Medical Abortion: A Special Edition of Contraception

This special edition is due to be published in final form in print and online in the February 2018 edition of Contraception. Meanwhile, the papers can all be accessed on the home page of the journal at: in HTML and PDF formats. All but three are fully open access. The remaining three have been made openly available by the journal’s editor to complete the set, for which we are very grateful.

EDITORIAL: Medical abortion pills have the potential to change everything

– Marge Berer, Lesley Hoggart

…The papers in this special edition of Contraception report on the search for and use of medical abortion pills in Argentina, Bangladesh, Benin, Burkina Faso, the Burma-Thailand border, Chile, Kyrgyzstan, Madagascar, Nepal, South Africa and the UK, as well as a roundtable of health professionals’ views on what the future holds for medical abortion from Norway, New Zealand, Australia, Spain, Colombia, Brazil and Mexico… These papers confirm a growing awareness in the field that medical abortion pills are easy to obtain almost everywhere; and that at least some women know of their existence and go looking for them when they need an abortion no matter where they live, even in most remote and rural areas of the poorest countries. In those same poorest countries, however, access to information about the pills and how to use them has lagged far behind… Until and unless both mifepristone and misoprostol can be registered and approved for induced abortion and made widely available through health services and pharmacies, healthcare providers and advocates can only try to ensure that women get the information they need from other sources, whether via telemedicine, safe abortion information hotlines, websites, leaflets, or social media. This is far better than nothing and has helped to reduce deaths from dangerous abortion methods greatly since the 1990s, but as long as abortion remains clandestine, it isn’t good enough.

Full text HTML / PDF – The final text of this paper and the link to it will be available soon, check the web page.


What if medical abortion becomes the main or only method of first trimester abortion? A roundtable of views

– Kevin Sunde Oppegaard, Margaret Sparrow, Paul Hyland, Francisca García, Cristina Villarreal, Aníbal Faúndes, Laura Miranda

Manual vacuum aspiration in Norway has been almost completely superseded by medical abortion… This has benefits for women seeking abortion, as they obtain abortion at an earlier gestational age and the waiting time has been reduced[1]. At the same time, practical skills in manual vacuum aspiration for trainees are now much more limited than they used to be…

Medical abortion [including in Australia] is the way of the future… Its acceptability hinges on effective pain management and control of bleeding, as well as “around the clock” medical supervision to ensure that patients are adequately supported both physically and mentally throughout the process… The ultimate method of providing this service is by supplying medications by mail for a home-based abortion, after telephone consultation — with no need for a face-to-face doctor visit…

… Provision of abortion is not widespread in the public health system [in Spain], [but] the way in which abortion is gradually being incorporated into the public system in some communities is due to… the expansion of provision of medical abortion pills to the detriment of surgical methods. Yet I believe that both types of method are necessary and their co-existence essential to offering a quality abortion service that safeguards the privacy of women.

A medication to induce abortion is something that women in Latin America have sought for years – it is the most awaited pill… Medications for abortion have two additional benefits. First, they reduce social injustice stemming from inequality of access to health services, and second, they compensate for the decrease in the number of abortion providers that we are seeing everywhere.

It is possible to foresee a future when women will be empowered to take a rapid decision when confronted with a delayed menses, purchasing and taking medication to “recover menses” without either the knowledge or intervention of anybody else — unless they wish it.

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Putting abortion pills into women’s hands: realising the full potential of medical abortion

Kinga Jelinska, Susan Yanow

…By creating community level access to medicines, medical abortion gives control to women who need abortion, regardless of the legal constraints of their country. Ironically, in legally restrictive settings medical abortion is currently more under women’s control than in settings where medical abortion is used within the official healthcare system. In many countries with legal abortion, abortion pills are subject to strict regulations of supply and provision, with penalties for those that transgress those limits… Medical abortion is subversive because it challenges traditional assumptions about service delivery requirements, the definition of a provider and the power dynamics related to providing abortion care. The experiences from settings where self-induced abortions are a lifeline for women provoke reflection about the level of regulation that is needed for medical abortion, and what defines quality of care…

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Efficacy of medical abortion prior to six gestational weeks: a systematic review

Nathalie Kapp, Maureen K Baldwin, Maria Isabel Rodriguez

These analyses support the use of medical abortion at gestational ages <42 days. Efficacy rates are high overall and appear to reflect those observed during the seventh week of pregnancy. Women who prefer to initiate treatment as soon as early pregnancy is diagnosed may do so without delay.

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Experience of clandestine use of medical abortion among university students in Chile: a qualitative study

– Irma Palma Manríquez, Claudia Moreno Standen, Andrea Álvarez Carimoney, Alondra Richards

…In-depth interviews with 30 young women who had had a medical abortion between 2006 and 2016 while attending university [found that] access to medical abortion has transformed the experience of abortion in Chile… The findings show that medical abortion did not take place completely outside the healthcare system for these students, who accessed ultrasound scans pre- and post-abortion and post-abortion care. However, even with help and support from contacts, partners and friends, the clandestine situation created uncertainty and fear, which dominated the whole process, from finding and purchasing the pills, to uncertainty about correct doses and whether the abortion was going as it should and was complete or not.

