Medical Abortion Services:
from Up-to-Date to Not-in-Use ************************ 29 April 2016
TelAbortion: A new direct-to-patient telemedicine abortion service in the USA
by Erica Chong, Gynuity Health Projects, USA
Access to abortion in the United States is increasingly constrained. At least four states have only one abortion provider.  Since 2011, at least 162 abortion providers have closed, while only 21 have opened.  Expenditures of money and time to reach the nearest clinic, as well as for lost wages and childcare, can be a substantial hardship for many women.  This hardship is so substantial that many women are considering forgoing formal care altogether – in 2015 there were more than 700,000 Google searches in the U.S. looking into self-induced abortion. 
One approach to increase access to abortion is the use of telemedicine. Medical abortion with mifepristone and misoprostol is perhaps an ideal fit for telemedicine. In the early first trimester the treatment has few contraindications, a very high efficacy rate, and a very low rate of major complications.  In current models of telemedicine abortion in the US, provided by Planned Parenthood of the Heartland and Whole Woman’s Health, a woman has pre-abortion assessments performed at a clinic that stocks the abortion medications but does not have a physician on site. The remote physician reviews the results of the assessments, speaks with the patient by videoconference, and then authorizes the clinic to dispense the medications.
While this model was shown to have increased the number of sites in Iowa offering abortion services,  it still requires the patient to visit a clinic that has mifepristone in stock (since unlike misoprostol the medication is prohibited from being distributed in pharmacies). An alternative model uses a direct-to-patient approach, in which the medications are provided directly to eligible patients by mail. The patient obtains the screening results locally, and she can speak with the clinician from her home.
Gynuity Health Projects is developing, implementing, and evaluating a direct-to-patient telemedicine service, called TelAbortion. Outcomes of this pilot study include: interest in the TelAbortion approach; feasibility of the TelAbortion procedures; safety; and acceptability to women and providers. Fifty women in New York, Hawaii, Oregon and Washington State will be enrolled. The study has launched in New York and is anticipated to begin in the other sites later in 2016. The service will be designed to incorporate all of the standard steps in medical abortion (Box 1), thus ensuring that the quality of care provided to each patient is the same as she would receive if she presented in person to an abortion facility. Gynuity’s hope is if TelAbortion proves to be a feasible model, it can be expanded to other states with favorable laws.
“It’s the future,” said Esther Priegue, the director of counselling at Choices Women’s Medical Center in New York, where the first of the pilots was launched in March 2016. She spoke in her office, after walking through a waiting room thronged with women, many of them holding young children. “Especially in the times we’re living in today, women experience so many struggles getting through our doors. They’re mothers. They work. Imagine if they could do it all from home, and never have to step into the clinic for even a moment.”
The study is the creation of Beverly Winikoff, Elizabeth Raymond, and Erica Chong of Gynuity, a New York research group which seeks ways to expand reproductive healthcare access with technology.
“We’d just [like to] keep expanding the study,” Raymond said.
The study may also finally deliver on what reproductive rights advocates have always seen as the true promise of medical abortion drugs: abortion without the clinic. “We always thought this drug was going to totally revolutionize how abortion was provided,” said Daniel Grossman, a professor with the obstetrics and gynecology department at the University of California, San Francisco, who has studied telemedicine and abortion. “This is moving us closer to what women’s health advocates see as the real potential of medical abortion… “There’s no medical reason why the pill has to be physically handed out by a clinician,” said Grossman. “This is such an incredibly safe medicine … There’s no reason to have any concerns about the safety of this model.”
Dr Paul Hyland, who runs the Tabbott Foundation in Australia, a similar telemedicine service designed for rural women, said that despite the likely opposition, Gynuity should exhilarated. “Mifepristone is the most revolutionary drug in reproductive medicine since contraception. It’s amazing that this can be provided so easily and that we’ve taken such a long time to realize its true potential.”
Raymond EG, Chong E, Hyland P. Increasing access to abortion with telemedicine. JAMA Internal Medicine published online March 28, 2016.
Raymond EG, Shannon C, Weaver MA, Winikoff B. First-trimester medical abortion with mifepristone 200mg and misoprostol: a systematic review. Contraception 2013; 87(1):26-37.
Grossman D, Grindlay K, Buchacker T, Lane K, Blanchard K. Effectiveness and acceptability of medical abortion provided through telemedicine. Obstet Gynecol 2011; 118(2,pt1):296-303.
