Strengthening regional commitment to ensuring access to medical abortion medicines in WHO's South-East Asia region: report of a participatory assessment and workshop.

BACKGROUND: In 2019, the World Health Organization identified improving access to safe abortion as an important priority toward improving sexual and reproductive health and rights and achieving Sustainable Development Goals. One strategy for addressing this priority is strengthening access to medicines for medical abortion. All 11 countries in the South-East Asia Region have some indications for legal abortion and permit post-abortion care. Therefore, strengthening access to medical abortion medicines is a reasonable strategy for improving access to safe abortion for the Region. METHODOLOGY: We applied an adapted version of an existing World Health Organization landscape assessment protocol for the availability of medical abortion medicines at the country-level in the South-East Asia Region. We collected publicly available data on the existence of national health laws, policies, and standard treatment guidelines; inclusion of medical abortion medicines in the national essential medicines list; and marketing authorization status for medical abortion medicines for each country and verified by Ministries of health. The findings were once more presented, discussed and recommendations were formulated during regional technical consultation workshop. Each country teams participated in the process, and subsequently, the suggestions were validated by representatives from Ministries of Health.. RESULTS: Few countries in the Region currently have national policies and guidelines for comprehensive safe abortion. However, either mifepristone-misoprostol in combination or misoprostol alone (for other indications) is included in national essential medicines lists in all countries except Indonesia and Sri Lanka. Few countries earmark specific public funds for procuring and distributing medical abortion commodities. In countries where abortion is legal, the private sector and NGOs support access to medical abortion information and medicines. Several countries only allow registered medical practitioners or specialists to administer medical abortion. CONCLUSION: Following this rapid participatory assessment and technical consultation workshop, the World Health Organization South-East Asia Regional Technical Advisory and Sexual and Reproductive Health and Rights technical committee recommended priority actions for policy and advocacy, service delivery, and monitoring and evaluation, and indicated areas for support.

Risk of teratogenicity in continued pregnancy after gestational exposure to mifepristone and/or misoprostol: a systematic review and meta-analysis.

PURPOSE: This meta-analysis aimed to comprehensively assess the teratogenic risk to offspring associated with continuing pregnancy after administering mifepristone and/or misoprostol during gestation. METHODS: We conducted a systematic search of multiple databases, including PubMed, Web of Science, Embase, Cochrane, CNKI, and CBM, from their inception to February 2024, with no language restrictions. We included cohort and case-control studies that analyzed the teratogenic effects of mifepristone and/or misoprostol on fetuses and newborns. Quality assessment was performed using the Newcastle-Ottawa Scale (NOS). The odds ratios (OR) from individual studies were combined using meta-analysis. Sensitivity testing and heterogeneity analysis were conducted. RESULTS: A total of 13 studies were eligible for inclusion, comprising 5193 cases of congenital malformations and 12,232 controls. CONCLUSION: Our findings indicated that the use of misoprostol during early pregnancy increased the risk of congenital abnormalities in offspring (OR = 2.69; 95% CI: 1.57-4.62). However, the potential teratogenic effect of mifepristone during pregnancy cannot be ruled out. Additionally, the use of mifepristone and/or misoprostol has been linked to a higher risk of certain congenital anomalies, such as hydrocephalus (OR = 3.41; 95% CI: 1.17-9.97), Möbius syndrome (OR = 26.48; 95% CI: 11.30-62.01), and terminal transverse limb defects (OR = 10.75; 95% CI: 3.93-29.41). (PROSPERO, CRD42024522093, 03182024).

Effectiveness and acceptability of home use of misoprostol for medical abortion up to 10 weeks of pregnancy.

