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Best practice with medical abortion: current evidence

Best practice with medical abortion: current evidence. Nathalie Kapp, MD, MPH Department of Reproductive Health and Research World Health Organization. Acknowledgements: Allan Templeton. Early medical abortion . Investigations have focused on: Dose of mifepristone

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Best practice with medical abortion: current evidence

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  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 >5,000 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% < 9 weeks in 2000 • 63% < 9 weeks in 2004 • Similar findings in Europe* • France (1987- 1997): 12% to 20% < 7 weeks • Scotland (1990- 2000): 51% to 67% < 10 weeks • Sweden (1991- 1999): 45% to 65% < 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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