Availability,practices and acceptance of postabortion contraceptive services in health facilities: A study in six states of India

ObjectiveTo assess the availability of and practices around postabortion contraceptive services in health facilities, and document women’s acceptance of postabortion contraception in six Indian states.Study DesignWe conducted a survey of 4001 public and private health facilities that provide abortion-related care in six Indian states. In this analysis, we assess the availability and range of contraceptive methods offered, the protocols and practices around postabortion contraceptive counseling, the extent to which facilities require women to adopt contraception, and contraceptive uptake among women.ResultsAlthough some contraceptive methods and information were available at a majority of facilities (75–97%), the range of methods was lacking and the information provided to women varied considerably by state. 8–26% of facilities required women seeking induced abortions to accept a modern contraceptive method. Only half to two-thirds of postabortion patients adopted a modern method.ConclusionThe limited number of methods offered in facilities suggests that some women may not obtain the method they desire, or get information about the full range of methods that should be available. While contraceptive uptake should be voluntary, the requirement imposed by some facilities for women to adopt a modern contraceptive method in order to obtain an abortion must be addressed.ImplicationsSome 15.6 million Indian women had an induced abortion in 2015. Understanding the provision of postabortion contraceptive services in health facilities, including counseling, is necessary to inform policies and practices to better enable women and couples to make informed decisions to prevent future unintended pregnancies.     

Provision of medical abortion using telemedicine in Brazil

Objective

To evaluate the need for and outcome of self-administered medical abortion with mifepristone and misoprostol in Brazil, provided through Women on Web, a global telemedicine abortion service.

Study Design

A retrospective case review of women from Brazil who contacted Women on Web in 2011. Information from the online consultation, follow-up questionnaire and emails were used to analyze data including demographics, gestational age, outcome of the medical abortion and symptoms that lead to surgical interventions.

Results

The Women on Web website had 109779 unique visitors from Brazil, 2104 women contacted the helpdesk by email. Of the 1401 women who completed the online consultation, 602 women continued their request for a medical abortion. Of the 370 women who used the medicines, 307 women gave follow-up information about the outcome of the medical abortion. Of these, 207 (67.4%) women were 9 weeks or less pregnant, 71 (23.1%) were 10, 11 or 12 weeks pregnant, and 29 (9.5%) women were 13 weeks or more pregnant. There was a significant difference in surgical intervention rates after the medical abortion (19.3% at < 9 weeks, 15.5% at 11–12 weeks and 44.8% at > 13 weeks, p=.06). However, 42.2% of the women who had a surgical intervention had no symptoms of a complication.

Conclusion

There is large need for medical abortion in Brazil. Home use of mifepristone and misoprostol provided through telemedicine is safe and effective. However, after 13 weeks gestation, there is an increased risk of surgical intervention that may be due to the regimen used and local clinical practices in Brazil.

Implications

The current study shows that there is an unmet need for medical abortion in Brazil, a country with legal restrictions on access to safe abortion services. Telemedicine can help fulfill the need and self administration of medical abortion is safe and effective even at late first trimester abortion. Prospective trials are needed to establish safety, effectiveness and acceptability of home use of medical abortion beyond 12 weeks of pregnancy.     

全国重点联系城市社区卫生服务机构医保工作进展

目的:了解全国重点联系城市社区卫生服务医疗保险工作的进展情况。方法:通过问卷对全国重点联系城市社区卫生服务机构进行基线调查和常规监测,并进行比较分析。结果:2008年,全国重点联系城市社区卫生服务中心和站纳入医保定点机构的比例分别为96.60%和65.53%,其中有医保收入的比例分别为84.21%和49.27%,医保收入占业务收入比例分别为28.00%和20.00%,医保患者构成比分别增加23.12%和12.52%;以上四个方面,东、中、西部呈不均衡发展态势。结论:重点联系城市社区卫生服务与医保衔接工作正稳步推进,但仍有很大的发展空间。     