INTRODUCTION: The administration of mifepristone, followed by misoprostol, is widely used for medical abortion. Many studies have demonstrated home abortion to be safe in pregnancies up to 63 days of gestation, and recent data support its safety when extended to more advanced pregnancies. We studied the efficacy and acceptability of home use of misoprostol up to 70 days of gestation in a Swedish setting and compared the outcomes between pregnancies with a gestational age of up to 63 days and pregnancies with gestational age 64-70 days. MATERIAL AND METHODS: This prospective cohort study was performed between November 2014 and November 2021 at Södersjukhuset and Karolinska University Hospital, Stockholm, and some patients were also recruited from Sahlgrenska University Hospital, Göteborg and Helsingborg Hospital. The primary outcome was the rate of complete abortions and was defined as complete abortion without any need for surgical or medical intervention and assessed by clinical assessment, pregnancy test and/or vaginal ultrasound. Secondary objectives were assessed by daily self-reporting in a diary and included pain, bleeding, side effects and women's satisfaction and perception of home use of misoprostol. A comparison of categorical variables was made with Fisher's exact test. The significance level was set to a p-value ≤0.05. The study was registered at Clinicaltrials.gov on July 14, 2014 (NCT02191774). RESULTS: During the study period we enrolled 273 women opting for medical abortion with home use of misoprostol. In the early group, up to 63 days of gestation, 112 women were included with a mean gestational length of 45 days and in the late group, 64-70 days of gestation, 161 women with a mean gestations length of 66.3 days were included. Complete abortion occurred in 95% (95% CI 89-98) of women in the early group and in 96% (95% CI 92-99) in the late group. No differences were found regarding side effects and acceptability was similarly high in both groups. CONCLUSIONS: Our results show high efficacy and acceptability of medical abortion when misoprostol is administered at home up to 70 days of gestation. This supports previous findings about maintained safety when misoprostol is administered at home even past a very early pregnancy.

Pathways to medical abortion self-use (MASU): results from a cross-sectional survey of women's experiences in Kenya and Uganda.

BACKGROUND: In Kenya and Uganda, unsafe abortions are a leading cause of maternal mortality. The new WHO policy guidelines on the safe termination of pregnancies up to 9 weeks lack information on women's experiences with self-administered medical abortion (MA), impeding the development of interventions to increase MA use. This study aimed to comprehend women's experiences with MA in Kenyan and Ugandan pharmacies. METHODS: A cross-sectional mixed-methods survey utilized data from medical registers in 71 purposefully identified pharmacies and clinics dispensing MA drugs between September and October 2021. Forty women who were MA users participated in focus group discussions. The main outcome variables were: sources of MA information, costs of MA services, complications from MA, pain management, follow-up rates, and use of post-MA contraception. Quantitative data were analyzed using Stata 15, while qualitative thematic analysis was conducted using Dedoose qualitative analysis software. RESULTS: 73.6% of 2,366 women got an MA, both in Kenya (79%) and Uganda (21%). Most (59.1%) were walk-in clients. Kenya had significantly more women referred for MA (49.9%) than Uganda (10.1%) (p 0.05). Friends and family members were the main sources of MA information. The median cost of MA was USD 18 (IQR 10-60.5) in Kenya and USD 4.2 (IQR 2-12) in Uganda. Most MA clients received pain management (89.6%), were followed up (81%), and received post-MA contraception (97.6%). Qualitative results indicated a lack of medicines, high costs of MA, complications, stigma, and inadequate training of providers as barriers to MA use. CONCLUSIONS AND RECOMMENDATIONS: Communities are a valuable information resource for MA, but only if they have access to the right information. A relatively weak health referral system in Uganda highlights the importance of pharmacies and clinicians collaborating to support clients' abortion needs and contraceptive use after medical abortion (MA). Low client follow-up rates show how important it is to make sure pharmacy technicians know how to give MA correctly. Finally, it is crucial to strengthen the supply chain for MA products in order to eliminate cost barriers to access.

Approved but Unavailable: A Mystery-Caller Survey of Mifepristone Access in a Large Ontario City.

