Integrating medical abortion into safe abortion services: experience from three pilot sites in South Africa

Abstract

Background and methodology South Africa's Choice on Termination of Pregnancy Act of 1996 provides for safe termination of pregnancy (TOP) in designated facilities in the public and private health sectors. In 2001, mifepristone-misoprostol medical abortion was approved for TOP up to 56 days, but this method is not yet available in the public sector. Information on the operational requirements for integrating mifepristone-misoprostol medical abortion into South Africa's public sector safe abortion services is required to guide policy decisions. This study trained health workers to provide medical abortion to 290 women attending three TOP sites. Prospective data were collected to ascertain women's experience of the method, pregnancy outcome, women's and provider's acceptability of the method, and the operational requirements for providing medical abortion.Results Twenty-nine (10%) women were lost to follow-up; 261 (90%) women had a confirmed abortion outcome, of 159 ©FSRH J Fam Plann Reprod Health Care 2008: 34(3) IntroductionNumerous clinical studies in the literature report the efficacy of mifepristone-misoprostol medical abortion in both developed and developing countries. [1][2][3][4][5][6] This regimen, with an efficacy of 92-98% for early termination of pregnancy (TOP), is effective outside clinical trial settings, 7-9 but is not registered and available in many countries where abortion is legal. The complexity of the original mifepristone-misoprostol regimen, requiring 600 mg mifepristone for pregnancies up to 49 days and three health facility visits, may limit its implementation in less developed countries. 10 Correspondence to: Dr Mary Kawonga, School of Public Health, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, Gauteng 2193, South Africa. E-mail: mary.kawonga@wits.ac.za whom 93% had a complete abortion. Given the option, the vast majority of women opted to use misoprostol at home. No serious side effects were reported; pain (66%), and heavy bleeding (67%) were the most common side effects. Most (96%) women were very satisfied with the experience. Health providers were satisfied with providing medical abortion and recommended its introduction to complement existing surgical TOP services. Discussion and conclusionThis study demonstrates that integration of medical abortion into public sector services is feasible. The results of this study will guide policy decisions about integrating medical abortion into South Africa's public sector safe abortion services, within the context of the existing enabling legislative framework.Keywords medical abortion, mifepristone, misoprostol, public sector safe abortion services, South Africa efficacy. 4,11 Home use of misoprostol is safe, acceptable and feasible even in less developed contexts, 12-14 and a modified regimen extending the limit to 56 days achieves success rates of 92-97%. 10,13 Medical abortion in South AfricaSouth Africa's Choice on Termination of Pregnancy Act of 1996 allows TOP on request up to 12 weeks from the last mens...

Termination of pregnancy: Perspectives of female students in Durban, South Africa

“…This is consistent with findings in the literature, further enforcing the idea that medical abortion will be a positive contribution to women's sexual and reproductive health (Cooper et al, 2005;Kawonga et al, 2008). Medical abortion has the potential to not only save lives, but also to expand women's options for protecting their sexual and reproductive health.…”

Assessments of the Importance of Provider Characteristics for Abortion Care: Data From Women in Rajasthan, India

“…For example, the acceptability of certain methods of abortion (Akin et al, 2009;Coyaji et al, 2001;Elul et al, 2001;Levine & Cameron, 2009;Teal, Harken, Sheeder, & Westhoff, 2009) or pain management regimens (Allen, Kumar, Fitzmaurice, Lifford, & Goldberg, 2006;Clark et al, 2002) has been well studied in recent years. Several situation analyses of abortion services and population-based surveys have also provided information on women's experiences with abortion services (Dickson et al, 2003;Duggal & Barge, 2003;Kawonga et al, 2008;Khan, Barge, Kumar, & Almroth, 1999;Lelong et al, 2005;Lie, Robson, & May, 2008). While the clinical acceptability and patient satisfaction literature provide some indication of the aspects of abortion care that women value once they arrive at a facility, they do not address the more fundamental question of what type of providers women prefer for pregnancy terminations.…”

Assessment of completion of early medical abortion using a text questionnaire on mobile phones compared to a self-administered paper questionnaire among women attending four clinics, Cape Town, South Africa

“…Earlier studies in South Africa have reported a high level of acceptance of use of misoprostol at home among both women 3 and providers. 4 In the USA, in an effort to simplify medical abortion provision and thus improve acceptability and access, the Planned Parenthood Federation of America recommended in 2005 that the in-clinic follow-up requirement be waived should it create undue hardship for women, if they could manage their follow-up with a serum hCG pregnancy test at a facility closer to them.…”

“…1 Improving access to abortion services by introducing medical abortion at more primary care facilities is expected to address some of the existing barriers to safe abortion care in South Africa, in particular the shortage of providers willing to perform surgical abortions. [2][3][4] Current standard medical abortion care up to 63 days LMP in both the NGO and public sectors in South Africa involves oral mifepristone (200 mg) followed by misoprostol used 1-2 days later at home (800 mcg = 400 mcg sublingual and 400 mcg oral or buccal), and a follow-up visit at the abortion facility to assess completion of abortion.…”