BACKGROUND: Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation. METHODS: An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country’s abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships. RESULTS: After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides. CONCLUSION: These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa. "
Despite broad grounds for legal abortion in Zambia, access to abortion services remains limited. Pharmacy workers, a primary source of health care for communities, present an opportunity to bridge the gap between policy and practice. As part of a larger operations study, 80 pharmacy workers, both registered pharmacists and their assistants, participated in a training on medical abortion in 2009 and 2010. Fifty-five of the 80 pharmacy workers completed an anonymous, structured training pre-test, treated as a baseline questionnaire; 53 of the 80 trainees were interviewed 12-24 months post-training in face-to-face interviews to measure the retention of information and training effectiveness. Survey questions were selected to illustrate the principles of a harm reduction approach to unsafe abortion. Bivariate analysis was used to examine pharmacy worker knowledge, attitudes and dispensing behaviours pre-training and at follow-up. A higher percentage of pharmacy workers reported referring women to a health care facility between surveys (47% to 68%, p = 0.03). The number of pharmacy workers who reported dispensing ineffective abortifacients decreased from baseline to end-line (30% to 25%) but the difference was non-significant. However, study results demonstrate that Zambian pharmacy workers have a role to play in safe abortion services and some are willing to play that role.
OBJECTIVE: To find out clinical presentation and outcome of unsupervised use of misoprostol as abortifacient among adolescents presenting with abortion complications. METHODS: Case series of thirty one adolescents that presented with abortion complications following unsupervised use of misoprostol. RESULTS: Over a period of 3 years, 31 adolescents were seen, with median age of 17 years. Twenty nine (93.5%) were unmarried and 22 (71%) were in secondary school. Pregnancy duration was 3months and above in 23 (74.2%) of the patients. The cumulative dose of misoprostol tablet ingested was 2 (400 µg) in 17 (54.8%) of the patients. Twenty three (74.2%) patients presented with incomplete abortion with mild sepsis while the remaining 8 (25.8%) patients were admitted and managed with incomplete abortion with severe sepsis. Treatments offered were manual vacuum aspiration in 23 (74.2%) patients, evacuation of retained product of conception under anaesthesia in 7 (22.6%) patients and 1 (3.2%) patient had laparotomy with uterine repair following inadvertent uterine perforation complicating curettage for incomplete abortion. Complications encountered were anaemia 67.7%, uterine perforation 3.2%, blood transfusion 9.7% and diarrhoea in 8 (25.8%) patients. CONCLUSION: Demedicalise abortion with misoprostol due to improper dosing protocol may be associated with incomplete abortion and its sequelae in an uninformed adolescent population. Establishment of adolescent friendly medical centre that offers post-abortion care will go a long way in alleviating this problem.
"Background: Pain is often cited as one of the worst features of medical abortion. Further, inadequate pain management may motivate some women to seek unnecessary clinical care. There is a need to identify effective methods for pain control in this setting. Methods/Design: We propose a randomized, placebo-controlled trial. 576 participants (288 nulliparous; 288 parous) from study sites in Nepal, South Africa and Vietnam will be randomly allocated to one of three treatments: (1) ibuprofen 400 mg PO and metoclopramide 10 mg PO; (2) tramadol 50 mg PO and a placebo; or (3) two placebo pills, to be taken immediately before misoprostol and repeated once four hours later. All women will be provided with supplementary analgesia for use as needed during the medical abortion. We hypothesize that women receiving prophylactic analgesia will report lower maximal pain scores in the first 8 h following misoprostol administration compared to women receiving placebos for medical abortion through 63 days’ gestation. Our primary objective is to determine whether prophylactic administration of ibuprofen and metoclopramide or tramadol provides superior pain relief compared to analgesia administration after pain begins, measured during the first eight hours after misoprostol administration. Secondary objectives include identifying covariates associated with higher reported pain scores; determining any impact of the study medicines on medical abortion success; and, qualitatively exploring women’s physical experiences of medical abortion, especially related to pain, and how can they be improved. Data sources include medical records, participant symptom diaries and interview data obtained on the day of enrollment, during the medical abortion, and at follow-up. Participants will be contacted via telephone on day 3 and return for follow-up will occur approximately 14 days after mifepristone, concluding study participation. A subset of 42 women will also be invited to undergo in-depth qualitative interviews following study completion. Discussion: Although pain is one of the most common side effects encountered with medical abortion, little is known about optimal pain management for this process. This multi-arm trial design offers an efficient approach to evaluating two prophylactic pain management regimens compared to use of pain medication as needed."