OBJECTIVES: Mifepristone/misoprostol (mife/miso) has been approved in Canada since 2017, and is available since 2018. Mife/miso does not require witnessed administration in Canada, and therefore most patients obtain a prescription for home use. We sought to determine the proportion of pharmacies in Hamilton, Ontario, Canada, a city of over 500 000, that had combination mife/miso in stock at any given time. METHODS: A mystery-caller approach was used to survey all pharmacies (n = 218) in Hamilton, Ontario, Canada between June 2022 and September 2022. RESULTS: Of the 208 pharmacies that were successfully contacted, only 13 (6%) pharmacies had mife/miso in stock. The most commonly cited reasons for the medication being unavailable were low patient demand (38%), cost (22%), lack of familiarity with medication (13%), supplier issues (9%), training requirements (8%), and medication expiry (7%). CONCLUSIONS: These findings suggest that while mife/miso has been available in Canada since 2017, significant barriers remain to patients accessing this medication. This study clearly demonstrates a need for further advocacy and clinician education to ensure mife/miso is accessible to the patients who require it.

Availability of medical abortion medicines in eight countries: a descriptive analysis of key findings and opportunities.

BACKGROUND: In recent years a growing number of manufacturers and medical abortion products have entered country markets and health systems, with varying degrees of quality and accessibility. An interplay of factors including pharmaceutical regulations, abortion laws, government policies and service delivery guidelines and provider's knowledge and practices influence the availability of medical abortion medicines. We assessed the availability of medical abortion in eight countries to increase understanding among policymakers of the need to improve availability and affordability of quality-assured medical abortion products at regional and national levels. METHODS: Using a national assessment protocol and an availability framework, we assessed the availability of medical abortion medicines in Bangladesh, Liberia, Malawi, Nepal, Nigeria, Rwanda, Sierra Leone and South Africa between September 2019 and January 2020. RESULTS: Registration of abortion medicines-misoprostol or a combination of mifepristone and misoprostol-was established in all countries assessed, except Rwanda. Mifepristone and misoprostol regimen for medical abortion was identified on the national essential medicines list/standard treatment guidelines for South Africa as well as in specific abortion care service and delivery guidelines for Bangladesh, Nepal, Nigeria, and Rwanda. In Liberia, Malawi, and Sierra Leone-countries with highly restrictive abortion laws and no abortion service delivery guidelines or training curricula-no government-supported training on medical abortion for public sector providers had occurred. Instead, training on medical abortion was either limited in scope to select private sector providers and pharmacists or prohibited. Community awareness activities on medical abortion have been limited in scope across the countries assessed and where abortion is broadly legal, most women do not know that it is an option. CONCLUSION: Understanding the factors that influence the availability of medical abortion medicines is important to support policymakers improve availability of these medicines. The landscape assessments documented that medical abortion commodities can be uniquely impacted by the laws, policies, values, and degree of restrictions placed on service delivery programs. Results of the assessments can guide actions to improve access.

Unsafe abortion is a leading cause of death and disability among women of reproductive age. Medical management of abortion with mifepristone and misoprostol pills, or just misoprostol, is a safe and effective way to end a pregnancy. Owing to an increase in the number of medical abortion products that have entered country health systems, we examined access to these medicines from supply to demand in selected countries. The overarching goal of the national landscape assessments was to produce evidence to support advocacy efforts and policymaking for improved access to quality medical abortion products that is appropriate to the needs of the country. This paper aims to describe key findings across eight country settings on the availability of medical abortion medicines and identify key opportunities to improve access to them across countries.

The serum lipidomics reveal the action mechanism of Danggui-Yimucao herbal pair in abortion mice.

Medical abortion is a common medical procedure that women choose to terminate an unwanted pregnancy, but it often brings post-abortion complications. Danggui (Angelica sinensis Radix)-Yimucao (Leonuri Herba), as a herbal pair (DY) in clinical prescriptions of traditional Chinese medicine, is often used in the treatment of gynecological diseases and has the traditional functions of tonifying the blood, promoting blood circulation, removing blood stasis and regulating menstruation. In this study, serum lipidomics were adopted to dissect the mechanism of DY in promoting recovery after medical abortion. A total of 152 differential metabolites were screened by lipidomics. All metabolites were imported into MetaboAnalyst for analysis, and finally key metabolic pathways such as glycerophospholipid metabolism, linoleic acid metabolism and pentose and glucuronate interconversions were enriched. Our results indicated that metabolic disorders in abortion mice were alleviated by DY through glycerophospholipid metabolism, while prostaglandin and leukotriene metabolites might be the key targets of DY to promote post-abortion recovery.

