BACKGROUND From 2001 through March 2006, Planned Parenthood health centers throughout the United States provided medical abortion (abortion by means of medication) principally by a regimen of oral mifepristone followed 24 to 48 hours later by vaginal misoprostol. In response to concern about serious infections, in early 2006 Planned Parenthood changed the route of misoprostol administration from vaginal to buccal and required either routine provision of antibiotics or universal screening and treatment for chlamydia; in July 2007, Planned Parenthood began requiring routine treatment with antibiotics for all medical abortions. METHODS We performed a retrospective analysis assessing the rates of serious infection after medical abortion during a time when misoprostol was administered vaginally (through March 2006), as compared with rates after a change to buccal administration of misoprostol and after initiation of additional infection-reduction measures. RESULTS Rates of serious infection dropped significantly after the joint change to buccal misoprostol from vaginal misoprostol and to either testing for sexually transmitted infection or routine provision of antibiotics as part of the medical abortion regimen. The rate declined 73%, from 0.93 per 1000 abortions to 0.25 per 1000 (absolute reduction, 0.67 per 1000; 95% confidence interval [CI], 0.44 to 0.94; P<0.001). The subsequent change to routine provision of antibiotics led to a further significant reduction in the rate of serious infection — a 76% decline, from 0.25 per 1000 abortions to 0.06 per 1000 (absolute reduction, 0.19 per 1000; 95% CI, 0.02 to 0.34; P = 0.03). CONCLUSIONS The rate of serious infection after medical abortion declined by 93% after a change from vaginal to buccal administration of misoprostol combined with routine administration of antibiotics.

Background From 2001 to March 2006, Planned Parenthood Federation of America (Planned Parenthood) health centers throughout the U.S. provided medical abortion principally by a regimen of oral mifepristone followed 24–48 h later by vaginal misoprostol. In late March 2006, analyses of serious uterine infections following medical abortions led Planned Parenthood to change the route of misoprostol administration and employ additional measures to minimize subsequent serious uterine infection. We conducted an extensive audit in August 2006 of medical abortion with the new buccal misoprostol regimen so that patients could be given accurate information about the success rate of the new regimen. Objectives We sought to evaluate the effectiveness of the buccal medical abortion regimen and examine correlates of its success during routine service delivery. Methods Audits at 10 large urban service points were conducted in 2006 to estimate success rates of the buccal regimen. Success was defined as medical abortion without vacuum aspiration. These audits also permitted an estimate of success rates with oral misoprostol following mifepristone in a subset in which 98% of the subjects stemmed from 2 sites. Results Effectiveness of the buccal misoprostol-mifepristone regimen was 98.3% for women with gestational ages below 60 days. The oral misoprostol-mifepristone regimen, used by 278 women with a gestational age below 50 days, had a success rate of 96.8%. Conclusion In conjunction with 200 mg of mifepristone, buccal use of 800 mcg of misoprostol up to 59 days of gestation is as effective as vaginal use of 800 mcg of misoprostol up to 63 days of gestation.

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ObjectiveTo determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman’s eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers.Study designWe conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman’s eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care.ResultsBoth women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women’s assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers’ (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women’s difficulty using the checklist. PPV of FCHVs’ determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively.ConclusionAlthough a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use.

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