Exploring the pathways of unsafe abortion in Madhya Pradesh,India

Abstract

Nearly 40 years after enactment of the Medical Termination of Pregnancy Act of 1971, unsafe abortion continues to be a neglected women's health issue in India. This prospective study of women presenting for post-abortion care in 10 selected hospitals in Madhya Pradesh, India, aimed to understand the incidence, types and severity of post-abortion complications, probable causes of complications and consequences to women in terms of hospitalisation and incurred costs. Among 1565 women presenting for induced abortion-related services between July and November 2007, 381 women with post-abortion complications consented to participate. Data reveal a high prevalence of post-abortion complications (29%). Approximately half of women originally attempted to induce abortion at home using medication, home-made concoctions or traditional methods. Ninety percent sought care from either qualified (37%) or unqualified providers. More than half of the women were hospitalised as a result of post-abortion complications. This study suggests that supporting access to safely induced abortion services and improving community awareness on legal aspects, safe methods and approved providers are all necessary to reduce morbidity associated with unsafe abortion.     

潍坊市医疗机构医疗欠费处理存在问题及对策

目的：分析潍坊市医疗机构医疗欠费追讨及处理情况,探讨存在问题及改进措施。方法：采用分层整群随机抽样方法,抽出潍坊市19所各级各类医疗机构,对其医疗欠费处理情况进行问卷调查和统计学分析。结果：医疗欠费已经对部分医疗机构的经营和发展产生了一定的影响;医疗欠费追讨方式单一,效果不够理想;医务人员和专业诊疗科室承担了过多的欠费追讨责任;医疗欠费损失后果全部由医疗机构承担,政府、社会缺乏救助办法。建议：政府应建立面向弱势群体的危急重疾病医疗救助基金;医疗机构内部应设置专职或兼职的医疗欠费管理机构,采取多种手段,加大欠费追讨力度;完善医疗欠费相关法律规定。     

Characteristics of abortion service providers in two northern Indian states

Background

Despite liberal laws, abortions are a major cause of maternal morbidity and mortality in India.

Study Design

This study uses health provider data (N=2039) collected in Bihar and Jharkhand states, India, in 2004. Logistic regression models are fitted to identify correlates of providers' practice of abortion services and intention to offer medical abortions.

Results

While a majority of respondents (63.2%) provide abortion services, only 2.9% currently provide medical abortions and 23.8% intend to provide medical abortions. Private rather than public clinic providers and female rather than male providers are more likely to offer abortion services and intend to provide medical abortions. Aspects related to medical abortion's market demand, its safety, efficacy and perceived ease of delivery weigh more than patients' rights and personal interests on providers' decision to provide medical abortions.

Conclusion

This study enlarges the knowledge base on abortion service providers and offers recommendations for improving access to safe abortion services in India.     

Evaluation of a network of medical abortion providers in two districts of Maharashtra,India

Abstract

The objective of this study was to examine experiences and service delivery of private medical doctors participating in a professional network designed to improve knowledge and service quality of medical abortion (MA) procedures. A cross-sectional assessment of 87 Medical Abortion Provider Network (MAPnet) participants was conducted between December 2006 and January 2007 to describe participants’ service delivery and network experiences. After participating in MAPnet, providers reported a statistically significant amount of more MA services (92%), national protocol adherence for timing of drug administration (93%) and drug dosage protocols (82%) when compared to their reports before MAPnet affiliation. In addition, MAPnet providers offered contraceptive counselling (100%) and pain management (54%). Nearly three-quarters of providers were interested in continuing their association with the network initiatives. However, the network failed to adequately facilitate inter-network sharing of knowledge and experiences. These findings suggest that establishing and nurturing a network of private medical doctors can improve availability and quality of safe and early abortion services through MA.     