Tags: USA, medical abortion, telemedicine
Shifting abortion care from a hospital to a community sexual and reproductive health care setting
Sharon T Cameron,Anna Glasier, Anne Johnstone Journal of Family Planning & Reproductive Health Care 2016;42:127-132 http://jfprhc.bmj.com/content/42/2/127.abstract?etoc Abstract
Community sexual and reproductive health (SRH) services are well placed to deliver abortion assessment services and early medical abortion (EMA), but comparative data on safety and acceptability from both settings are important for future service planning. Methods: Retrospective review of computerised records of 1,342 women undergoing outpatient EMA (≤9 weeks) in a community SRH or hospital department of gynaecology in the same city, and a self-completed, anonymous survey of 303 women requesting abortion at both sites. Primary outcome was safety in terms of re-attendance rates for a complication related to EMA. Secondary outcomes were telephone contact with each site for an EMA-related concern and satisfaction with information about abortion (defined as score out of 10) received at each site. Results: There was no difference in re-attendance rates to either service for a complication following outpatient EMA (2.7%). A higher proportion of women undergoing EMA at the SRH site made telephone contact compared to women at the hospital site (18.8% vs 10.8%; p=0.033). Women rated both settings highly in terms of information received before abortion (9.2 and 9.6 out of 10) at the hospital and SRH sites, respectively. Conclusions: This study suggests that provision of outpatient EMA in a community SRH setting is as safe as that delivered from a hospital setting, and that women are similarly satisfied with the information they receive about abortion from each setting. More abortion assessment and outpatient EMA services in Great Britain could shift from hospital to community SRH settings.
Tags: Scotland, abortion clinics & services, early medical abortion
Two studies in Switzerland: early medical abortion with only one visit
by Anne-Marie Rey, APAC-Suisse
APAC-Suisse (Association de professionnels de l’avortement et de la contraception) carried out research in Switzerland on the practice of medical abortion (mifepristone+misoprostol) in public hospitals. The results were published in 2015 in the Swiss Medical Forum in Germanand French. Apparently, the protocols being used are very diverse between hospitals, for example, varying from two consultations (including the post-abortion follow-up visit) to as many as five consultations imposed on women. However, the trend is going towards less control; for example, more and more hospitals offer home use of misoprostol. But there is still great potential to simplify procedures further.
In the same journal issue, there is an article by André Seidenberg and Christian Fiala on “One stop MToP”, describing medical abortion with only one primary level consultation with a doctor, use of both kinds of tablets at home, and post-abortion self-follow-up using the CheckToP® pregnancy test.
Las Libres, Guanajuato: A feminist approach to abortion within and around the law
by Elyse Ona Singer
At a recent Mexico City training session in her organization’s model of abortion accompaniment (the provision of emotional and logistical support for abortion either in-person or via phone), Veronica Cruz, founding director of NGOLas Libres(The Free Ones) in Guanajuato, stated unequivocally that “abortion is the most important claim of feminism… the fact that abortion is a crime rather than a human right [reflects how] this system does not want women to be free.”
Guanajuato is one of 16 Mexican states that made its abortion laws more restrictive in a backlash against the decriminalization of abortion in Mexico City in 2007, in which first-trimester abortion is available on request and free of cost in the public programme of the Ministry of Health. To date, more than 152,000 public abortion procedures have been carried out in the federal capital (GIRE, 2016 ).
Las Libres’ work recently made international headlines when seven Guanajuato women who had been accused of inducing abortions and jailed on homicide charges were set free thanks to Las Libres’ successful legal defence. As the public face of Las Libres, Veronica has gained widespread recognition for her work. In 2006, Human Rights Watch named her a key “Defender of Human Rights”. In addition to providing legal aid for abortion-related charges, Las Libres offers in-person emotional support and medical instruction to Guanajuato women on how to induce abortion at home with misoprostol, which is available over the counter throughout Mexico. While the organization has a doctor on staff in case of an emergency, Veronica said complication rates are extremely low and that this method is both cost-effective and empowering for women, who feel in charge of the procedure.
Las Libres circumvents health institutions in large part due to force of circumstance . However, those in attendance at Veronica’s training session (a mix of university students and activists) wanted to replicate the model in a context where abortion is legal and accessible in order to evade the practice of “obstetric violence” that is endemic in Mexico’s public health institutions (see Roberto Castro’s work). Those in attendance felt that if women in Mexico City knew how to induce abortion at home they could avoid paternalistic treatment. Veronica confirmed that while at one point Las Libres had sent women to Mexico City for abortion, “we received too many complaints about harsh treatment in the public clinics”.
Las Libres’s way of working is controversial among reproductive rights NGOs in Mexico City. While Las Libres operates outside of local law, invoking instead an international human rights framework around abortion to defend their work, Mexico City NGOs use the human rights framework to struggle for abortion legalization, calling on the state to recognize and grant abortion rights.
“I don’t understand why [Mexico City feminists] keep fighting for causales [legal grounds for abortion as exceptionsto illegal abortion]. We don’t fear the law.” she said. Importantly, Veronica noted that Guanajuato law does not explicitly prohibit abortion accompaniment, a loophole that has protected the group legally.
