Rajendran Nallusamy
(Advocate)
06 April 2008
Medical Abortion – Rural Experience
– Dr Kurus J Coyaji Director & Hony. Professor, Pune
Although legal in India, abortion is frequently performed under unsafe or undesirable conditions. Moreover, the advancements required to make surgical abortion safe in India appear surmountable in the near future. Because it requires a less extensive infrastructure than surgical abortion, medical abortion offers great potential for improving abortion access and safety.
The safety, efficacy and acceptability of oral regimen of medical abortion were compared with surgical abortion in 3 developing countries: China, Cuba and India. Women with amenorrhoea <56 days chose either surgical abortion (as provided routinely) or medical abortion.
The medical regimen was found to have more side- effects, particularly bleeding, than did surgical abortion, but with very few serious side-effects. Failure rates of medical abortion, although low, exceeded those for surgical abortion: 8.6% versus 0.4% (China), 16% versus 4% (Cuba) and 5.2% versus 0% (India). Nearly half the failures among medical clients were not true drug failures, however, but surgical interventions were done though not medically necessary. Women were satisfied with either method, but more preferred medical abortion.
The most widely-used standard protocol consists of 600mg mifepristone orally on D1, (waiting period 30 minutes) followed 2 days later by misoprostol 400µg orally on D3 (waiting period 4 hours) with a scheduled follow up visit on D15.
Using data from a comparative trial of medical andsurgical abortion, women’s experiences with side-effects were investigated in 3 developing countries: China, Cuba and India. Medical abortion clients at all sites experienced more side-effects than their surgical counterparts. The disparity between the 2 groups was particularly pronounced for bleeding and pain. Despite more reports of side-effects among medical abortion clients, however, assessments of well-being and reports of satisfaction at the exit interview were similar in both treatment groups.
To examine the feasibility of introducing medical abortion and to assess its potential as an alternative to surgical abortion, three separate studies were conducted on the use of 600mg mifepristone and400µg oral misoprostol for medical abortion. Study I (1990-1993) focused on the safety, efficacy and feasibility of the standard three-visit protocol and was conducted in urban research centres in China, Cuba and India. Study 2 (1995-1998) liberalized the protocol to collect information from women using the method under more "real life" conditions in urban family planning clinics in India. Study 3 (1995-1998) was extended to village Vadu in rural India to examine feasibility in settings typical of where the majority of the population resides.
In all the three settings in India, mifepristone- misoprostol proved to be not only feasible, but safe and acceptable as well.
To evaluate the feasibility of providing medical abortion, adherence to the study protocol was assessed. Compliance to protocol was equal in all the 3 studies(98.4% in study 1, 96.2% in study 2 and 98% in study3) with complete abortion rate of 96.8%, 94.7% and95.9%, respectively.
As the gestational age increases, the efficacy decreases. Nearly 100% success was noted in gestationless than 5 weeks as compared to 89.5% in gestation between 8-9 weeks and 95% for gestation between 5-8 weeks.
Most women in all 3 studies aborted either at home(46%, 56%, and 59%, respectively) or at the clinic(45%, 30% and 37%, respectively). Very few women (less than 3% ) aborted in transit, and the remainder aborted elsewhere or were unsure of the place of abortion.
Most side-effects occurred during the 4 hours after misoprostol ingestion. These included bleeding and pain (part of the abortion process) and nausea, vomiting, diarrhoea, fainting or hypotension. Duration of bleeding varied from 1 to 15 days (urban) and 1 to 17 days (rural) with mean days of bleeding of 10.1 and 7.4, respectively. None of the subjects required blood transfusion. Fewer rural women had nausea, vomiting and /or diarrhoea. Rest of the side-effects were similar.
Medical abortion holds great promise in less- developed countries where abortion morbidity and mortality remain high. The Mifepristone-Misoprostol regimen was tested in urban outpatient family planning clinics (n=600) with gestation <63 days, and a rural hospital (n=300) with gestation <56 days in India only.4% of urban women and 1% of rural women were lost less than 5 weeks as compared to 89.5% in gestation between 8-9 weeks and 95% for gestation between 5-8 weeks. to follow up. Perfect use and typical use success rates were as high as European rates at all sites. Although rural women reported fewer side-effects, most women in urban and rural settings were satisfied with their medical abortion.
Thus, medical abortion proved safe, effective, acceptable and feasible in all settings, indicating that it can be safely introduced in India and other developing countries to be made available to all women who wish to terminate unwanted pregnancies in rural hospitals and PHCs with adequate back-up facilities and a physician trained to do vacuum aspiration.
It well certaintly contribute to health and rights of women, rich or poor.
Table 5.3.1
Site Total ComplianceNumber CompleteAbortion
1. Research 125 98.4% 96.8%
2. Urban FP 312 96.2% 94.7%
3. Rural 3300 98.0% 95.9%
