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

Baraitser, Paula; Free, Caroline; Norman, Wendy V.; Lewandowska, Maria; Meiksin, Rebecca; Palmer, Melissa; Scott, Rachel; French, Rebecca; Wellings, Kaye; Ivory, Alice; Wong, Geoff

doi:10.1136/bmjopen-2022-066650

Cited by 11 publications

(6 citation statements)

References 75 publications

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“…Our data are unable to explain why there is an association between opt-in codeine and greater satisfaction with pain management; however, we postulate that the opt-in approach prompted clinicians to have a more detailed discussion of pain, which better prepared patients for the experience. Our findings align with results from qualitative abortion research that suggest that patients value information, preparation and choice as markers of quality abortion care 24–26. Evidence also shows that pre-abortion information, particularly regarding pain and side effects, can reduce anxiety during the abortion and create a more positive experience overall 27…”

Section: Discussionsupporting

confidence: 83%

Opt-in versus universal codeine provision for medical abortion up to 10 weeks of gestation at British Pregnancy Advisory Service: a cross-sectional evaluation

Taghinejadi,

McCulloch,

Krassowski

et al. 2024

BMJ Sex Reprod Health

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ObjectiveTo assess patient experiences of pain management during medical abortion up to 10 weeks’ gestation with opt-in versus universal codeine provision.MethodsWe invited patients who underwent medical abortion up to 10 weeks of gestation to participate in an online, anonymous, English-language survey from November 2021 to March 2022. We performed ordinal regression analyses to compare satisfaction with pain management (5-point Likert scale) and maximum abortion pain score (11-point numerical rating scale) in the opt-in versus universal codeine provision groups.ResultsOf 11 906 patients invited to participate, 1625 (13.6%) completed the survey. Participants reported a mean maximum pain score of 6.8±2.2. A total of 1149 participants (70.7%) reported using codeine for pain management during their abortion. Participants in the opt-in codeine provision group were significantly more likely to be satisfied with their pain management than those in the universal group (aOR 1.48, 95% CI 1.12 to 1.96, p<0.01). Maximum abortion pain scores were lower on average among the opt-in codeine provision group (OR 0.80, 95% CI 0.66 to 0.96, p=0.02); however, this association was not statistically significant in the model adjusted for covariates (aOR 0.85, 95% CI 0.70 to 1.03, p=0.09).ConclusionOur findings suggest that patients have a better experience with pain management during medical abortion when able to opt-in to codeine provision following counselling versus receiving this medication routinely.

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Section: Discussionsupporting

confidence: 83%

Opt-in versus universal codeine provision for medical abortion up to 10 weeks of gestation at British Pregnancy Advisory Service: a cross-sectional evaluation

Taghinejadi,

McCulloch,

Krassowski

et al. 2024

BMJ Sex Reprod Health

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“…The importance of overall choice, highlighted by our participants at several points in the abortion path, resonates with other empirical evidence. 33 , 48 While many of the women we interviewed would have changed nothing about their abortion experience, a few claimed that, in hindsight, they might have chosen an alternative abortion method. Studies comparing satisfaction levels in medical and surgical abortion 49 – 51 suggest that, were all women able to fully exercise choice, the proportion of abortions that are medically induced could be lower than the current rate in Britain of almost 9 in 10.…”

Section: Discussionmentioning

confidence: 99%

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

Lewandowska,

Scott,

Meiksin

et al. 2024

Womens Health (Lond Engl)

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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.

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“…In a qualitative study conducted in England during the COVID‐19 pandemic, we found that women were overwhelmingly in favor of home self‐management of medical abortion, but some stressed that the option of an in‐person interaction with health practitioners should remain available 34 . Personal and informed choice pertaining to the abortion method and its location is crucial, and should remain available and accessible 13,35,36 …”

Section: Discussionmentioning

confidence: 99%

“…34 Personal and informed choice pertaining to the abortion method and its location is crucial, and should remain available and accessible. 13,35,36…”

Section: Discussionmentioning

confidence: 99%

Impact of approval of home use of misoprostol in England on access to medical abortion: An interrupted time series analysis

Lewandowska,

Carter,

Gasparrini

et al. 2023

Intl J Gynecology & Obste

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ObjectiveIn 2018, the Department of Health and Social Care in England approved the use of misoprostol at home for early medical abortions, following administration of mifepristone at clinic. The objective of the present study was to assess the impact of the approval of home administration of misoprostol in England on access to medical abortion, assessed through proxy measures of the proportion of all abortions that were medical and gestational age.MethodsThis study uses the clinical data from the British Pregnancy Advisory Service on abortions in England in years 2018–2019, containing demographic and procedure characteristics of patients. We conducted an interrupted time series analysis to establish the differences before and after the approval in access to medical abortion, measured by the proportion of all abortions that were medical, and gestational age. The analysis also examined whether these changes were equitable, with focus on area‐level deprivation.ResultsThe analysis of the data (145 529 abortions) suggested that there was an increase in the proportion of medical abortions and decrease in gestational age of abortions after the approval. Compared with the situation if former trends had continued, the actual proportion of early medical abortions was 4.2% higher in December 2019, and the mean gestational age 3.4 days lower. We found that the acceleration of existing trends in increase in proportion of medical abortions and decrease in gestational age were larger in the most deprived quintiles and in those reporting a disability, but not equal across ethnic groups, with Black and Black British women experiencing little change in trajectories post‐approval.ConclusionThe approval of home use of misoprostol as part of an early medical abortion regimen in England was associated with material and equitable improvements in abortion access. Pre‐approval trends toward greater uptake of medical abortion and declining gestational age were accelerated post‐approval and were greatest in the most deprived areas of England, but not across all racial/ethnic groups. The present findings strongly support the continuation or introduction of home management of medical abortions.

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

Cited by 11 publications

References 75 publications

Opt-in versus universal codeine provision for medical abortion up to 10 weeks of gestation at British Pregnancy Advisory Service: a cross-sectional evaluation

Opt-in versus universal codeine provision for medical abortion up to 10 weeks of gestation at British Pregnancy Advisory Service: a cross-sectional evaluation

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

Impact of approval of home use of misoprostol in England on access to medical abortion: An interrupted time series analysis

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