药物流产失败相关因素分析

目的 探讨药物流产失败的相关因素,以利于在今后终止妊娠方式的选择上提供更好的依据.方法 选择笔者所在医院2003年1月～2009年1月药物流产终止妊娠的病例5968例,其中失败499例,失败率8.36%,分析失败的相关因素并加以整理.结果 年龄大于35岁、子宫位置后倾后屈,多次流产、有剖宫产史、孕囊直径小于10 mm大于30 mm,胎龄小于43 d等药物流产失败率明显升高.结论 药物流产成功率受妊娠次数、孕囊大小、孕妇年龄、有无剖宫产史等多种因素的影响.在药物流产病例的选择上应综合以上因素考虑,以达到最佳效果.     

药物流产与手术流产比较可接受性的Meta分析

目的 评价米非司酮配伍米索前列醇药物流产与手术流产终止早期妊娠的可接受性，为非意愿妊娠妇女选择流产方法提供参考和为临床医生的临床决策提供证据。方法 检索MEDLINE、EMBASE、Cochranelibrary、CBMdisc、CNKI、VIP等6个医学数据库，手工检索12种相关杂志，并追查参考文献。由2名评价员独立筛选、评价文献和提取数据。对没有异质性的文献进行Meta分析。结果 纳入9篇文献（3565例病例）。流产前妇女认为药物流产痛苦更少（OR=466．51，95％CI：91．37～2381．88）；而手术流产更快捷（OR=0．02，95％CI：0．01～0．06）。流产后妇女对两种流产方法满意度相似，差异无统计学意义（P=0．89）；药物流产的再选择率更高（OR=2．72，95％a：2．13～3．47）；向他人推荐药物流产的比率也更高（OR=4．91，95％CI：2．16～11．16）。结论 药物流产是一种痛苦小的方法，但不如手术流产快捷，其再次选择率和推荐给他人的比率高于手术流产。药物流产与手术流产比较各有利弊，二者的满意度相似，不能相互代替。     

A comparison of transabdominal and transvaginal ultrasonography for determination of gestational age and clinical outcomes in women undergoing early medical abortion

Background

We sought to establish the accuracy of abdominal ultrasonography in determining gestational age and identifying the presence of a gestational sac and embryonic pole before and after medical abortion.

Methods

We included all 120 women enrolled in a study of simultaneous oral mifepristone and buccal misoprostol for abortion through 63 days' gestation. Vaginal and abdominal ultrasound examinations were performed before and 24 h after medication administration. Visualization of a gestational sac and embryonic pole and presence or absence of cardiac activity were recorded. Sensitivity and specificity were calculated with the results from vaginal ultrasonography as the gold standard. The effect of body mass index (BMI) on ultrasound findings was also assessed.

Results

Before treatment, the sensitivities of abdominal ultrasonography were 100% (95% CI 97-100) and 68% (95% CI 58-77) for presence of a gestational sac and an embryonic pole, respectively. Overall, abdominal imaging underestimated mean gestational age by 1.6 days (95% CI 1.0-2.2). After treatment, abdominal ultrasonography missed three of 34 retained gestational sacs (sensitivity 91%, 95% CI 76-98%). Fourteen women had gestational cardiac activity by vaginal ultrasound at follow-up. Abdominal imaging identified the gestational sac in all cases, but cardiac motion was only visible in 10 (71%, 95% CI 42-92%). For every 10-point increase in BMI, the odds ratio for missing an embryonic pole at baseline was 2.8 (95% CI 1.5-5.0).

Conclusions

Abdominal ultrasonography is sensitive for diagnosing the presence or absence of a gestational sac, but less sensitive at detecting an embryonic pole. This may lead to a small underestimation of gestational age and missing a continuing pregnancy at follow-up when one exists.     

