary or secondary outcomes in this review. Only one study found evidence of an effect between interventions on pain score: a prophylactic dose of ibuprofen 1600 mg likely reduces the pain score when compared to a dose of paracetamol 2000 mg (mean difference (MD) 2.26 out of 10 lower, 95% confidence interval (CI) 3.00 to 1.52 lower; 1 RCT 108 women; moderate-certainty evidence). There may be little to no difference in pain score when comparing pregabalin 300 mg with placebo (MD 0.5 out of 10 lower, 95% CI 1.41 lower to 0.41 higher; 1 RCT, 107 women; low-certainty evidence).  There may be little to no difference in pain score when comparing ibuprofen 800 mg with placebo (MD 1.4 out of 10 lower, 95% CI 3.33 lower to 0.53 higher; 1 RCT, 61 women; low-certainty evidence). Ambulation or non-ambulation during medical abortion treatment may have little to no effect on pain score, but the evidence is very uncertain (MD 0.1 out of 5 higher, 95% CI 0.26 lower to 0.46 higher; 1 NRSI, 130 women; very low-certainty evidence). There may be little to no difference in pain score when comparing therapeutic versus prophylactic administration of ibuprofen 800 mg (MD 0.2 out of 10 higher, 95% CI 0.41 lower to 0.81 higher; 1 RCT, 228 women; low-certainty evidence).   Other outcomes of interest were reported inconsistently across studies. Where these outcomes were reported, there was no evidence of difference in incidence of gastrointestinal side effects, complete abortion rate, interval between misoprostol administration to pregnancy expulsion, unscheduled contact with a care provider, patient satisfaction with analgesia regimen nor patient satisfaction with abortion experience overall. However, the certainty of evidence was very low to low.

AUTHORS' CONCLUSIONS

The findings of this review provide some support for the use of ibuprofen as a single dose given with misoprostol prophylactically, or in response to pain as needed. The optimal dosing of ibuprofen is unclear, but a single dose of ibuprofen 1600 mg was shown to be effective, and it was less certain whether 800 mg was effective. Paracetamol 2000 mg does not improve pain scores as much as ibuprofen 1600 mg, however its use does not appear to cause greater frequency of side effects or reduce the success of the abortion. A single dose of pregabalin 300 mg does not affect pain scores during medical abortion, but like paracetamol, does not appear to cause harm. Ambulation or non-ambulation during the medical abortion procedure does not appear to affect pain scores, outcomes, or duration of treatment and so women can be advised to mobilise or not, as they wish. The majority of outcomes in this review had low- to very low-certainty evidence, primarily due to small sample sizes and two studies at high risk of bias. High-quality, large-scale RCT research is needed for pain management during medical abortion at gestations less than 14 weeks. Consistent recording of pain with a validated measure would be of value to the field going forward.

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.

Cross-country abortion travel to England and Wales: results from a cross-sectional survey exploring people's experiences crossing borders to obtain care

Background

The laws governing abortion access vary across Europe. Even in countries with relatively liberal laws, numerous barriers to abortion access exist. In response to these barriers, evidence suggests that people living in countries with both restrictive and liberal laws travel outside of their home country for abortion care. England and Wales are common destinations for those who travel to seek abortions, but little is known about the motivations and experiences of those who undertake cross-country travel to England or Wales to obtain care. This paper aims to describe the abortion seeking and travel experiences of women and pregnant people who traveled to England and Wales for an abortion between 2017 and 2019.

Methods

We recruited 97 participants who had traveled cross-country from both liberal and restrictive contexts to seek abortion care at three participating BPAS clinics in England and Wales. Participants completed an electronic survey about their reproductive histories, abortion decision-making, experiences seeking abortion care, and traveling. We conducted a descriptive analysis, and include comparisons between participants who traveled from liberal and restrictive contexts.

Results

Over a third of participants considered abortion four weeks or more before presenting for care at BPAS, and around two-thirds sought abortion services in their home country before traveling. The majority of participants indicated that they would have preferred to have obtained an abortion earlier and cited reasons including scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. About seventy percent of participants reported travel costs between €101–1000 and 75% of participants reported that the cost of the abortion procedure exceeded €500. About half of participants indicated that, overall, their travel was very or somewhat difficult.

Conclusions

This analysis documents the burdens associated with cross-country travel for abortion and provides insight into the factors that compel people to travel. Our findings highlight the need for expanded access to abortion care throughout Europe via the removal of legal impediments and other social or procedural barriers. Removing barriers would eliminate the need for cumbersome abortion travel, and ensure that all people can obtain necessary, high-quality healthcare in their own communities.