Trend of serum beta-human chorionic gonadotropin levels after medical abortion in the early first trimester of pregnancy.

AIM: This study aimed to study serum beta-human chorionic gonadotropin level trends after medical abortion using mifepristone and misoprostol in the early first trimester. METHODS: We enrolled women at ≤63 days of gestation who were indicated for pregnancy termination. We excluded women with incomplete abortions, nonviable pregnancies, extrauterine pregnancies, and contraindications for mifepristone/misoprostol use. Women received oral mifepristone (200 mg), followed by vaginal misoprostol (800 mcg) after 48 h. Serum beta-human chorionic gonadotropin levels were monitored pre-mifepristone administration (day 1); 48 h post-mifepristone, pre-misoprostol administration (day 3); day 10; and weekly after day 10, until negative beta-human chorionic gonadotropin levels (<25 mIU/mL) were achieved. RESULTS: Among 39 enrolled women, 36 (92.3%) who underwent complete abortion without further interventions were included. The median gestational age was 51 (32-61) days. Three phases of beta-human chorionic gonadotropin levels were observed: an increase of up to 5.1% within 48 h of taking mifepristone, before misoprostol administration; a rapid decline on day 10 (by 98.5% compared with initial levels); and a slow decline after day 10 until negative results were attained within 7 weeks. CONCLUSION: Serum beta-human chorionic gonadotropin levels minimally increased 48 h after taking mifepristone, rapidly declined within 1 week of misoprostol administration, and slowly declined until negative within 7 weeks post-abortion.

Knowledge, attitude, and intended practice of abortion among pharmacy students in Thailand after the amendment of the Thai Abortion Law.

BACKGROUND: The recently amended Thai abortion law allows pregnant women to undergo abortions up to the gestational age of 12 weeks. Medical abortion is significant because it has revolutionized access to safe abortion care-abortion medicine can now be safely and effectively administered outside of a healthcare facility to women in early pregnancy. This contribution supports the pharmacists' role in interprofessional safe abortion teamwork. Adequate knowledge of the current laws regarding safe abortion services will increase pharmacists' competence in providing services. However, safe abortions as a subject have not been formally incorporated into the curriculum for Thai pharmacy students. Therefore, this study aimed to evaluate the knowledge, attitude, and intended practice of fifth-year pharmacy students at Chulalongkorn University. METHODS: A cross-sectional study was conducted using an electronic self-administered questionnaire adapted from previously published studies to evaluate participants' knowledge of the recently amended Thai abortion law, attitude toward abortion, and intended practices. The invitations were sent to all fifth-year pharmacy students at Chulalongkorn University. RESULTS: Among all invitations sent, 104/150 (69.3%) participants responded to the survey. Only a third of the participants (31.7%) had good knowledge scores. Based on five questions regarding the gestational age limit for legal abortion, most participants (52.7%) answered questions incorrectly. Although more than half of the participants (52.5%) disagreed with two pro-choice statements, an overwhelming majority (87.5%) agreed that abortion was a woman's right. Safe abortion services were mostly agreed upon with serious fetal defects (91.9%), non-HIV maternal health conditions (82.2%), and sexual assaults (77.4%). A positive attitude toward abortion affects the intention to perform an abortion under socioeconomic conditions. CONCLUSION: Most participants lacked knowledge on the amended abortion law, especially on the gestational limits of abortion. Participants with favorable attitudes toward abortion tended to be more liberal regarding safe abortion services.

Mifepristone priming and subsequent misoprostol for second trimester medical abortion in women with previous caesarean delivery.