雌激素在药物流产中的应用

目的:探讨补佳乐在药物流产后缩短出血时间、促进内膜修复和月经恢复的作用。方法:将早孕行药物流产者60例随机分为试验组和对照组,试验组在孕囊排出后第2天开始口服补佳乐1mg,2次/d,共21天。观察两组阴道出血时间、清宫率及月经恢复时间。结果:试验组和对照组在阴道出血时间、清宫率及月经恢复时间方面差异均有统计学意义。结论:药物流产后加用补佳乐可以通过促进子宫内膜增生、修复的作用,从而缩短出血时间、促进月经周期恢复、减少清宫率,进一步提高药物流产的成功率及满意度,减少并发症。     

药物与人工流产终止早期妊娠的临床比较

目的比较药物流产和人工流产两种不同方式在终止早期妊娠上的被接受程度以及临床效果。方法选取2008~2012年在茂名市人口和计划生育综合服务中心终止早期妊娠的286例受术者,根据终止妊娠方式的不同,分为药物流产组(128例)和人工流产组(158例),比较两组受术者终止妊娠的临床效果以及再次意外妊娠后会选择的终止妊娠方式。结果两组在完全流产率、不完全流产率、人工流产综合征发生率、流产后阴道出血时间上比较差异无统计学意义(P0.05)。两组再次意外妊娠后会选择的终止妊娠方式比较,差异有统计学意义(P0.05)。结论药物流产和人工流产在终止早期妊娠中有各自的优点和缺点,可根据受术者的具体情况和既往流产病史选择流产方式,在终止早期妊娠中取得比较好的临床效果。     

影响早孕药物流产结局的多因素分析

目的:探讨影响米非司酮配伍米索前列醇药物终止早孕结局的相关因素,为选择合适的终止早孕方法提供思路。方法:以药物流产后因不全流产或失败行手术干预者为病例组,以药物流产后完全流产者为对照组,采用病例-对照研究的方法,按1:4比例匹配对照组,分析药物流产时手术干预的相关影响因素。结果:经单因素分析,药物流产后需手术干预的相关影响因素为孕次(OR=2.051,P<0.001)、流产次数(OR=2.677,P<0.001)、有分娩史(OR=2.328,P<0.001)、孕囊直径(OR=2.115,P<0.001)、子宫前倾前屈位和后倾后屈位(OR=2.031,P<0.001;OR=2.384,P<0.001)。经多因素分析,药物流产后需手术干预的危险因素为孕次(OR=2.317,P<0.001)、流产次数(OR=1.897,P<0.001)、孕囊直径(OR=1.196,P<0.001)和子宫位置(OR=1.494,P>0.05)。结论:妊娠次数多(≥3次)、流产次数多(≥3次)、孕囊直径大(>25mm)、屈位子宫(前倾前屈或后倾后屈)的早孕妇女选择药物流产时需要手术干预的可能性较大,而剖宫产史与药物流产结局无明显相关性。     

Factors associated with second trimester abortion in rural Maharashtra and Rajasthan,India

Abstract

Many married women in India experience abortion in their second trimester of pregnancy. While there is an impression that second trimester abortions are now overwhelmingly used for sex selection, little is known about the extent to which second trimester abortions are indeed associated with son preference and sex selection motives, relative to other factors. Using data from a community-based study in rural Maharashtra and Rajasthan, research highlights the role of limited access in explaining second trimester abortion. While women with a single child who was a daughter were indeed more likely than other women to have terminated a pregnancy carrying a female foetus in the second trimester, more strikingly, exclusion from abortion-related decision-making, unsuccessful prior attempts to terminate the pregnancy, and distance from the facility in which their abortion was performed, were significantly associated with second trimester abortion, even after controlling for confounding factors. The study calls for greater efficiency in implementing the PCPNDT Act and addressing deep-rooted son preference. At the same time, findings that poverty and limited access to facilities are as, if not more, important drivers of second trimester abortion, highlight the need to meet commitments to ensure accessible abortion facilities for poor rural women.     