Medical abortion is a method of pregnancy termination that by its nature enables more active involvement of women in the process of managing, and sometimes even administering the medications for, their abortions. This qualitative evidence synthesis/Dissertation reviewed the global evidence on experiences with, preferences for, and concerns about greater self-management of medical abortion with lesser health professional involvement. We focused on qualitative research from multiple perspectives on women's experiences of self-management of first trimester medical abortion (12weeks gestation). We included research from both legal and legally-restricted contexts whether medical abortion was accessed through formal or informal systems. A review team of four identified 36 studies meeting inclusion criteria, extracted data from these studies, and synthesized review findings. Review findings were organized under the following themes: general perceptions of self-management, preparation for self-management, logistical considerations, issues of choice and control, and meaning and experience. The synthesis/Dissertation highlights that the qualitativ evidence base is still small, but that the available evidence points to the overall acceptability of self-administration of medical abortion. We highlight particular considerations when offering self-management options, and identify key areas for future research. Further qualitative research is needed to strengthen this important evidence base.
"BACKGROUND: Although abortion is legally available in South Africa, barriers to access exist. Early medical abortion is available to women with a gestational age up to 63 days and timely access is essential. This study aimed to determine women’s acceptability and ability to self-assess eligibility for early medical abortion using an online gestational age calculator. Women’s acceptability, views and preferences of using mobile technology for gestational age (GA) determination were explored. No previous studies to ascertain the accuracy of online self-administered calculators in a non-clinical setting have been conducted. METHODS:A convenience sample of abortion seekers were recruited from two health care clinics in Cape Town, South Africa in 2014. Seventy-eight women were enrolled and tasked with completing an online self-assessment by entering the first day of their last menstrual period (LMP) onto a website which calculated their GA. A short survey explored the feasibility and acceptability of employing m-Health technology in abortion services. Self-calculated GA was compared with ultrasound gestational age obtained from clinical records. RESULTS: Participant mean age was 28 (SD 6.8), 41 % (32/78) had completed high school and 73 % (57/78) reported owning a smart/feature phone. Internet searches for abortion information prior to clinic visit were undertaken by 19/78 (24 %) women. Most participants found the online GA calculator easy to use (91 %; 71/78); thought the calculation was accurate (86 %; 67/78) and that it would be helpful when considering an abortion (94 %; 73/78). Eighty-three percent (65/78) reported regular periods and recalled their LMP (71 %; 55/78). On average women overestimated GA by 0.5 days (SD 14.5) and first sought an abortion 10 days (SD 14.3) after pregnancy confirmation. CONCLUSIONS: Timely access to information is an essential component of effective abortion services. Advances in the availability of mobile technology represent an opportunity to provide accurate and safe abortion information and services. Our findings indicate that an online GA calculator would be accurate and helpful. GA could be calculated based on LMP recall within an error of 0.5 days, which is not considered clinically significant. An online GA calculator could potentially act as an enabler for women to access safe abortion services sooner. "