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Accompaniment of second trimester abortions: the model of the feminist Socorrista network of Argentina

– Ruth Zurbriggen, Brianna Keefe-Oates, Caitlin Gerdts

Second-trimester abortion affects vulnerable groups of women disproportionately and is often more difficult to access. In Argentina, where abortion is legally restricted except in cases of rape or threat to the health of the woman, the Socorristas en Red, a feminist network, offers a model of accompaniment wherein they provide information and support to women seeking second-trimester abortions. This qualitative analysis aimed to understand Socorristas’ experiences supporting women who have second-trimester medication abortion outside the formal health care system.

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Complications with use of misoprostol for abortion in Madagascar: between ease of access and lack of information

– Dolorès Pourette, Chiarella Mattern, Rila Ratovoson, Patricia Raharimalala

This was a qualitative study in 2015-16 among 19 women who had experienced complications after use of misoprostol, with or without additional methods, for abortion, what information they received before use, what dosage and regimens they used, what complications they experienced and what treatment they received post-use. The 19 women were aged 16-40, with an average age of 21-26 at interview and average age of 18-21 at abortion. To obtain an abortion, they sought advice from partners, friends, family members, and/or traditional practitioners and healthcare providers. Misoprostol was easily accessible through the formal and informal sectors, but the dosages and regimens the women used on the advice of others were extremely variable, did not match WHO guidelines, and were apparently ineffective, resulting in failed abortion, incomplete abortion, heavy bleeding/hemorrhage, strong pain, and/or infection…

Full text HTML / PDF – The final text and the link to it will be available soon, check the web page.

“It is just like having a period with back pain”: Exploring women’s experience with community-based distribution of misoprostol for early abortion on the Thailand–Burma border

– Ellen Tousaw, Sweet Naw Hser Gay Moo, Grady Arnott, Angel M Foster

The lack of economic development and longstanding conflict in Burma have led to mass population displacement. Unintended pregnancy and unsafe abortion are common and contribute to maternal death and disability. In 2011, stakeholders operating along the Thailand-Burma border established a community-based distribution program of misoprostol for early abortion, with the aim of providing safe and free abortion care in this low-resource and legally restricted setting… Community-based distribution of misoprostol is an effective and culturally appropriate method of improving safe abortion care on the Thailand-Burma border… Our findings indicate providing misoprostol through lay provision in a legally restricted context is not only safe and effective but also culturally resonant.

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Abortion in two Francophone African countries: a study of whether women have begun to use misoprostol in Benin and Burkina Faso

– Carine Baxerres, Ines Boko, Adjara Konkobo, Fatoumata Ouattara, Agnès Guillaume

This study aimed to document the means women use to obtain abortions in the capital cities of Benin and Burkina Faso, and to learn whether or not use of misoprostol has become an alternative to other methods of abortion, and the implications for future practice… We conducted in-depth, qualitative interviews between 2014 and 2015 with 34 women – 21 women in Cotonou (Benin) and 13 women in Ouagadougou (Burkina Faso).. Twenty-five of the women had had 37 abortions in the previous 5 years… Six of the 37 abortions in the previous 5 years involved misoprostol use, and were all among educated women with significant social and economic capital and personal contact with clinicians. [This and other evidence] suggests that increased awareness of and use of misoprostol in both countries is likely in the coming years.

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Medical abortion can be provided safely and effectively by pharmacy workers trained within a harm reduction framework: Nepal

– Anand Tamang, Mahesh Puri, Sazina Masud, Deepak Kumar Karki, Diksha Khadka, Minal Singh, Poonam Sharma, Subash Gajurel

This operations research study [in 2015] examined the treatment efficacy, safety and satisfaction of women using medical abortion pills provided by pharmacists following an education intervention based on a harm reduction approach… [It found that] trained pharmacy workers dispensed MA safely and effectively to the satisfaction of almost all women clients, and the positive results of training had continued several years later… The rate of complete abortions in two group of women, 96.9% and 98.8%, was [high]. The women reported no serious complications, and there was little difference in their satisfaction levels… The role of pharmacy workers as providers of correct and complete information on safe and effective use of MA needs to be recognized and policies formulated to allow them to provide MA drugs for first trimester use.

