The majority of abortions take place in less-developed countries, often under unsanitary conditions. Medical abortion, which entails swallowing pills, holds great promise for reducing death and disease related to unsafe surgical abortion in poorer countries. Cost, however, prevents medical abortion from becoming more common in these countries. To address this obstacle, Population Council researchers Batya Elul, Charlotte Ellertson, and Beverly Winikoff and their colleagues tested a medical abortion regimen in Tunisia and Vietnam that uses fewer pills and requires fewer clinic visits, and is therefore significantly less expensive than regimens currently used.
Mifepristone-misoprostol abortion
Under the usual procedure for mifepristone-misoprostol abortion, a woman with a pregnancy duration of 49 days or less takes 600 milligrams of mifepristone, in the form of three pills, at a clinic. Mifepristone blocks progesterone, a hormone that helps maintain pregnancy. The woman returns to the clinic 48 hours later to take 400 micrograms of misoprostol orally, which causes her uterus to contract and helps to complete the abortion. Approximately two weeks later, the woman again returns to the clinic to confirm that her pregnancy has ended.
The researchers studied a simplified regimen of mifepristone-misoprostol abortion. Participants in the study included 120 women in Vietnam and 195 women in Tunisia who were pregnant and had last menstruated eight weeks (56 days) or less before entering the study. Rather than taking three 200 milligram mifepristone pills, each woman took only one such pill. (Studies done previously by the World Health Organization had shown that a lower dose of mifepristone might be as effective as the standard dose.)
After being told that bleeding and pain were likely to follow the administration of misoprostol, the women were allowed to choose whether to take the drug at home or in the clinic; roughly 88 percent chose to take the misoprostol at home. When asked about their choice, many Vietnamese home-users reported that this decision was more compatible with being able to meet their obligations at work or at home, or that they were more comfortable at home. Tunisian home-users said that returning to the clinic for misoprostol was inconvenient. Most home-users in both countries had a companion—usually a husband, boyfriend, mother, sister, or other relative—present after taking the misoprostol.
“Clinic visits, especially in less-developed countries where women can ill afford time lost from work or childcare and associated transportation costs, are burdensome and inconvenient and should be minimized as much as possible without endangering women’s health,” says Winikoff. Clinic visits also compromise privacy, which is essential in places where abortion is stigmatized.
Many women who opted to return to the clinic for misoprostol, some of whom lived alone, said that they felt comforted by the presence of the clinic staff. At the end of the study, participants were asked where they would take misoprostol if they needed another medical abortion. Clinic-users were far more likely than home-users to indicate that they would switch the site of misoprostol administration in the future.
All of the women were asked to return to the clinic for follow-up two weeks after taking the mifepristone.
Feasibility of the simplified regimen
Overall, about 90 percent of women were very satisfied or somewhat satisfied with the simplified medical abortion regimen. The simplified regimen was highly successful among women with known study outcomes; it resulted in complete abortion in 93 percent of Vietnamese participants and 91 percent of Tunisian participants. (In 11 cases, women did not return to the clinic and it was impossible to confirm the status of the abortion.) Women with incomplete medical abortions received surgical abortions.
Misoprostol home-users were much more likely than clinic-users to rate their experience positively. And, in both Vietnam and Tunisia, there were substantially more failures among women who had misoprostol in the clinic than among those who took the drug at home.
“It’s possible that being in a familiar environment improved women’s abortion experiences, both emotionally and clinically,” explains Elul. Indeed, clinic counselors in France have reported that women who feel more relaxed and comfortable have more successful medical abortions.
On the basis of these findings the researchers concluded that “no scientific rationale emerges for continued use of high-dose mifepristone for early abortion” in less-developed countries. Population Council researchers are testing the simplified mifepristone-misoprostol abortion regimen in the United States.
Source
Elul, Batya, Selma Hajri, Nguyen Thi Nhu Ngoc, Charlotte Ellertson, Claude Ben Slama, Elizabeth Pearlman, and Beverly Winikoff. 2001. “Can women in less-developed countries use a simplified medical abortion regimen?” Lancet 357(9266):1402–1405.
Outside funding
The Fred H. Bixby Foundation and an anonymous donor
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