OBJECTIVE: Training midlevel providers (MLPs) to conduct surgical abortions and manage medical abortions has been proposed as a way to increase women's access to safe abortion. This paper reviews the evidence that compares the effectiveness and safety of abortion procedures administered by MLPs versus doctors. METHODS: A systematic search was conducted of published trials and comparison studies assessing the effectiveness and/or safety of abortion provided by MLPs compared to doctors. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Popline were searched. The primary outcomes of interest were: (1) incomplete or failed abortion; and (2) measures of safety (adverse events and complications) of abortion procedures administered by MLPs and doctors. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated for each study. Data were synthesized in a narrative fashion. FINDINGS: Five studies were included in this review (n = 8539 women), comprising two randomized controlled trials (RCTs) (n = 3821) and three prospective cohort studies (n = 4718). In total, 4198 women underwent a procedure administered by an MLP, and 4341 women underwent a physician-administered procedure. Studies took place in the US, Nepal, South Africa, Vietnam, and India. Four studies used surgical abortion with maximum gestational ages ranging from 10 to 16+ weeks, while a medical abortion study had gestational ages up to 9 weeks. In RCTs, the effect estimates for incomplete or failed abortion for procedures performed by MLPs compared with doctors were OR = 2.00 (95% CI 0.85-4.68) for surgical abortion, and OR = 0.69 (95% CI 0.34-1.37) for medical abortion. Complications were rare among both provider types (1.2%-3.1%; OR = 1.80, 95% CI 0.83-3.90 for surgical abortions), and no deaths were reported. CONCLUSION: There were no statistical differences in incomplete abortion and complications for first trimester surgical and medical abortion up to 9 weeks performed by MLPs compared with physicians. Further studies are required to establish more precise effect estimates.
Unsafe abortion continues to be a major contributor to maternal mortality and morbidity around the world. This article examines the role of pharmacists in expanding women's access to safe medical abortion in Latin America, Africa, and Asia. Available research shows that although pharmacists and pharmacy workers often sell abortion medications to women, accurate information about how to use the medications safely and effectively is rarely offered. No publication covered effective interventions by pharmacists to expand access to medical abortion, but lessons can be learned from successful interventions with other reproductive health services. To better serve women, increasing awareness and improving training for pharmacists and pharmacy workers about unsafe abortion - and medications that can safely induce abortion - are needed.
Over 99% of deaths due to abortion occur in developing countries. Maternal deaths due to abortion are preventable. Increasing the use of misoprostol for elective abortion could have a Notable impact on maternal mortality due to abortion. As a test of this hypothesis/Dissertation, this study estimated the reduction in maternal deaths due to abortion in Africa, Asia and Latin America. The estimates were adjusted to changes in assumptions, yielding different possible scenarios of low and high estimates. This simple modeling exercise demonstrated that increased use of misoprostol, an option for pregnancy termination already available to many women in developing countries, could significantly reduce mortality due to abortion. Empirical testing of the hypothesis/Dissertation with data collected from developing countries could help to inform and improve the use of misoprostol in those settings.
"Objective: To determine the success rate of medical abortion when a progestin-based contraceptive—either an etonogestrel implant or depot medroxyprogesterone acetate (DMPA) injection—is given on the same day as mifepristone for medical abortion. Methods: In a retrospective chart review, data were assessed for women aged 15–49 years who underwent medical abortion (≤ 63 days of pregnancy) at two hospitals in KwaZulu Natal, South Africa, between August 2013 and July 2014. The women were given oral mifepristone (200 mg) and buccal misoprostol (800 μg), and received an etonogestrel implant or DMPA injection on the same day as mifepristone. The primary outcome was the success rate of medical abortion. Comparative data were obtained through a PubMed search. Results: A total of 89 women were included. Complete termination was achieved in 87 (98%, 95% confidence interval 95%–100%) women. This success rate is similar to that reported in a previous systematic review of the rate of medical abortion success without progestin contraceptive administration (94.8%). Conclusions: Administration of a progestin-based contraceptive such as an etonogestrel implant or DMPA injection on the same day as mifepristone for medical abortion did not alter the success rates."