Elsevier

Contraception

Volume 70, Issue 5, November 2004, Pages 387-392
Contraception

Original research article
Acceptability of home-use of misoprostol in medical abortion

https://doi.org/10.1016/j.contraception.2004.06.005Get rights and content

Abstract

Introduction

Home-use of misoprostol would reduce the number of visits and improve access to medical abortion. We evaluated acceptance of home-use of misoprostol among women and their partners.

Materials and Methods

One hundred women with up to 49 days of amenorrhea were given mifepristone, followed by misoprostol taken at home.

Results

Women chose home-use of misoprostol because it felt more natural, private and allowed the presence of a partner/friend. Two women had a vacuum aspiration due to incomplete abortion. Five unscheduled visits occurred. Ninety-six women were satisfied with their choice of home-use. The male partners were generally satisfied with their partner's choice of home-use and felt that their presence and support had been valuable.

Discussion

Our study shows a high acceptability among women and their partners and confirms the safety and efficacy of home-use of misoprostol. Women should be offered this choice to allow more flexibility and privacy in their abortions.

Introduction

Medical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined with a prostaglandin has been available in Europe since 1988. Several large multicenter studies have since confirmed the safety and efficacy of this regimen with efficacy rates over 95%, comparable to that of surgical abortion [1], [2], [3]. Several studies have examined women's preferences for medical versus surgical abortion. When given the choice, 60–80% of women chose the medical method (reviewed in Ref. 4).

The prostaglandin most widely used today is misoprostol (Cytotec, Pfizer), a prostaglandin E1 analogue widely available for the prevention of gastric ulcers in patients taking nonsteroidal anti-inflammatory drugs. Mifepristone is approved for medical abortion in almost all countries of the European Union and the US with 600 mg mifepristone followed 36–48 h later by a prostaglandin. The most commonly used regimen of prostaglandin up to 49 days of amenorrhea in continental Europe is 400 μg misoprostol administered orally as a single dose. This regimen is highly effective to terminate a pregnancy up to 49 days of amenorrhea but less effective in more advanced pregnancy [5], [6], [7], [8]. At a gestational duration beyond 49 days, vaginal administration of a higher dose of misoprostol, 800 μg instead of 400 μg, has been shown to be more effective [9].

In a few European countries, including Sweden, France and the UK, abortion can, according to the law, be performed only in hospital-affiliated facilities or facilities approved by the Department of Health. This requirement has also been applied to medical abortion, resulting in the interpretation that all the drugs have to be given in an authorized facility followed by an obligatory observation period after misoprostol. Currently, three visits are required for medical abortion: the first is for abortion counseling, examination, contraceptive counseling and administration of mifepristone; the second visit is for the administration of misoprostol including a 3- to 4-h observation period. Finally, a follow-up visit takes place 1–4 weeks later. Although the method has been shown to be very safe and effective, several improvements have been suggested to increase acceptability and accessibility. A review of patient attitudes towards medical abortion showed that most women prefer oral administration of misoprostol, a shorter waiting time until complete abortion is confirmed and fewer visits to the clinic [4], [10]. In several studies from the USA, home administration of misoprostol has been shown to be successful and safe [11], [12]. It has also been shown to be safe and preferred in Guadeloupe as well as in several developing countries, including Tunisia and Vietnam [13], [14]. The practice of giving women the misoprostol to take at home has been adopted as clinical routine in the US. Home-use of misoprostol was accepted rapidly because of the abundant experience with home-use of misoprostol following methotrexate in medical abortion. In Europe, there has been a very slow acceptance and frequently even a resistance to giving misoprostol at home. The reluctance to allow women more autonomy is surprising given the huge amount of evidence showing the safety and efficacy of home-use and the strong preference by many women for this option.

A study on acceptability of home-use in the European context was undertaken since this option is rarely available to women in Europe. To our knowledge, the acceptability and experience of the male partner has not been studied previously.

The objective of the present study was to assess acceptability of home-use of oral misoprostol for termination of pregnancies up to 49 days of gestation. In addition, the experience of the male partner was investigated.

Acceptability of a shortened interval between mifepristone and misoprostol to 1 day (day 1, day 2) followed by a second dose of misoprostol on day 3 will be analyzed in a separate paper.

Section snippets

Material and methods

The study was performed from December 2001 to August 2003, at the Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden. Women who presented at the abortion clinic and fulfilled the inclusion criteria were given the option of participating in the study. Women were not randomized but could decide on their own where they wanted to take the misoprostol. The objective of the study was to evaluate acceptability of home-use. The patient's preference was therefore

Population characteristics, compliance, efficacy and side effects

One hundred women were included in the study. All women completed the study, used misoprostol at home according to the study protocol and returned for follow-up. Characteristics of the participating women are shown in Table 1. No patient reversed her initial decision to choose home-use during further counseling.

Women chose home-use of misoprostol because it felt more natural, like a delayed menstruation or a spontaneous abortion (25%), easier (27%) and because they preferred to have the

Discussion

Misoprostol, especially when used orally, is not complicated to administer, and there is no need for monitoring immediately following administration. Most European protocols nevertheless require that women stay in the facility for a 3- to 4-h period of observation after misoprostol administration. However, the development of a standard practice of home-use of misoprostol in the USA during the last years has changed the practice in many countries, while others remain more skeptical [11], [13],

Acknowledgments

The authors are grateful to the staff at the SESAM clinic, Karolinska Hospital, Stockholm, Sweden, for taking excellent care of the patients. The study was supported by grants from the Population Council and the Swedish Medical Research Council (0855).

References (18)

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