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Best practice with medical abortion: current evidence

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Title: Best practice with medical abortion: current evidence


1
Best practice with medical abortion current
evidence
Nathalie Kapp, MD, MPH Department of
Reproductive Health and Research World Health
Organization
Acknowledgements Allan Templeton
2
Early medical abortion
  • Investigations have focused on
  • Dose of mifepristone
  • Interval between mifepristone and misoprostol
  • Dose and route of misoprostol
  • Increasingly, research focusing on
  • Increasing flexibility
  • Increasing women's control (timing of abortion,
    home use), increasing the cadre of providers,
    decreasing costs (fewer clinic visits)

3
Outline
  • Regimens of medical abortion
  • Regimen flexibility
  • Access to abortion
  • Future research

4
Mifepristone dose 600 vs. 200 mg
Kulier, et al. Medical methods for first
trimester abortion. Cochrane database of
systematic reviews. 2010, in press.
5
Mifepristone dose effect on access
  • Access can be directly related to cost
  • Use of 200 vs. 600 can decrease cost by
    two-thirds
  • May be setting dependant
  • Generic, inexpensive mifepristone likely to make
    greater difference
  • Practical
  • Mifepristone produced in 200 mg tablets
  • Access may not be increased where there is
  • Resistance from pharmaceutical companies
  • Potential resistance from providers for off-label
    use

6
Shortening the interval
Kulier, et al. Medical methods for first
trimester abortion. Cochrane database of
systematic reviews. 2010, in press.
7
But not too short.
Kulier, et al. Medical methods for first
trimester abortion. Cochrane database of
systematic reviews 2010, in press.
8
Efficacy
  • High efficacy in both clinical trials and in
    clinical setting
  • Clinical trials range 95-98
  • Lower efficacy with oral misoprostol or in
    settings unfamiliar with medical abortion
  • Clinical settings
  • Planned Parenthood 98 effective (200 mg
    mifepristone 800 buccal misoprostol)
  • Aberdeen (4132 women) 98 effective (200 mg
    mifepristone 800 vaginal misoprostol)
  • Finland database (20,000) 93 effective
    (mifepristone prostaglandin)
  • Efficacy increases with increasing provider
    experience

Kahn, et al. The efficacy of medical abortion a
meta-analysis. Contraception, 2000.
9
Outline
  • Regimens of medical abortion
  • Regimen flexibility
  • Access to abortion
  • Future research

10
Administrative routes of misoprostol
Kulier, et al. Medical methods for first
trimester abortion. Cochrane database of
systematic reviews. 2010, in press.
11
Efficacy of home use of misoprostol
  • Several studies in resource-rich countries (UK,
    US, France, Sweden, Canada)
  • In 8 studies including gt5,000 women, efficacy for
    completed abortion 93 to 98
  • In 1 study, efficacy was 91.5
  • Studies in developing countries include Albania,
    Nepal, Tunisia, India, Viet Nam
  • 89-97 efficacy
  • All used oral misoprostol

12
Acceptability of home use
Kallner, et al. Home self-administration of
vaginal misoprostol for medical abortion at 50-63
days compared with gestation of below 50 days.
Human Reproduction, 2010.
13
Mid-level providers for medical abortion
  • RCT of mid-levels vs. physicians providing MVA
    to12 weeks
  • Included 1734 women in Viet Nam and 1160 in South
    Africa
  • Rates of complications
  • were similar between provider
  • groups (0-1.4)
  • Smaller skill set required for
  • medical abortion provision
  • Large, ongoing RCT in
  • Ethiopia, Nepal anticipated
  • to complete enrolment shortly

Warriner, et al. Rates of complication in first
trimester MVA done by doctors and mid-level
providers. Lancet, 2006.
14
Outline
  • Regimens of medical abortion
  • Regimen flexibility
  • Access to abortion
  • Future research

15
Effect on abortion availability
  • Investigation on access to abortion after
    mifepristone introduction in US (2000)
  • Over 5 years 14 mifepristone-only providers over
    50 miles from surgical provider
  • Only 5 had provided 10 or more abortions
  • Little to no effect on expanding abortion
    availability

Finer, Wei. Effect of mifepristone on abortion
access in the US. Obstet Gynecol 2009.
16
Decrease in gestational age with medical abortion
introduction
  • Additional findings of Finer and Wei report
    decrease in mean gestational age
  • 58 lt 9 weeks in 2000
  • 63 lt 9 weeks in 2004
  • Similar findings in Europe
  • France (1987- 1997) 12 to 20 lt 7 weeks
  • Scotland (1990- 2000) 51 to 67 lt 10 weeks
  • Sweden (1991- 1999) 45 to 65 lt 9 weeks

Jones and Henshaw. Mifepristone for early
medical abortion. Perspectives on Sexual and
Reproductive Health, 2002.
17
Outline
  • Regimens of medical abortion
  • Regimen flexibility
  • Access to abortion
  • Future research

18
Future research
  • Very little literature on pain control
  • Yet it is one of the most common experiences
    among women having medical abortion
  • Novel methods of follow-up
  • Regimens beyond 63 days
  • Assessing medical regimens in special populations
  • Choice
  • Little information on how choice of timing/
    place/ follow-up/ routes of administration effect
    women's experiences
  • Acceptance
  • Women's reports of acceptability of the abortion
    method often reflects efficacy

19
Thank you
Thank you
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