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Provision of menstrual regulation with medication among pharmacies in three municipal districts of Bangladesh: a situation analysis

– Fauzia Akhter Huda, Hassan Rushekh Mahmood, Anadil Alam, Faisal Ahmmed, Farzana Karim, Bidhan Krishna Sarker, Nafis Al Haque, Anisuddin Ahmed

The objective [of this study] was to assess the provision of the combination of mifepristone–misoprostol for menstrual regulation (MR) in randomly selected urban pharmacies in Bangladesh. We conducted a cross-sectional survey among 553 pharmacy workers followed by 548 mystery client visits to the same pharmacies in 3 municipal districts during July 2014–December 2015… We found knowledge gaps regarding recommended dosage for MRM and inconsistent practice in informing women on effectiveness, follow-up visits, possible complications and provision of post-MR contraceptives among the pharmacy workers, particularly during the mystery client visits… [We recommended] that pharmacy workers in Bangladesh need to be trained on legal time limits for MR services provision, on providing accurate information on disbursed medicine, and on proper referral mechanisms.

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Feasibility of assessing the safety and effectiveness of menstrual regulation medications purchased from pharmacies in Bangladesh: a prospective cohort study

– Katharine Footman, Rachel Scott, Fahmida Taleb, Sally Dijkerman, Sadid Nuremowla, Kate Reiss, Kathryn Church

This paper assesses the outcomes of women who self-manage menstrual regulation medications purchased from pharmacies. The methodology requires further development, but our study provides preliminary positive evidence on the safety and effectiveness of self-management despite low information provision from pharmacy workers.

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Provision of medical abortion by mid-level healthcare providers in Kyrgyzstan: testing an intervention to expand safe abortion services to under-served rural and peri-urban areas

– Brooke Ronald Johnson Jr, Elmira Maksutova, Aigul Boobekova, Ainura Davletova, Chinara Kazakbaeva, Yelena Kondrateva, Sihem Landoulsi, Gunta Lazdane, Kubanychbek Monolbaev, Armando H Seuc Jo

Between August 2014 and September 2015, midwives provided medical abortion to 554 women with a complete abortion rate of 97.8%, of whom 62% chose to use misoprostol at home. No women were lost to follow-up. Nearly all women (99.5%) chose a contraceptive method post-abortion; 61% of women receiving services completed the acceptability form, of whom more than 99% indicated a high level of satisfaction with the service and would recommend it to a friend…This study demonstrates that trained Kyrgyz midwives and nurses can provide medical abortion safely and effectively. This locally generated evidence can be used by the Kyrgyz Ministry of Health to reduce unintended pregnancy and expand safe abortion care to women in underserved peri-urban and rural settings.

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Doing more for less: identifying opportunities to expand public sector access to safe abortion in South Africa through budget impact analysis

– Naomi Lince-Deroche, Jane Harries, Deborah Constant, Chelsea Morroni, Melanie Pleaner, Tamara Fetters, Daniel Grossman, Kelly Blanchard, Edina Sinanovic

The public sector performed an estimated 20% of the expected total number of abortions in 2016/17; 26% of all abortions were performed illegally and 54% in the private sector. Costs were lowest in scenarios where method mix shifting occurred. Holding the proportion of abortions performed in the public-sector constant, shifting to more cost-effective service provision (more first-trimester services with more medication abortion and using the combined regimen for medical induction in the second trimester) could result in savings of $28.1 million in the public health service over a 10-year period. Expanding public sector provision through elimination of unsafe abortions would require an additional $192.5 million.

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Barriers to accessing abortion service and perspectives on using mifepristone and misoprostol at home in Great Britain

– Abigail RA Aiken, Katherine A Guthrie, Marlies Schellekens, James Trussell, Rebecca Gomperts

We conducted a mixed-methods study among women resident in England, Scotland, and Wales who requested at-home medication abortion through Women on Web between November 2016 and March 2017. Over a 4-month period, 519 women contacted WoW seeking medication abortion [despite the presence of abortion services in Great Britain]. Among 180 of them, 49% [contacted WoW due to] access barriers, including long waiting times, distance to clinic, work or childcare commitments, lack of eligibility for free NHS services, and prior negative experiences of abortion care; 30% were privacy concerns, including lack of confidentiality of services, perceived or experienced stigma, and preferring the privacy and comfort of using pills at home; and 18% were controlling circumstances, including partner violence and partner/family control…, a diverse group of women still experiences logistical and personal barriers to accessing care through the formal healthcare system, or prefer the privacy of conducting their abortions in their own homes…

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Developing a forward-looking agenda and methodologies for research on self-use of medical abortion

– Nathalie Kapp, Kelly Blanchard, Ernestina Coast, Bela Ganatra, Jane Harries, Katharine Footman, Ann Moore, Onikepe Owolabi, Clementine Rossier, Kristen Shellenberg, Britt Wahlin, Cynthia Woodsong

Research has not kept abreast of women’s self-use of medical abortion, leaving many gaps in the scientific literature regarding the ideal conditions for safe and effective use… focused on the emerging practice of self-use… Research gaps can be summarized in three broad categories: women’s preferences and experiences with self-use of medical abortion, the distribution and provision of medical abortion information and drugs, and clinical outcomes following self-use. For each of these three broad groups, we identified specific research questions varying in level of detail by the contexts they reflect.

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