Self-managed abortion via the internet: Analysis of one year of service delivery data from Women Help Women.

Background: To better comprehend the demand for online medication abortion and to inform service delivery practice, we conducted an analysis of Women Help Women (WHW) service delivery statistics. The primary goals were to understand their user profile, evaluate self-reported outcomes and use of other medical services, and assess the overall experience both with the abortion itself and with the counseling and care provided by WHW. Methods: We retrospectively evaluated user characteristics, abortion outcomes, and acceptability of both the medication abortion and WHW's services, using consultation data and corresponding evaluation data from a one-year period. For users who did not complete the evaluation form, WHW staff reviewed email correspondences to identify key outcomes. Results: From August 2016-July 2017, 3,307 individuals received abortion pills from WHW. Users were geographically located in thirty countries and correspondence was conducted in seven languages. Most reported their gestational age to be less than eight weeks. Of the 2,295 who took the pills and provided outcome information, almost all (99.1%, n=2275) reported that they were no longer pregnant. The majority (84.1%, n=1576/1875) used symptoms to confirm outcome; one fourth (22.8%, n=428) sought an ultrasound and one sixth (18.0%, n=338) used urine and/or serum testing. One in eight users (12.6%, n=292/2317) reported seeking additional medical care after taking the abortion pills. Most (87.5%, n=1551/1773) reported being satisfied or very satisfied with the abortion. Conclusions: Our study confirms that self-managed abortion is a process that people can do safely and effectively with community support and without medical supervision. In the context of a global backlash against abortion rights, self-managed abortion is an integral part of a spectrum of options for abortion care that must be made available to all.

Preventing unsafe abortion: Achievements and challenges of a global FIGO initiative.

FIGO established a Working Group on the Prevention of Unsafe Abortion in 2007 and a parallel program or "Initiative" with the same name. The initiative involved 46 FIGO member societies from seven regions: South-Southeast Asia, Eastern-Central Europe and Central Asia, North Africa and Eastern Mediterranean, Eastern-Central-Southern Africa, Western-Central Africa, Central America and Caribbean, and South America. Each society working in collaboration with the corresponding Ministry of Health and other agencies conducted a situational analysis and prepared a plan of action based on the findings. Such plans of action are continuously monitored by annual evaluation of the progress in the implementation at regional workshops. A substantial progress has been achieved in providing legal and safe abortion services, replacing curettage for manual vacuum aspiration or misoprostol and introducing and expanding postabortion contraception with emphasis on long-acting methods, such as IUDs and contraceptive implants.

Simplified medical abortion screening: a demonstration project.

OBJECTIVES: The objectives were to evaluate the safety and acceptability of outpatient medical abortion in selected women without a pretreatment ultrasound or pelvic examination. STUDY DESIGN: We conducted a prospective case-series study to estimate the incidence of serious adverse events (death, life-threatening event, hospitalization, transfusion or any other medical problem that we judged to be significant), surgical completion of the abortion and satisfaction in women provided with medical abortion without a pretreatment ultrasound or pelvic examination. We enrolled 406 women requesting medical abortion in Moldova, Mexico and the United States. To be eligible, a woman must have been certain that her last menstrual period started within the prior 56days, have had regular menses before the pregnancy, not have used hormonal contraceptives in the prior 2months (in the United States and Mexico) or 3months (in Moldova), have no risk factors for or symptoms of ectopic pregnancy, and not have had an ultrasound or pelvic exam in this pregnancy. One site also excluded women with uterine enlargement on abdominal palpation. Each participant received mifepristone (200mg orally) and misoprostol (400 mcg sublingually in Moldova; 800 mcg buccally at all other sites) and was followed until complete abortion, defined as requiring no further treatment. RESULTS: Of the 365 (90%) participants who provided sufficient follow-up information for analysis, 347 (95%) had complete abortion without additional treatment, 5 (1%) had surgical aspiration, and 10 (3%) had extra misoprostol. Three participants (1%) had serious adverse events; these included two hospital admissions for heavy bleeding managed with aspiration and one diagnosis of persistent gestational sac 19days after enrollment. Most (317, 90%) participants were pleased with omitting the pretreatment ultrasound and pelvic exam. CONCLUSIONS: In this study, medical abortion without screening ultrasound or pelvic exam resulted in no serious adverse events that were likely to have been prevented by those tests and was highly acceptable. IMPLICATIONS: Screening for medical abortion without exam or ultrasound shows promise as a means for increasing access to this service. More research is needed to develop screening criteria that are more inclusive and simpler for clinical use.

Acceptability and feasibility of phone follow-up with a semiquantitative urine pregnancy test after medical abortion in Moldova and Uzbekistan.

OBJECTIVE: To evaluate the feasibility and acceptability of phone follow-up with a home semiquantitative pregnancy test and standardized checklist, and compare the alternative method of follow-up with in-clinic follow-up after medical abortion. STUDY DESIGN: Two thousand four hundred women undergoing medical abortion with mifepristone and misoprostol in Moldova and Uzbekistan were randomized to phone or clinic follow-up. All women in the clinic group returned to the clinic 2 weeks later. Women randomized to phone follow-up used a semiquantitative pregnancy test at the initial visit and repeated the test at home 2 weeks later when they also filled out a symptom checklist. Women were called at 2 weeks to review the test results and checklist. Participants who screened "positive" were referred to clinic to verify abortion completion. RESULTS: Most women in the phone group were successfully contacted on the phone (97.6%). Staff were unable to contact one woman in the phone follow-up group, and all women in clinic group returned to the clinic. The ongoing pregnancy rate was similar in both groups (0.4-0.6%), and the semiquantitative pregnancy test identified all ongoing pregnancies in the phone follow-up group. Women in the phone group found the test and checklist easy to use, and most (76.1%) preferred phone follow-up in the future. Overall, 92.8% of women in the phone group did not undergo in-clinic follow-up. CONCLUSION: Phone follow-up with a semiquantitative urine pregnancy test and symptom checklist is a feasible and a highly effective approach in identifying ongoing pregnancy after medical abortion. IMPLICATIONS: The semiquantitative pregnancy test can make home follow-up after medical abortion possible for many women and provide reassurance that ongoing pregnancies will be detected.