Tags: Mexico, medical abortion, self-help abortions
Doctors learning safe abortion methods to cut maternal deaths in Banglalore
Lying in bed clutching her abdomen, a young Indian woman leans over her toddler to retrieve some pain relief from her bedside table at a private hospital in Delhi. Kiran, 22, had just had an abortion with D&C (dilatation and curettage), a painful procedure using general anaesthesia, cervical dilatation and scraped of the uterus, an out-of-date method which as not been recommended by the World Health Organization for many years because it carries a higher risk of complications, requires an overnight hospital stay and general anaesthesia, and a more highly skilled practitioner.
The hospital room is filled with other women, lying on metal gurneys after undergoing the procedure. Babli, 22, was five months pregnant when she found out her baby had anencephaly and could not survive. “It was my first child, and the procedure was so painful. I’m so depressed,” she says. Despite the circumstances, both women were able to have safe abortions.
India’s abortion laws are liberal, allowing the procedure under almost any circumstances, but there is no guarantee the services will be safe. According to a Guttmacher Institute reviewabout 9% of maternal deaths in India are still from complications of unsafe abortions.
At Vani Vilas hospital for women and children in Bangalore, Karnataka, doctors and nurses are being trained in manual vacuum aspiration (MVA) – a safer, quicker procedure – and how to better support the women in their care. MVA is significantly under-utilised in India. The training programme is run by Ipas in the 11 states that have the highest maternal mortality ratios, in order to certify doctors who haven’t undertaken post-graduate study to be legally allowed to provide abortion services.
Over the past 18 months, more than 150,000 women have received services by newly trained providers, with about 70% of those providers based in rural facilities. The trainees are also learning the importance of discussing post-abortion contraception choices with patients.
One session in the course is on pre- and post-abortion counselling, and being non-judgemental and supportive, which is often neglected by doctors, who don’t understand its importance. Many women face difficulties accessing services because of the stigma of having an abortion, lack of awareness and lack of services in their community, which disproportionately affects poorer women, often living in rural areas. As a result, many women take drugs purchased over-the-counter, increasingly misoprostol; many still rely on uncertified practitioners, who may or may not provide a safe method.
According to the WHO, in most Indian states fewer than 20% of primary health centres offer abortion services. Ipas is striving to change this. Dr Ganesh Sonavane works at a health centre in Pune and became an accredited provider last year. “Many women have financial troubles and their only option is to go to a private hospital, which is too expensive for them. After the training I’m giving very good and helpful abortion services to women who need it,” he says.
Tags: India, manual vacuum aspiration, D&C, post-abortion care, training
Dimitar Cvetkoff Raising awarensss of medical abortion among women and abortion care providers
by Dimitar Cvetkoff, Obstetrician-Gynaecologist, Nadezhda Women Health Hospital, and
FIAPAC Board member, Sofia, Bulgaria
After the last FIAPAC board meeting in Berlin, we set out to to popularize medical abortion in Bulgaria and to raise awareness of safe abortion and contraception methods among the population. We have made several presentations at Bulgarian National Conferences that led to lively discussions. We have published several articles in newspapers as well, which attracted the attention of our gynaecologist colleagues. We were left with the impression that, although medical abortion is an attractive option for our patients, only a few doctors have the knowledge and willingness to provide it. Usually these are doctors who have practised abroad. Many health care providers were unclear whether there is any difference between illegal usage and off-label usage of medications; the two were believed to be one and the same thing.
Moreover, even though in Bulgaria there are currently three registered preparations for termination of pregnancy (Mifegyne, Mifepristone Linepharma, Topogyne), medical abortion is still associated solely with the misoprostol-only regime, which is not registered at all in Bulgaria.
This situation led several doctors to founding the Bulgarian Association of Contraception and Safe bortion (BACSA) as a representative organization of health care providers, working actively in those gynaecological services. The aim is to make provision of medical abortion easier for the professionals by disseminating already available information and guidelines, and making the true facts clear with regards to medical abortion. This Association is quickly becoming popular within ob/gynae circles and is being contacted by clinicians for advice and guidance.
Recently, after a few months of active negotiation with WHO, BASCA obtained the right to translate the WHO Clinical Practice Handbook for Safe Abortion into Bulgarian. This is a great opportunity to have a practical guideline for safe abortion in our language. It is important because, despite the widespread knowledge of English, the level of proficiency for most doctors is not high enough to allow comprehensive use of the handbook in English. This may be one reason for the lack of knowledge and confidence in medical abortion as a procedure.
In an attempt to familiarize clinicians with medical abortion, we successfully conducted a one-day workshop on 13 February 2016 in Sofia, with the kind support of the regional branch of pharma company Novotel. Two guest lecturers – Sharon Cameron, president of FIAPAC and Anne Johnstone, health care provider from the Royal Infirmary, Edinburgh, UK shared their long experience in providing medical abortion from the first steps back in time to the present days of offering early medical abortion for use at home with follow-up by phone, with a very high success rate and patient acceptability. Their presentations illustrated the way we have to go about making medical abortion a safe and widely accepted procedure in Bulgaria.