In Europe, people who live in countries where abortion is severely restricted or illegal altogether lack access to abortion care entirely, but even people who live in countries with more liberal laws face barriers due to gestational age limits, waiting periods, and a lack of trained and willing providers. Existing evidence suggests that restrictions and barriers compel people from both countries with restrictive laws as well as those from countries with more liberal laws to travel outside of their home country for abortion services. England and Wales are common destinations for people traveling within Europe to obtain abortion services, but little is known about the experiences of these travelers. We surveyed individuals who had traveled from another country to seek abortion services in England or Wales. Our analysis documents that many participants contemplated getting an abortion and sought care in their home countries before traveling. Likewise, many participants indicated that they would have preferred to have obtained an abortion earlier in their pregnancy, and referenced scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. A majority of participants indicated that covering the costs of their abortion, and the costs of travel was difficult, and that the travel experience in its entirety was difficult. Our findings document the reasons for, and burdens associated with abortion travel and highlight the need to expand access to abortion across Europe via the elimination of all legal restrictions and impediments.

Provision of medication abortion in Hawai'i during COVID-19: Practical experience with multiple care delivery models

Objective

To demonstrate the effectiveness of medication abortion with the implementation of telemedicine and a no-test protocol in response to the COVID-19 pandemic.

Study design

This is a retrospective cohort study of patients who had a medication abortion up to 77 days gestation at the University of Hawai‘i between April and November 2020. Patients had the option of traditional in clinic care or telemedicine with either in clinic pickup or mailing of medications. During this time, a no-test protocol for medication abortion without prior labs or ultrasound was in place for eligible patients. The primary outcome was the rate of successful medication abortion without surgical intervention. Secondary outcomes included abortion-related complications.

Results

A total of 334 patients were dispensed mifepristone and misoprostol, 149 (44.6%) with telemedicine with in-person pickup of medications, 75 (22.5%) via telemedicine with medications mailed, and 110 (32.9%) via traditional in person visits. The overall rate of complete medication abortion without surgical intervention was 95.8%, with success rates of 96.8, 97.1, and 93.6% for the clinic pickup, mail, and clinic visit groups, respectively. Success for those without an ultrasound performed prior to the procedure was 96.6%, compared to 95.5% for those with ultrasound. We obtained follow-up data for 87.8% of participants.

Conclusions

Medication abortion was safe and effective while offering multiple modes of care delivery including telemedicine visits without an ultrasound performed prior to dispensing medications.

Implications

Incorporating telemedicine and a no-test protocol for medication abortion is safe and has the potential to expand access to abortion care. All care models had low rates of adverse events, which contradicts the idea that the Risk Evaluation and Mitigation Strategyincreases the safety of medication abortion.

Women's experiences with information before medication abortion at home, support during the process and follow-up procedures - A qualitative study

OBJECTIVE

To explore women's experiences of having a medication abortion at home in regard to their perceptions of the information provided before the abortion, support throughout the process and follow-up procedures.

STUDY DESIGN

A qualitative study based on interviews with 23 women between October 2019 and January 2020. Systematic text condensation was used for data analysis.

RESULTS

Three themes were identified from the analysis. The first theme covers how the women found the information given before the abortion to be inadequate and how this affected their feelings of safety. In the second theme, the participants described how they experienced lack of acknowledgement from health care professionals, and how this affected their feeling of support. The third theme covers how the women perceived access to health care professionals during the home abortion, and how this affected their feeling of well-being.

CONCLUSIONS

In general, the women stated that the information provided was inadequate, especially in regard to bleeding and pain. The women also found support during and after the abortion to be insufficient and would have preferred more help and information throughout the process. This suggests that health care professionals should improve their procedures for providing information, support and care.

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.

Implementation of mifepristone medical abortion in Canada: pilot and feasibility testing of a survey to assess facilitators and barriers

BACKGROUND

Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada.

METHODS

In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh's conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin's framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré's validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility.

RESULTS

We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada.

CONCLUSIONS

Our team operationalized Greenhalgh's theoretical framework for Diffusion of Innovations in health systems to explore factors influencing the implementation of first-trimester medical abortion provision. This process may be useful for those evaluating other health system innovations. Identification of facilitators and barriers to implementation of mifepristone practice in Canada and knowledge translation has the potential to inform regulatory and health system changes to support and scale up facilitators and mitigate barriers to equitable medical abortion provision.