AIMS: To assess clinical outcomes and complications in women with ≥1 prior caesarean delivery (CS) during mid-pregnancy medical abortion with misoprostol following mifepristone priming. MATERIALS AND METHODS: Retrospective analysis of abortions at 13-28 weeks gestation using sequential mifepristone and misoprostol at a single centre from 1/2008-12/2018. Procedural outcomes were compared between cases with no prior CS, one prior and ≥2 prior CS. RESULTS: There were 1399 consecutive women who underwent a medical abortion, with 304 (21.7%) having ≥1 prior lower segment CS (241 one, 49 two, 12 three, one four) and one a prior classical CS. Median gestation was 19 weeks (interquartile range (IQR) 17-21) among nulliparas, multiparas with no prior CS and multiparas with prior CS, P = 0.505. Compared with nulliparas (median procedural duration 10.8 h, IQR 7.5-16.5; adjusted hazards ratio (aHR) = 1.20 95%CI 1.04-1.40, P = 0.015), multiparas with prior CS had a shorter procedural duration (9.5 h, IQR 6.5-13.5) while multiparas with no CS had the shortest duration (7.0 h, IQR 5.0-9.8; aHR = 2.28 95%CI 2.01-2.58, P < 0.001). Complications were more frequent with prior CS: estimated blood loss (medians: 100 cc no CS vs 150 cc ≥1 CS, P = 0.002), blood loss >1000 cc (3.6% no CS vs 7.2% ≥1 CS; odds ratio (OR) = 2.11 95%CI 1.23-3.62, P = 0.007) and placental retention (17.3% no CS vs 25.3% ≥1 CS; adjusted OR = 1.44 95%CI 1.05-1.99, P = 0.024). Uterine rupture occurred in 4/304 women with ≥1 prior CS (1.3%). CONCLUSIONS: Mifepristone-misoprostol abortion in women with prior CS is generally safe but associated with an increased risk of procedural complications. Lowering of the misoprostol dosage with prior CS may reduce uterine rupture, although this hypothesis requires ongoing research.

Telephone follow-up after early medical abortion using Australia's first low sensitivity urine pregnancy test.

BACKGROUND: Follow-up after early medical abortion (EMA) in Australia often entails tracking serum human chorionic gonadotropin levels or performing ultrasonography in-clinic. In other countries, methods of follow-up such as using a low-sensitivity urine pregnancy test (LSUPT), telephone evaluation and a questionnaire have been demonstrated to be safe and acceptable. AIMS: To evaluate the safety and efficacy of telephone follow-up after EMA using an LSUPT and questionnaire. MATERIALS AND METHODS: A prospective observational cohort study of patients undergoing telephone follow-up after EMA using an LSUPT and questionnaire was conducted from March 26 to July 31, 2020. Outcomes of patients who returned to clinic because of a positive LSUPT were evaluated and adverse event rates were calculated. Routinely collected adverse event information was used to compare complication rates during the evaluation period with that prior to introduction of the LSUPT. RESULTS: During the study period, 2223 patients underwent the new protocol. One hundred and ninety-seven patients had a positive LSUPT at their telephone follow-up. One hundred and thirty-two had an incomplete abortion, 11 had a continuing pregnancy, 53 had a complete abortion and one left the clinic before full assessment. CONCLUSIONS: Introduction of telephone follow-up with an at-home LSUPT reduced the number of patients requiring unnecessary clinic appointments, with over 90% of patients completing their follow-up at home. Complication rates during the study period were found to be at least comparable with previously identified organisational adverse events.

Telemedicine medical abortion service in Georgia: an evaluation of a strategy with reduced number of in-Clinic visits.

PURPOSE: To evaluate feasibility and acceptability of a medical abortion service that offers: a telemedicine visit (in place of an in-person visit) during a mandatory waiting period, and at-home follow-up with the use of multi-level pregnancy tests (MLPT). METHODS: Participants were screened for eligibility in clinic, and during the waiting period, received a telephone call to confirm desire to proceed with the service. Participants were mailed a study package containing mifepristone, misoprostol, two multi-level pregnancy tests, and instructions for their use. Follow-up consultation took place by phone to evaluate abortion completeness. The analysis was descriptive. RESULTS: One-hundred twenty-two participants were enrolled in the study, and 120 chose to proceed with the abortion after the waiting period and were sent a study package. One participant was lost to follow up. The majority of participants did not experience problems receiving the study package (94.1%, n = 112), took mifepristone (100%, n = 119), misoprostol (99.2%, n = 118), and MLPTs (99.1%, n = 116) as instructed, and forwent additional clinic visits (91.6%, n = 109). All participants were satisfied with the service. Most participants had a complete abortion without a procedure (95.8%, n = 114). CONCLUSIONS: The adapted telemedicine medical abortion service was feasible and satisfactory to participants and has the potential to make medical abortion more patient-centered where waiting periods are mandated.

