Thoai D Ngo

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    Efficacy and Acceptability of Home-Based Medical Abortion: A Systematic Review

    Thoai D. Ngo, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Research and Metrics Team, Health System Department, Marie Stopes International,

    London, UK

    Background: Home-use of misoprostol can reduce the number of clinic visits required and improve access to medical abortion.  We conducted a systematic review to assess the efficacy, safety, and acceptability of medical abortion administered at home versus at clinic.

    Methods: The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Popline were searched for randomized and non-randomized prospective studies of medical abortion at home versus clinic.  The main outcomes of interest were failure to achieve complete abortion, side effects, and acceptability.  We calculated relative risks (95% CIs), and pooled estimates using a random-effects model.

    Findings: Nine studies met the inclusion criteria (n=4,522 participants).  All studies used a mifepristone-misoprostol combination for medical abortion.  The proportion of women who had a complete abortion in home-based groups (n=3,478) ranged from 86% in India to 97% in Albania, with average success of 89.7%.  Complete abortion in clinic-based groups (n=1,044) ranged from 80% in Turkey to 99% in France, with average success of 93.1%.  Pooled analyses indicate that there is no difference in complete abortion between home-based (n=3,215) and clinic-based (n=593) intervention groups (OR=1.11; 95% CI: 0.65, 1.91).  Serious complications of abortion were rare.  Acceptability data indicate that women using self-administered medical abortion at home were more likely to be satisfied, to choose the method again, and to recommend medical abortion to a friend than women who opted for medical abortion at the clinic.

    Interpretations: Evidence from prospective cohort studies suggests that the option of home-use of misoprostol for medical abortion is efficacious, safe, and acceptable to women living in both resource-limited and resource-rich settings.   This option allows women greater flexibility and privacy in the abortion process, and could increase access to and acceptability of medical abortion.

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    Risk factors for repeat termination of pregnancy:
    implications for addressing unintended pregnancy
    in Vietnam
    Ngo, T1; Keogh, S1; Nguyen, T1; Le, H2; Kiet, P2;
    Nguyen, Y2
    1 Marie Stopes International; 2 Hanoi Medical University, Vietnam
    Objective: Vietnam has one of the highest pregnancy termination
    rates in the world; 26 terminations of pregnancy (TOPs) per 1000
    women. We explored factors associated with having repeat TOPs
    in three provinces in Vietnam.
    Methods: A cross-sectional survey was conducted from September
    to December 2011 among abortion clients at 61 health facilities in
    Hanoi, Khanh Hoa and Ho Chi Minh City. After their procedure,
    women participated in an exit interview asking about socio-
    demographic factors, contraceptive use, and knowledge and
    experience of TOP services. The primary outcome was repeat TOP
    (‡2 TOPs).
    Results: A total of 1233 women were interviewed. The median
    age was 28 years; 92.5% had secondary education; 77.8% were
    married; and 31.9% had no children. Half the respondents were
    not using contraception prior to their recent pregnancy. The
    prevalence of repeat TOP was 32.9%. A significantly higher
    proportion of repeat TOP compared to first time TOP clients
    intended to adopt long-acting contraceptive methods, particularly
    the IUD (35% vs. 23%, P £ 0.001), in future. In a multivariate
    model, individuals living in Hanoi, older women, and those with
    two (vs. fewer) children were more likely to have a repeat TOP
    (P < 0.001). While women with ‡2 daughters (vs. 1) were more
    likely to have a repeat TOP (P = 0.03), women with no sons
    (vs. 1) were less likely to have one (P = 0.03).
    Conclusions: Repeat TOP remains high in Vietnam. Strengthening
    post-TOP family planning interventions is critical to reduce the
    high number of repeat unintended pregnancy in Vietnam.

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    Safety and effectiveness of termination services
    performed by doctors versus midlevel providers: a
    systematic analysis
    Ngo, T1,2; Park, MH1,2
    1 Marie Stopes International; 2 London School of Hygiene & Tropical
    Medicine, UK
    Objective: We review the evidence that compares the effectiveness
    and safety of termination of pregnancy (TOP) procedures
    administered by mid-level providers (MLPs) versus doctors.
    Methods: We conducted a systematic search of published studies
    assessing the effectiveness and/or safety of TOP provided by MLPs
    compared to doctors. The Cochrane Central Register of
    Controlled Trials, EMBASE, MEDLINE and Popline were searched
    for trials and comparison studies. The primary outcomes were:
    (i) incomplete or failed TOP and; (ii) measures of safety (adverse
    events and complications) of TOP procedures administered by
    MLPs and doctors. Odds ratios and their 95% confidence intervals
    (CIs) were calculated for each study.

    Results: Two prospective cohort studies (n = 3821) and two
    randomised controlled trials (RCTs) (n = 3821) were included.
    Three thousand seven hundred and forty-nine women underwent
    a procedure administered by an MLP and 3893 women underwent
    a physician-administered procedure. Three studies used surgical
    TOP with maximum gestational ages ranging from 12 to 16+
    weeks; a medical TOP study had maximum gestational ages up to
    9 weeks.
    There was no difference in incomplete/failed TOP for
    procedures performed by MLPs compared to doctors in RCTs of
    surgical (OR: 2.00; 95% CI: 0.85, 4.68) and medical TOP (OR:
    0.69; 95% CI: 0.34, 1.37). One prospective cohort study showed
    increased odds of incomplete/failed TOP among MLPs versus
    physician groups (OR: 4.03; 95% CI 1.07–15.28).
    None of the included studies found a difference in the odds of
    overall complications between provider groups.
    Conclusions: Based on this evidence, there is no indication that
    procedures performed by MLPs are less effective or safe than
    those provided by physicians.