Snapshot of medication abortion provision in the primary health care setting of regional and rural Victoria

OBJECTIVE

This study aimed to identify enablers and barriers to the provision of medication abortion in the primary health care setting of regional and rural areas of Victoria, Australia.

DESIGN

An online cross-sectional questionnaire was used.

SETTING

Regional and rural areas of Victoria, Australia.

PARTICIPANTS

Thirty-nine GPs and 30 primary health care nurses.

MAIN OUTCOME MEASURES

Abortion views, medication abortion knowledge and practice, interest in medication abortion training and provision, and perceived uptake barriers.

RESULTS

Most participants reported being consulted by women with unintended pregnancies and most of them included abortion counselling in their consultation. However, familiarity with provision of medication abortion was limited, and only five GPs and two primary health care nurses were currently medication abortion providers. The majority of participants expressed a high level of interest in receiving medication abortion training, but indicated a wide range of barriers to service provision, such as a lack of training opportunities, legal uncertainties or surgical access concerns in case of complications.

CONCLUSIONS

Findings demonstrate the need for education on medication abortion and training opportunities. Most identified barriers to service uptake are addressable and relate to a lack of local support services, including the absence of a 24-hour contact advice service, insufficient follow-up access and a lack of local ultrasound facilities. These barriers require educational programs at professional, organisational and community level to ensure that interested rural and regional primary health care providers can start offering medication abortion for their patients.

Could implementation of mifepristone address Canada's urban-rural abortion access disparity: a mixed-methods implementation study protocol

INTRODUCTION

In January 2017, mifepristone-induced medical abortion was made available in Canada. In this study, we will seek to (1) understand facilitators and barriers to the implementation of mifepristone across Canada, (2) assess the impact of a 'community of practice' clinical and health service support platform and (3) engage in and assess the impact of integrated knowledge translation (iKT) activities aimed to improve health policy, systems and service delivery issues to enhance patient access to mifepristone.

METHODS AND ANALYSIS

This prospective mixed-methods implementation study will involve a national sample of physicians and pharmacists recruited via an online training programme, professional networks and a purpose-built community of practice website. Surveys that explore constructs related to diffusion of innovation and Godin's behaviour change frameworks will be conducted at baseline and at 6 months, and qualitative data will be collected from electronic interactions on the website. Survey participants and a purposeful sample of decision-makers will be invited to participate in in-depth interviews. Descriptive analyses will be conducted for quantitative data. Thematic analysis guided by the theoretical frameworks will guide interpretation of qualitative data. We will conduct and assess iKT activities involving Canada's leading health system and health professional leaders, including evidence briefs, Geographical Information System (GIS)maps, face-to-face meetings and regular electronic exchanges. Findings will contribute to understanding the mechanisms of iKT relationships and activities that have a meaningful effect on uptake of evidence into policy and practice.

ETHICS AND DISSEMINATION

Ethical approval was received from the University of British Columbia Children's and Women's Hospital Ethics Review Board (H16-01006). Full publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to research participants through newsletters and media interviews, and to policy-makers through invited evidence briefs and face-to-face presentations.

Experiences of women who travel for abortion: A mixed methods systematic review

OBJECTIVE

To systematically review the literature on women's experiences traveling for abortion and assess how this concept has been explored and operationalized, with a focus on travel distance, cost, delays, and other barriers to receiving services.

BACKGROUND

Increasing limitations on abortion providers and access to care have increased the necessity of travel for abortion services around the world. No systematic examination of women's experiences traveling for abortion has been conducted; this mixed-methods review provides a summary of the qualitative and quantitative literature on this topic.

METHODS

A systematic search was conducted using PubMed, Embase, Web of Science, Popline, and Google Scholar in July 2016 and updated in March 2017 (PROSPERO registration # CRD42016046007). We included original research studies that described women's experiences traveling for abortion. Two reviewers independently performed article screening, data extraction and determination of final inclusion for analysis. Critical appraisal was conducted using CASP, STROBE, and MMAT checklists.

RESULTS

We included 59 publications: 46 quantitative studies, 12 qualitative studies, and 1 mixed-methods study. Most studies were published in the last five years, relied on data from the US, and discussed travel as a secondary outcome of interest. In quantitative studies, travel was primarily conceptualized and measured as road or straight-line distance to abortion provider, though some studies also incorporated measures of burdens related to travel, such as financial cost, childcare needs, and unwanted disclosure of their abortion status to others. Qualitative studies explored regional disparities in access to abortion care, with a focus on the burdens related to travel, the impact of travel on abortion method choice, and women's reasons for travel. Studies generally were of high quality, though many studies lacked information on participant recruitment or consideration of potential biases.