Preabortion ultrasound - a patient perspective.

PURPOSE: To explore women's perception of the need for an ultrasound scan before medical abortion provided by telemedicine services. METHODS: We have analysed women's requests for medical abortion through the website www.womenonweb.org from the 1st of January 2019 to the 5th of October 2020. Before receiving abortion drugs for self-managed medical abortion, women received online counselling and were asked to complete an online survey on pre-abortion ultrasound scan and the reasons for having or not having one. The initial dataset included 62641 entries from 207 countries. Each entry corresponded to a person's request for medical abortion. Women reported only one or multiple reasons for not having a pre-abortion ultrasound scan. RESULTS: Among 59648 women requesting a medical abortion, 45653 (76,54%) did not have any pre-abortion ultrasound scan and specified a reason for that. The countries with the highest rates of women not having a pre-abortion ultrasound scan were Thailand, Poland, Northern Ireland, Mexico, South Korea, Japan, Chile, Indonesia, Germany, and Brazil. The main reasons for not having a pre-abortion ultrasound scan were being confident regarding pregnancy length; and thus, no need for a scan stated by 10910/34390 women (31.7%), lack of resources stated by 10589/34390 women (30.8%), and privacy issues stated by 6472/34390 women (18.8%). CONCLUSION: Most women opting for medical abortion through telemedicine did not undergo a pre-abortion ultrasound scan. The main reason stated was that women did not find it necessary, lack of resources and privacy issues.

Women requesting medical abortion through telemedicine were asked about their views and experiences regarding pre-abortion ultrasound scan. Of 59648 women included in the study, 76% did not have a scan. The main reason stated was that women did not find it necessary, lack of resources and privacy issues.

10-year evaluation of the use of medical abortion through telemedicine: a retrospective cohort study.

OBJECTIVE: To provide a descriptive overview and evaluate changes in the use and outcome of abortions provided worldwide by telemedicine in the past 10 years. DESIGN: Retrospective cohort study. SETTING: Multi-country. POPULATION/SAMPLE: 30 344 women who completed the follow-up survey of the telemedical abortion service Women on Web from January 2009 till January 2020. METHODS: Analyses of follow-up surveys, binary logistic regressions to test the association between year and outcomes. MAIN OUTCOME MEASURES: Rate of complete abortions, surgical interventions, ongoing pregnancies, blood transfusions per year, socio-economic situation, knowledge on medical abortion, acceptability of receiving service, appropriateness of method and the likelihood of recommending the service to a friend. RESULTS: Medical abortions were provided to 81 683 women, of whom 30 344 (37.2%) completed the follow-up survey. In total, 26 076 women reported doing the medical abortion, of whom 1.5% reported an ongoing pregnancy, 10.2% a surgical intervention and 0.6% a blood transfusion. Acceptability of the service was 99%, and 59.2% of the users reported previous knowledge of medical abortion. We found a significant increase in complete abortions in 2019 (odds ratio 1.92; 95% CI 1.59-2.31) and decrease in surgical interventions (odds ratio 0.49; 95% CI 0.40-0.60) compared with 2009. CONCLUSION: Low follow-up rates present a limitation in analysing trends in telemedical abortion usage. However, our findings suggest that it is a highly acceptable method around the world and that there has been an increase in complete abortions by telemedical abortions and a decrease in surgical interventions in the last 10 years. TWEETABLE ABSTRACT: In the last 10 years, there has been an increase in complete abortions and decrease in surgical interventions of telemedical abortion.

