What can obstetrician/gynecologists do to support abortion access?

Unsafe abortion causes approximately 13% of all maternal deaths worldwide, with higher rates in areas where abortion access is restricted. Because safe abortion is so low risk, if all women who needed an abortion could access safe care, this rate would drop dramatically. As women's health providers and advocates, obstetrician/gynecologists can support abortion access. By delivering high-quality, evidence-based care ourselves, supporting other providers who perform abortion, helping women who access abortion in the community, providing second-trimester care, and improving contraceptive uptake, we can decrease morbidity and mortality from unsafe abortion.

Introduction of the dilation and evacuation procedure for second-trimester abortion in Vietnam using manual vacuum aspiration and buccal misoprostol.

BACKGROUND: The dilation and evacuation (D&E) procedure was modified for use in a low-resource setting where access to electric vacuum aspiration is limited. METHOD: In this demonstration project, buccal misoprostol is used for cervical preparation, followed by evacuation using manual vacuum aspiration (MVA) and forceps. Senior physicians at the Hanoi Obstetrics and Gynecology Hospital were trained in D&E and subsequently conducted 439 D&E procedures. RESULTS: The primary outcomes were efficacy and safety. Secondary outcome measures include efficacy of buccal misoprostol for cervical preparation prior to D&E and the feasibility of MVA for use in the D&E procedure. CONCLUSION: Successful abortion took place in 100% of the cases. Three major complications occurred. This procedure may be appropriate in other low-resource settings lacking safe, effective abortion services in the second trimester.

Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure.

OBJECTIVE: To examine patient treatment preferences and satisfaction with an office-based procedure for early pregnancy failure and to compare resource use and cost between office and operating room management of early pregnancy failure. METHODS: This study was a prospective observational study of 165 women presenting for surgical management of early pregnancy failure. Participants completed a preoperative questionnaire addressing treatment preferences and expectations and a postoperative questionnaire measuring level of pain experienced and satisfaction with care. Resource use was determined by measuring the time patients spent at the health care facility and the actual procedure time. Cost was estimated using an institutional database. RESULTS: One hundred fifteen women from the office and 50 from the operating room were enrolled. Patients selecting outpatient management scored "privacy," "avoiding going to sleep," and "previous experience" higher than the operating room group (P < .05). Patients who perceived that their physicians preferred one procedure over the other were more likely to select that procedure (P < .001). Satisfaction was high in both groups, and underestimating the procedure's discomfort was negatively associated with satisfaction (P < .002). Costs were greater than two-fold higher in the operating room group compared with the office group (P < .01). Complications were uncommon, but hemorrhage-related complications were four times more common in the operating room group than in the office group (P < .01). CONCLUSION: Office-based surgical management of early pregnancy failure is an acceptable option for many women and offers substantial resource and cost savings. LEVEL OF EVIDENCE: II-2.

A systematic review of more than one dose of misoprostol after mifepristone for abortion up to 10 weeks of gestation.

OBJECTIVES: This review aimed to assess the effectiveness, acceptability and safety of regimens that include mifepristone and multiple misoprostol doses for abortion up to 10 weeks of gestation. METHODS: We searched MEDLINE and reference lists for English-language reports (published between January 1990 and September 2005) of trials evaluating a medication abortion regimen consisting of mifepristone and multiple doses of misoprostol. Eligible trials had to either be restricted to women with less than 10 weeks' gestation or report stratified results that allowed the extraction of data for this subset. RESULTS: Although we identified 26 eligible studies, only 3 were randomized controlled trials (RCTs), comparing regimens that differed in the repeat-dose misoprostol component. These trials did not detect differences in effectiveness between the randomized groups. One RCT found evidence of higher effectiveness from repeat misoprostol doses among a subgroup of women with more advanced gestations. CONCLUSIONS: Although clinicians often prescribe a repeat dose of misoprostol to increase effectiveness in medication abortion, the effect of the repeat dose has not been established. Because mifepristone followed by a single misoprostol dose is highly effective in inducing abortion, determining the effect of a repeat misoprostol dose would require a large sample size. The resource expenditure on such large trials might not be warranted. Any future studies should use induction-to-completion time to measure effectiveness and should assess acceptability and side effects.

Buccal misoprostol as cervical preparation for second trimester pregnancy termination.

The objective of the study was to assess the efficacy of cervical preparation with misoprostol or laminaria suction abortion up to 18 weeks gestation. The study was conducted among a consecutive case series of patients presenting for dilatation and evacuation at a single center. Cervical preparation was effected by either 600 mg buccal misoprostol (n = 32) or laminaria (n = 78). Dilatation and evacuation was then performed using vacuum aspiration, with fetal parts or placenta removed as necessary with appropriate forceps. The principle outcome of interest was procedure time. Complete abortion was effected in 100% of the cases. In all cases, the cervix was adequately prepared to allow either the introduction of a size 14-mm suction cannula or was easily dilated to this diameter. Group size was sufficient for detection of a 20% difference in mean procedure time with 80% power (calculated with two separate standard deviations for procedure time). Procedure times were not significantly different when misoprostol was used compared to laminaria for cervical preparation. It is concluded that the use of misoprostol to provide cervical preparation in second trimester abortion procedures appeared effective and offers an alternative to laminaria. Buccal misoprostol should be more widely investigated for this purpose.