CONCLUSIONS

Standardized measurements of travel, including burdens associated with travel and more nuanced considerations of travel costs, should be implemented in order to facilitate comparison across studies. More research is needed to explore and accurately capture different dimensions of the burden of travel for abortion services on women's lives.

Service provider perceptions of the trend in severity of symptoms and complications in women admitted following an incomplete abortion

Background

Sri Lankan abortion law which dates back to the year 1883, and still unchanged, only allows a legal termination when the mother's life is in danger. Many studies undertaken in the country estimates that even in the light of such a backdrop, and with a high contraceptive prevalence rate, many women attempt an abortion when faced with an unwanted pregnancy. This study aims to describe the changes in abortion-related complications in the country over a period of time and explore the reasons for any changes in severity of symptoms among women hospitalized following an abortion based on the perceptions of healthcare service providers.

Method

Using an interviewer guide, in-depth interviews were carried out among 30 service providers of post abortion care with more than 5 years of experience in obstetrics and gynecology in Sri Lanka.

Results

Service providers perceived that the number of women presenting to hospitals after an induced abortion caused by a mechanical method is minimal or not at all at present. Over time, a significant reduction is seen in the number of women presenting with any abortion-related complications and the severity of complications has also reduced significantly. The common method of termination at present identified by the providers was the use of "drugs" or "the drug - Misoprostol."

Conclusion

Over the years, women appear to have switched from surgical and mechanical methods to medical means (drugs) to induce an abortion and this change has contributed to reduce the severity of complications.

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.

Implementing medical abortion with mifepristone and misoprostol in Norway 1998-2013

Background: Medical abortion with mifepristone and misoprostol was introduced in Norway in 1998, and since then there has been an almost complete change from predominantly surgical to medical abortions. We aimed to describe the medical abortion implementation process, and to compare characteristics of women obtaining medical and surgical abortion.

Methods: Information from all departments of obstetrics and gynaecology in Norway on the time of implementation of medical abortion and abortion procedures in use up to 12 weeks of gestation was assessed by surveys in 2008 and 2012. We also analysed data from the National Abortion Registry comprising 223 692 women requesting abortion up to 12 weeks of gestation during 1998–2013.

Results: In 2012, all hospitals offered medical abortion, 84.4% offered medical abortion at 9–12 weeks of gestation and 92.1% offered home administration of misoprostol. The use of medical abortion increased from 5.9% of all abortions in 1998 to 82.1% in 2013. Compared with women having a surgical abortion, women obtaining medical abortion had higher odds for undergoing an abortion at 4–6 weeks (adjusted OR 2.33; 95% confidence interval 2.28-2.38). Waiting time between registered request for an abortion until termination was reduced from 11.3 days in 1998 to 7.3 days in 2013.

Conclusions: Norwegian women have gained access to more treatment modalities and simplified protocols for medical abortion. At the same time they obtained abortions at an earlier gestational age and the waiting time has been reduced.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial

INTRODUCTION

Although home use of misoprostol for early medical abortion is considered to be safe, effective and feasible, it has not become standard service delivery practice. The aim of this study was to compare the efficacy, safety, and acceptability of home use of misoprostol with clinic misoprostol in a low-resource setting.

MATERIAL AND METHODS

This was a secondary analysis of a randomized controlled trial conducted in six primary care clinics in India. Women seeking medical abortion within up to nine gestational weeks (n = 731) received mifepristone in the clinic and were allocated either to home or clinic administration of misoprostol. Follow-up contact was after 10-15 days.

RESULTS

Of 731 participants, 73% were from rural areas and 55% had no formal education. Complete abortion rates in the home and clinic misoprostol groups were 94.2 and 94.4%, respectively. The rate of adverse events was similar in both groups (0.3%). A greater proportion of home users (90.2%) said that they would opt for misoprostol at home in the event of a future abortion compared with clinic users (79.7%) who would opt for misoprostol at the clinic in a similar situation (p = 0.0002). Ninety-six percent women using misoprostol at home or in the clinic were satisfied with their abortion experience.

CONCLUSIONS

Home-use of misoprostol for early medical abortion is as effective and acceptable as clinic use, in low resource settings. Women should be offered a choice of this option regardless of distance of their residence from the clinic and communication facilities.