Validation of a Spanish-language scale for evaluating perceived quality of care of medical abortions before 9 weeks gestation.

BACKGROUND: Spanish Organic Law 2/2010 legalizes abortion within 14 weeks of gestation. Medical abortion with mifepristone and misoprostol is around 97% effective and is offered at primary care centers during the first 9 weeks of gestation. It consists of the administration of 200 mg of mifepristone by a healthcare professional and of the self-administration 800 mg of misoprostol by the patient at home, along with prescribed analgesics. However, the quality of this process as perceived by patients has never been assessed. This study aims to validate a scale designed to assess the perceived quality of the entire process, structure and results of at-home medical abortion. METHODS: Validation study of a Spanish adaptation of the SERVPERF scale. In total, 289 patients completed a self-administered questionnaire consisting of 26 items previously evaluated by a group of experts. A re-test was performed on 53 of these patients 15 days later to assess interobserver consistency. RESULTS: The highest non-response rate for any single item was 2.1%. The floor effect was 26% and the ceiling effect did not surpass 83%. The linearly weighted Kappa coefficient was good to excellent, in general. An exploratory factor analysis was performed with Varimax rotation, obtaining a total of 7 dimensions that explain 65.9% of the variability. The internal consistency (Cronbach's alpha) for all items was 0.862. CONCLUSION: This psychometric instrument is valid and reliable for assessing the quality of care of medical abortion. Medical abortion is efficient, effective and eliminates the need for hospital care, anesthesia and surgical risk. However, user satisfaction has yet to be determined. This study offers a validated scale to assess perceived quality of care, their quality experience and person-centered care for abortion as a fundamental part of overall service quality as a fundamental part of overall service quality.

Quality of care in abortion in the era of technological and medical advancements and self-care.

BACKGROUND: Discussions around quality of abortion care have been focused mainly on service-delivery aspects inside healthcare facilities. More recently, with availability of medical abortion (MA), increase in its self-use, and emergence of other delivery platforms such as telemedicine, the responsibility of quality care has broadened to actors outside of facilities. BODY OF TEXT: This commentary discusses the meaning of quality of abortion care with the paradigm shift brought by medical and technological advancement in abortions, and raises questions on the role of the state in ensuring quality in abortion management-especially in settings where abortion is decriminalized, but also in countries where abortion is permitted under certain circumstances. It consolidates the experience gained thus far in the provision of safe abortion services and also serves as a forward-thinking tool to keep pace with the uptake of newer health technologies (e.g., availability of medical abortion drugs), service delivery platforms (e.g., telemedicine, online pharmacies), and abortion care providers (e.g., community based pharmacists). CONCLUSIONS: This commentary provides context and rationale, and identifies areas for action that different stakeholders, including health advocates, policymakers, program managers, and women themselves, can adopt to fit into an alternative regime of abortion care.

Detection of ectopic pregnancy and serum beta hCG levels in women undergoing very early medical abortion: a retrospective cohort study.

OBJECTIVE: To evaluate the outcome of the very early medical abortion (VEMA) protocol and whether it could increase early diagnosis and treatment of an asymptomatic ectopic pregnancy (EP). To investigate serum ß-hCG levels correlated to ultrasound findings, and decline in ß-hCG after successful VEMA. STUDY DESIGN: A retrospective case-note review. The population consisted of all women undergoing a VEMA during 2004-14 in Austria and 2012-13 in Sweden. Two cohorts identified based on sonography findings; 106 women with an empty uterine cavity were classified as a pregnancy of unknown location (PUL) and 576 women with an intrauterine sac-like structure without a yolk sac or foetal structure were classified as probable intrauterine pregnancy (probable IUP). RESULTS: Overall, 660 women (97.6%) had a successful VEMA, 94/101 women (93.1%) in the PUL group and 566/575 women (98.4%) in the probable IUP group (p < 0.001). We identified six asymptomatic EP (0.88%). A gestational sac (< 10 mm) was detected at a median/range ß-hCG level 2728 (1600-4497) IU/l. The mean decline in ß-hCG was 93%, (95% CI 91.7-94.2) 5-10 days after successful abortion. CONCLUSIONS: VEMA may be of particular clinical benefit for women. Apart from offering a possibility to start an abortion without delay as soon as the woman has sought abortion care, it may also offer an opportunity to detect and treat EP at an early gestational age. However, the rate of EP was very low.