Comparison of 400 mcg buccal and 400 mcg sublingual misoprostol after mifepristone medical abortion through 63 days' LMP: a randomized controlled trial.

BACKGROUND: Buccal misoprostol 800 mcg and sublingual misoprostol 400 mcg demonstrate high efficacy and few adverse effects when used with 200 mg mifepristone for medical abortion through 63 days since the last menstrual period (LMP). Little is known about a 400-mcg buccal dose. This study compares two in-the-mouth routes of misoprostol using the same dose. STUDY DESIGN: Eligible and consenting women (n=550) were randomized to 400 mcg of misoprostol buccally or sublingually 24 h after ingestion of 200 mg of mifepristone. Abortion status was assessed 2 weeks later. RESULTS: Complete abortion occurred in 97.1% of the buccal group and 97.4% of the sublingual group (p=.97, RR: 1.00, 95% CI=0.97-1.03). Adverse effects were similar in both groups. Over 90% of women in both arms expressed high satisfaction with the method. CONCLUSIONS: Both 400 mcg buccal misoprostol and 400 mcg sublingual misoprostol after mifepristone appear to be good options for medical abortion through 63 days' LMP.

Prevention of unsafe abortion in countries of Central Eastern Europe and Central Asia.

Despite permissive laws and a well-developed network of facilities, the incidence of unsafe abortion and the resulting maternal mortality is unacceptably high in Central and Eastern Europe and Central Asia, with one-quarter of all maternal deaths reported to occur as a consequence of abortion. Among the reasons that oblige women to submit themselves to risky procedures are new legislative barriers to accessing pregnancy termination, the unequal distribution of abortion services and healthcare providers, the increased costs of abortion services or unofficial payments, coupled with an increase in the number of impoverished and disadvantaged individuals. The quality of abortion services remains very poor. Safe abortion techniques, including manual vacuum aspiration under local anesthesia and medical abortion, are slowly being implemented. Less safe methods such as dilatation and curettage and general anesthesia are widely used. Unsafe techniques are also practiced extensively in the case of second trimester abortions. Many women from these regions of the world still rely on and accept abortion as a means of fertility control. Although abortions have fallen significantly in Eastern Europe over the last decade, both in absolute numbers and as rates, this region continues to have the highest abortion rates in the world. Concerted efforts by governments, professional associations, and international donors are needed to reduce the consequences of unsafe abortion.

Two routes of administration for misoprostol in the treatment of incomplete abortion: a randomized clinical trial.

BACKGROUND: This study was conducted to compare the safety, effectiveness and acceptability of 400 mcg sublingual misoprostol and 600 mcg oral misoprostol for treatment of incomplete abortion. STUDY DESIGN: We used an open-label randomized controlled trial conducted from July 2005 to August 2006 in a large tertiary level maternity hospital in Antananarivo, Madagascar, and a large tertiary level hospital in Chisinau, Moldova. Three hundred consenting women seeking treatment for clinically diagnosed incomplete abortion with uterine size

Two-pill regimens of misoprostol after mifepristone medical abortion through 63 days' gestational age: a randomized controlled trial of sublingual and oral misoprostol.

BACKGROUND: A 400 mcg dose of sublingual misoprostol has high efficacy and few side effects when used with 200 mg mifepristone for medical abortion through 63 days' gestation. STUDY DESIGN: Eligible and consenting women (n=480) were randomized to 400 mcg of misoprostol sublingually or orally, 24 h after 200 mg of mifepristone. Abortion status was assessed two weeks later. RESULTS: Complete abortion occurred in 98.7% of the sublingual group and 94.0% of the oral group (p value=.006, RR: 1.05, 95% CI=1.01--1.09). Over 90% of women in both arms expressed high satisfaction with the method. Side effects were similar in both groups, with only fever or chills reported by significantly more women in the sublingual arm. CONCLUSIONS: The sublingual route appears superior to the regimen of 400 mcg misoprostol used orally and may be a good option for mifepristone medical abortion.

A project to improve the quality of abortion services in Moldova.

Abortion has been available legally in Moldova since 1955, and since then the abortion rate has gradually declined. The quality of abortion care remains low, however, and there is a high level of maternal mortality related to unsafe abortion. The goals of the 2005-2015 National Reproductive Health Strategy are to reduce unwanted pregnancy, reduce abortion-related morbidity and mortality, improve access to and quality of abortion care, including the methods of vacuum aspiration and medical abortion. This paper presents information on the current abortion law, policy and services in Moldova. It describes a project whose aim is to improve the quality of abortion services, including the introduction of medical abortion through training of service providers and community education. Manual vacuum aspiration has also recently been introduced. The drugs for medical abortion are officially approved, a clinical study evaluating the efficacy and acceptability of medical abortion in a low-resource setting has been completed, and training of providers has been carried out. However, institutionalisation of medical abortion faces many problems in relation to organisation of service delivery, the higher cost of medical than aspiration abortion, and doctors' reluctance to use new methods.