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24 May 2010

Clinical Update: Home management of Early Medical Abortion

By Patricia Lohr, Medical Director, BPAS.

This Q&A is based on the study ‘Women’s opinions on the home management of early medical abortion in the UK’, by Patricia Lohr and colleagues, published in the Journal of Family Planning and Reproductive Health Care 2010: 36(1) 21. The full study is available here.

Patricia Lohr’s Q&A appears in the Summer 2010 print edition of Abortion Review. Download a .pdf of the print edition here.

Q) What is the situation regarding the home management of early medical abortion in the UK?

Under the 1967 Abortion Act, any treatment for abortion has to be carried out in a hospital or a place approved for this purpose by the Secretary of State (1). The Department of Health currently interprets this as meaning that both medications used for early medical abortion (EMA) – mifepristone
and misoprostol - must be given in an authorised medical facility.

Practically, this means women must make a separate visit to receive each medication in addition to their consultation and follow-up appointments. Many hospital-based services admit women to the wards after administering misoprostol (2), but most independent abortion providers, like BPAS, discharge women after misoprostol administration to complete the process at home.

This service development occurred in response to clients’ requests to go home and with the knowledge from studies in other countries that completing an early medical abortion at home was safe and acceptable.

Q) What was the purpose of this study?

There hasn’t been much research in the UK on the home management of EMA so we felt it was important to find out women’s opinions and experiences of this service. We invited all eligible women undergoing EMA at any BPAS clinic during a two-week period to take part. One week after the administration of misoprostol, we contacted them by telephone and asked them to answer a short structured questionnaire.

We also included one open-ended question to give women the opportunity to add other comments.

Q) What did the results find?

We surveyed 162 women and found that most (86%) would rather go home to complete an EMA than remain at the clinic. The majority (96%) found home management very or somewhat acceptable and 96% felt they could have obtained medical help easily if necessary. Most respondents (62%) would prefer home use of misoprostol as opposed to returning to the clinic to obtain and use the medication.

The study also found that Asian women, or those with a gestational age of greater than 49 days, were less likely to prefer home management than others in the sample.

Q) What reasons did women give for their preference?

We didn’t specifically ask women about the reasons behind their preferences. However, in the open-ended question many women chose to comment on the meaning that being at home had for them. They described it as a good experience, commenting on the benefit of being in ‘my own space’, and using words such as ‘right’, ‘comfortable’, ‘relaxed’, ‘convenient’ and ‘private’.

Interestingly, 21% of the women who provided qualitative comments remarked on the difficulty of the journey home after misoprostol administration. They described it as inconvenient or noted that they were very concerned about experiencing symptoms before they got home. Some even commented that they began to have bleeding or cramping on the journey home. However, rather than encouraging them to stay in the clinic for the duration of the abortion, these experiences appeared to increase their support for the idea that misoprostol could be used at home. As one woman said: ‘I felt so anxious because I really felt that I had to hurry home. I would much rather have been able to do the second medicine in the comfort of my own home’.

Relatively smaller numbers of women gave reasons why they would prefer to stay in the clinic, such as reassurance that the abortion was proceeding as expected, or that they were concerned about things that were unexpected, such as variability in the time to complete the abortion. And a few women also took the opportunity to tell us that they felt that the decision to have home management should be an individual choice, emphasising that the option should be available for everyone, even if some choose not to take it.

Q) How does this study relate to others in the UK?

In many countries, home use of misoprostol is routine, and several studies show that it is safe and highly acceptable (3–7). In the UK, however, the restriction on home use means that information about women’s opinions of this practice is limited. One 1992 study in Edinburgh found that only 24% of 180 women who had experienced a medical abortion in a clinical setting would prefer to have the abortion at home. (8)

In 2005, Hamoda et al. surveyed 366 women in four hospital-based services in England and Scotland, all of whom remained in this setting after the administration of misoprostol but were asked for their views on the hypothetical situation of having a medical abortion at home. (9) Seventy-one per cent of respondents reported that there was nothing during their stay in hospital that they could not have managed on their own; nonetheless, only 36% would have opted for a home EMA.

Different findings came out of a clinical trial in Aberdeen in 2005, in which 49 women up to 56 days’ gestation were treated with 200mg oral mifepristone in a clinical setting followed by self-administration of 600 μg sublingual misoprostol 36–48 hours later at home. (10) Forty-five participants returned study questionnaires about their experiences and opinions: most (96%) were very satisfied or satisfied with home EMA, and 93% stated they would opt for medical abortion at home if necessary in future. Our finding of a high acceptability of home management of EMA is similar to this study, perhaps because it reflects the opinions of women who have safely and satisfactorily experienced a medical abortion outside of a clinical setting.

Q) What are the practical implications of this study?

The limited amount of information about women’s opinions on home management of EMA in the UK, and the differences found by those studies that do exist, means that those designing abortion services need to take care not to assume women’s preferences. Some women express a strong preference for managing their abortion at home, and it is important to manage their expectations and provide adequate support services such as a 24-hour telephone advice line. Other women may prefer to stay in the clinic, and giving women this option is reasonable if resources allow it.

However, our study does indicate, in line with research from other countries where home use of misoprostol is routine, that many women find managing their abortion at home highly acceptable, and voice a preference for administering misoprostol at home rather than having to do so in the clinic. My view is that EMA provision in the UK would be improved, and further research into this area permitted, if consideration were given to updating the interpretation of the UK’s abortion law to allow home administration of misoprostol.

Also read:

Abortion Review topic archive: Clinical Update Q&A

References

(1) Abortion Act 1967 (c. 87).  [Accessed 24 July 2009].

(2) Ingham R, Lee E. Evaluation of Early Medical Abortion (EMA) Pilot Sites. London, UK: Department of Health, 2008.

(3) Fiala C, Winikoff B, Helström L, Hellborg M, Gemzell-Danielsson K. Acceptability of home-use of misoprostol in medical abortion. Contraception 2004; 70: 387–392.

(4) Clark WH, Hassoun D, Gemzell-Danielsson K, Fiala C, Winikoff B. Home use of two doses of misoprostol after mifepristone for medical abortion: a pilot study in Sweden and France. European Journal of Contraception and Reproductive Health Care 2005; 10: 184–191.

(5) 5 Guengant JP, Bangou J, Elul B, Ellertson C. Mifepristone-misoprostol medical abortion: home administration of misoprostol in Guadeloupe. Contraception 1999; 60: 167–172.

(6) Schaff EA, Fielding SL, Westhoff C, Ellertson C, Eisinger SH, Stadalius LS, et al. Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion: a randomised trial. JAMA 2000; 284: 1948–1953.

(7) Ngoc NT, Nhan VQ, Blum J, Mai TT, Durocher JM, Winikoff B. Is home-based administration of prostaglandin safe and feasible for medical abortion? Results from a multisite study in Vietnam. British Journal of Obstetrics and Gynaecology 2004; 111: 814–819.

(8) Thong KJ, Dewar MH, Baird DT. What do women want during medical abortion? Contraception 1992; 46: 435–442.

(9) Hamoda H, Critchley HOD, Paterson K, Guthrie K, Rodger M, Penney GC. The acceptability of home medical abortion to women in UK settings. British Journal of Obstetrics and Gynaecology 2005; 112:781–785.

(10) Hamoda H, Ashok PW, Flett GMM, Templeton A. Home selfadministration of misoprostol for medical abortion up to 56 days’ gestation. Journal of Family Planning and Reproductive Health Care 2005; 31:189–192.

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