Self-reported elevated pain levels: A coping strategy used by women undergoing medical abortion procedures.

PURPOSE: Epidural analgesia alleviates pain during normal labour but women who undergo medical abortion procedures using epidural analgesia continue to express high pain levels. To understand this we assessed if patients undergoing medical abortions, treated with epidural analgesia, use their pain for psychological benefits. METHODS: This study comprised 105 patients over 13 weeks of gestational age diagnosed with foetal abnormalities after selecting a medical abortion procedure using epidural analgesia. Three questionnaires were handed-out: 1) 'Need for Affect', assessed the motivation to react to emotions; 2) 'Pain-Levels' 3) PANA- 'Positive Affect' (PA), 'Negative Affect' (NA) assessed emotions pre-abortion and post-abortion. RESULTS: Patients with a strong Need for Affect and high Pain-Levels expressed a stronger PA post-abortion (b = .69, se = .11, ß = .68, p < .001, 95%CI [.48,.90]). Patients with a strong NA pre-abortion and high Pain-Levels expressed a higher NA post-abortion (b = .48, se = .11, ß = .53, p < .001, 95%CI [.26, .70]). CONCLUSION: Patients with a strong Need for Affect who express a strong PA pre-abortion intensify their pain to fulfill their Need for Affect, which then helps recovery. Patients with a strong NA pre-abortion and high Pain-Levels indicate a less favourable outcome.

The Case for Telemedical Early Medical Abortion in England: Dispelling Adult Safeguarding Concerns.

Access to abortion care has been hugely affected by the COVID-19 pandemic. This has prompted several governments to permit the use of telemedicine for fully remote care pathways, thereby ensuring pregnant people are still able to access services. One such government is that of England, where these new care pathways have been publicly scrutinised. Those opposed to telemedical early medical abortion care have raised myriad concerns, though they largely centre on matters of patient safeguarding. It is argued that healthcare professionals cannot adequately carry out their safeguarding duties if the patient is not in the room with them. These concerns lack empirical support. Emerging evidence suggests that safeguarding processes may, in fact, be more effective within telemedical abortion care pathways. In this article, we address two specific safeguarding concerns: (1) that a remote consultation prevents a healthcare professional from identifying instances of abuse, and (2) that healthcare professionals cannot reliably confirm the absence of coercion during a remote consultation. We demonstrate that such concerns are misplaced, and that safeguarding may actually be improved in telemedical care pathways as victims of abuse may find it easier to engage with services. It is inevitable that some individuals will fall through the net, but this is unavoidable even with in-person care and thus does not constitute a strong critique of the use of telemedicine in abortion care. These safeguarding concerns set aside, then, we argue that the current approval that enables telemedical early medical abortion should be afforded permanence.

The Excessive Regulation of Early Abortion Medication in the UK: The Case for Reform.

Early medical abortion (EMA) involves the administration of two medications-mifepristone and misoprostol-24-48 hours apart. These routinely used medications are recognised as safe and effective by the World Health Organization which recommends this combination of medications as a safe form of abortion until nine weeks' gestation. Despite the safety and effectiveness of this drug regimen, there exists excessive regulation around EMA. This is despite new regulations introduced in Northern Ireland in 2020 and (temporary) changes made in 2020 to allow at-home administration of mifepristone in Great Britain (following earlier changes to permit home use of misoprostol). We argue that the excessive regulation of EMA is inappropriate because it fails to recognise that abortion is essential healthcare. Further, the regulation constitutes disproportionate interference with clinical discretion and service organisation because it is medically unnecessary and prevents abortion providers in the UK from adapting their service provision in line with emerging evidence of best practice.