药物流产的可接受性及影响因素分析

目的:了解药物流产可接受性及其影响因素。方法:采用分层整群随机抽样方法,在三级医院、二级医院、计划生育服务站共调查要求人工流产的妇女1342人,有效问卷1305份,以药物流产组331人作为观察组,手术流产组974人作为对照组进行分析。采用视觉模拟表格做可接受性的评估。结果:药物流产组20～39岁年龄比例(98.5%)高于手术流产组,大专及以上学历(60.4%)、月收入>3000元者(38.1%)、管理营销和自由职业(76.4%)均高于手术流产组。多因素分析显示年龄、文化程度是流产方式选择的影响因素。医护人员和乡(村)计生人员等渠道获取流产知识不利于药物流产的选择。对既有药物流产史又有手术流产史的108人进行分析,结果显示该人群对两种流产方式的满意度无差异。结论:药物流产更易被教育水平高的人群接受,有人工流产经历的妇女对药物流产的可接受性与手术流产相似,应尊重妇女流产方式的知情选择,更好地开展流产后计划生育服务。     

Mifepristone-misoprostol abortion: a trial in rural and urban Maharashtra,India

As several important policy questions remain regarding the use of medical abortion in developing countries, we investigated the safety, efficacy, and acceptability of mifepristone-misoprostol abortion in the outpatient family planning departments of two urban hospitals and one rural hospital in India. Nine-hundred women (with gestations of < or =63 days in the urban sites and < or =56 days in the rural site) received 600 mg mifepristone followed 48 h later by 400 microg oral misoprostol in the clinic. Four point four percent or fewer urban women and 1.0% rural women were lost to follow-up. Perfect and typical-use failure rates were low at all sites. While rural women reported fewer side effects at all sites, the vast majority of women were satisfied with their medical abortions. Medical abortion can be offered safely, effectively, and acceptably in the outpatient family planning departments of urban and rural hospitals in India.     

Efficacy of medical abortion prior to 6 gestational weeks: a systematic review

Objective

The objective was to describe the efficacy of medical abortion using mifepristone and misoprostol for gestations less than 6 weeks.

Comparing two early medical abortion regimens: mifepristone+misoprostol vs. misoprostol alone

Background

Nonsurgical abortion methods have the potential to improve access to high-quality abortion care. Until recently, availability and utilization of mifepristone medical abortion in low-resource countries were restricted due to the limited availability and perceived high cost of mifepristone, leading some providers and policymakers to support use of misoprostol-only regimens. Yet, this may not be desirable if misoprostol-only regimens are considerably less effective and ultimately more costly for health care systems. This study sought to document the differences in efficacy between two nonsurgical abortion regimens.

Study Design

This double-blind randomized placebo-controlled trial enrolled women with gestational ages up to 63 days seeking early medical abortion from August 2007 to March 2008 at a large tertiary hospital in Ho Chi Minh City, Vietnam. Eligible consenting women received either (1) two doses of 800 mcg buccal misoprostol 24 h apart or (2) 200 mg mifepristone and 800 mcg buccal misoprostol 24 h later. Participants self-administered all study drugs and returned to the hospital for follow-up 1 week later. The trial is registered at ClinicalTrials.gov as NCT00680394.

Results

Four hundred women were randomized to either misoprostol-only (198) or mifepristone+misoprostol (202). Complete abortion occurred for 76.2% (n=147) of women allocated to misoprostol-only vs. 96.5% (n=194) of those given mifepristone+misoprostol (RR 0.79, 95% CI 0.73–0.86). Ongoing pregnancy was documented for 16.6% (32) of misoprostol-only users and 1.5% (3) of mifepristone+misoprostol users (1.62, 0.68–3.90). Side effects were generally similar for both groups, although significantly more women allocated to misoprostol-only reported diarrhea.

Conclusions

Mifepristone+misoprostol is significantly more effective than use of misoprostol-alone for early medical abortion. The number of ongoing pregnancies documented with misoprostol-only warranted an early end of the trial after unblinding of the study at interim analysis. Policymakers should advocate for greater access to mifepristone. Future research should prioritize misoprostol-only regimens with shorter dosing intervals.