Clinical Outcomes and Women’s Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa

Abstract

ObjectiveTo document clinical outcomes and women’s experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only.MethodsRepeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2–4 weeks after discharge for the 2014 cohort.ResultsThe 2014 cohort received 200 mg mifepristone, which was self-administered 24–48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3–4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts.ConclusionThe introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.

A randomised controlled trial to compare the efficacy of preinduction with mifepristone 12 hours versus 24 hours prior for second trimister pregnancy termination

“…10 Constant et al in their study of clinical outcome before and after introduction of mifepristone in second trimester abortion services in South Africa concluded that this regimen has been successful in reducing the induction abortion interval, decreasepain, and had greater acceptability by women, but there were higher rates of placental retention and need for surgical evacuation for the same in their study. 11 But we did not have any case of placental retention.…”

Implementing and expanding safe abortion care: An international comparative case study of six countries

“…Closely related to task sharing was, for first‐trimester abortions, the widespread use of low technology procedures requiring little infrastructure: MVA and medical abortion using combination mifepristone‐misoprostol. Midwives, nurses, and other cadres of providers newly included under the task‐sharing rubric, were readily able to learn and employ these techniques . However, in two of the higher HDI countries (Portugal and Uruguay), the Ministry of Health also decided to provide medical abortion almost exclusively.…”

“…Midwives, nurses, and other cadres of providers newly included under the task-sharing rubric, were readily able to learn and employ these techniques. 52,56,57,[60][61][62][63][64] However, in two of the higher HDI countries (Portugal and Uruguay), the Ministry of Health also decided to provide medical abortion almost exclusively. This decision was made for similar logistical reasons, as medical abortion requires less infrastructure and training, and for political reasons, as it was anticipated that there would be less provider resistance to medical rather than surgical abortion.…”

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

“…For second-trimester services, the economic evaluation presented health service costs and cost-effectiveness for D&E and medical induction with and without mifepristone [21]. The clinical data for the second-trimester economic evaluation were collected in hospitals in Western Cape Province as part of a clinical trial in 2012-2013 [24] and a separate cross-sectional study that included observations in 2008, 2010, and 2014 [4,25].…”

“…In the second trimester, dilation and evacuation (D&E) is available in a limited number of high volume settings, most, if not all, in one province. Medical induction services performed with misoprostol only are the standard nationwide, although, in 2014, one province changed their medical induction regimen to include mifepristone [4].…”