Medical abortion: Safety, access probed
Medical abortion: Safety, access probed
If medical abortion using mifepristone (Mifeprex, Danco Group) and misoprostol is offered at your facility, be sure to review a new study that asserts the safety of a particular mifepristone/misoprostol regimen.1 According to study results, rates of serious infection decreased at Planned Parenthood facilities after protocol was changed from vaginal to buccal administration of misoprostol, combined with routine administration of antibiotics.
Understand that the risk for infection is small for medical abortion; a 2004 literature review reported the frequency of diagnosed and/or treated infection after such regimens as very low (0.92%, N = 46,421).2
The current study is a retrospective analysis assessing the rates of serious infection after medical abortion at some 300 Planned Parenthood facilities. From 2001 through March 2006, most of the health centers used a regimen of oral mifepristone, followed 24-48 hours later by vaginal misoprostol. In response to concern about serious infections, Planned Parenthood revised its protocol in early 2006 and changed the route of misoprostol administration from vaginal to buccal and initiated additional infection-reduction measures. In July 2007, Planned Parenthood began requiring routine treatment with antibiotics for all medical abortions.
To get providers up to speed on the changes, Planned Parenthood held numerous national teleconferences so that clinicians in different time zones had opportunities to join the call, understand why the changes in the regimen were being made, and give them opportunities to ask questions, says Mary Fjerstad, NP, MHS, lead author of the article. The organization also circulated documents throughout the Planned Parenthood system that explained the regimen changes, notes Fjerstad, now senior clinical advisor for the Medical Abortion Initiative at Ipas, a Chapel Hill, NC-based international reproductive health advocacy organization. Fjerstad was a co-presenter of the study findings at the recent Reproductive Health 2009 conference.3
Rates of serious infection dropped significantly after the joint change to buccal misoprostol from vaginal misoprostol and to testing for sexually transmitted infection or routine provision of antibiotics as part of the medical abortion regimen, study authors state. The rate declined 73%, from 0.93 per 1,000 abortions to 0.25 per 1,000 [absolute reduction, 0.67 per 1,000; 95% confidence interval (CI), 0.44 to 0.94; P < 0.001]. The subsequent change to routine provision of antibiotics led to a further significant reduction in the rate of serious infection: a 76% decline, from 0.25 per 1,000 abortions to 0.06 per 1,000 (absolute reduction, 0.19 per 1000; 95% CI, 0.02 to 0.34; P=0.03).1
Has access expanded?
Reproductive health advocates held high hopes for the advent of medical abortion in the United States as a means of expanding abortion access to women, particularly those in rural areas. While use of mifepristone has become widespread and has contributed to the shift toward earlier abortions, its use has not improved women's geographic access to abortion services, states a new report.3
The number of medical abortions and the number of providers offering mifepristone increased dramatically between 2000 and 2007, even as the total number of abortions performed in the United States declined steadily over this period, the study authors note. In 2007, 902 providers performed 158,000 mifepristone abortions, which represented an estimated 21% of eligible abortions performed that year. However, most of these abortions were performed at or near facilities that also provided surgical abortions, the authors state. Only five mifepristone-only providers of 10 or more abortions were located farther than 50 miles from any surgical provider of 400 or more abortions, findings indicate.
Mifepristone now is an integral part of U.S. abortion service provision, accounting for about one-fifth of very early abortions.4 Many factors have led to its increased use, says Rachel Jones, PhD, senior research associate at the Guttmacher Institute, which reviews reproductive health access. Many abortion providers, particularly those who already were performing surgical abortions, wanted to provide women with options in reproductive health, notes Jones. Also, when the Food and Drug Administration approved mifepristone in 2000, many organizations, such as the National Abortion Federation and Planned Parenthood Federation of America, promoted training for interested health care professionals so they could include early medical abortion in their practices, states Jones. Over time, more providers have become more comfortable with early medical abortion and have added it to their practice or expanded its use, she notes.
References
- Fjerstad M, Trussell J, Sivin I, et al. Rates of serious infection after changes in regimens for medical abortion. N Engl J Med 2009; 361:145-151.
- Shannon C, Brothers LP, Philip NM, et al. Infection after medical abortion: A review of the literature. Contraception 2004; 70:183-190.
- Fjerstad M, Trussell J. Reducing serious infection following abortion. Presented at the Reproductive Health 2009 conference. Los Angeles; Sept. 30-Oct. 3, 2009.
- Finer LB, Wei J. Effect of mifepristone on abortion access in the United States. Obstet Gynecol 2009; 114:623-630.
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