Understanding women's experiences with medical abortion: In-depth interviews with women in two Indian clinics

Abstract

We explored women's perspectives on using medical abortion, including their reasons for selecting the method, their experiences with it and their thoughts regarding demedicalisation of part or all of the process. Sixty-three women from two urban clinics in India were interviewed within four weeks of abortion completion using a semi-structured in-depth interview guide. While women appreciated the non-invasiveness of medical abortion, other factors influencing method selection were family support and distance from the facility. The degree of medicalisation that women wanted or felt was necessary also depended on the way expectations were set by their providers. Confirmation of abortion completion was a source of anxiety for many women and led to unnecessary interventions in a few cases. Ultimately, experiences depended more on women's expectations about the method, and on the level of emotional and logistic support they received rather than on inherent characteristics of the method. These findings emphasise the circumstances under which women make reproductive choices and underscore the need to tailor service delivery to meet women's needs. Women-centred counselling and care that takes into consideration individual circumstances are needed.

Self-management of medical abortion: a qualitative evidence synthesis

“…In legal settings, we found that the older studies described more medicalized approaches that required women to remain in clinic for four hours following misoprostol administration. 16,17 Shifts to less medicalized care in the more recent studies took the following forms: administering the misoprostol to women at the second appointment but then sending them home to abort, [18][19][20]4 giving women misoprostol at the second appointment but allowing them to selfadminister it at home, 18,21 giving women misoprostol at the first appointment to be self-administered at home, 19,[22][23][24][25][26][27] and giving women both mifepristone and misoprostol at the first appointment to be taken at home. 27,28 The studies from legal settings that reported misoprostol-only abortions reported self-administration at home.…”

“…They often reported some degree of anxiety at the beginning of the process but reported relief at the end and a strong sense of satisfaction with the choice to self-manage. 19,20,22,23,29 In some contexts, the use of misoprostol at home for early medical abortion falls within existing interpretive frameworks and practices (such as "menstrual regulation" (Bangladesh) and was understood as one of many treatments for local illness categories referring to missed menstrual periods (e.g. "late menses" in Brazil).…”

“…36,38 Women's perceptions of the acceptability of self-management without in-person contact with health professionals depended on: the standard of care and their prior experiences with medical abortion, local notions of professional medical hierarchy, abortion taboos and stigma, and perceptions around the strength, danger and complexity of the drugs. 20,32,40,41 Providers' perceptions about which healthcare workers should be able to provide medical abortion drugs to women for self-administration varied and depended on: perceptions of the strength of the drugs and hence the expertise in anatomy and physiology needed to explain their full effects; a provider's training in appropriate counselling for abortion; a provider's knowledge of abortionfriendly emergency departments to refer women to in the case of complications; and the client's experience, and therefore trust, of different healthcare workers. 16,33,42 Preparation for self-management In preparing for self-management of medical abortion, women reported anxiety, uncertainty, or ambivalence, sometimes to do with the decision to terminate the pregnancy, but more often in relation to the process and experience of the medical abortion.…”

“…16,33,42 Preparation for self-management In preparing for self-management of medical abortion, women reported anxiety, uncertainty, or ambivalence, sometimes to do with the decision to terminate the pregnancy, but more often in relation to the process and experience of the medical abortion. 19,20,22,23,29,39,43,44 Effective counselling by trained providers during the first step of medical abortion that offered women a sense of confidence, being prepared, having a choice, and being in control, was important in building the acceptability of self-management among women. 17,[22][23][24]44 Women and providers both felt that critical aspects of the educational component of counselling included preparing women for possible side effects and complications.…”

“…Critical psychosocial components of counselling included: preparing women for the variability in individual women's physical experiences of medical abortion; the practical and physical difficulties of managing the expulsion process at home; and the fact that most women reported anxiety during the beginning of the medical abortion process but relief at its completion. 20,22,23,30,33,36 Providing adequate counselling in the context of health facilities was, however, seen as time consuming for health professionals and written materials for patients were reported to be underutilized. 19,22,29,33,34 We also derived a number of insights from evidence in both restricted and legal contexts where women self-administer misoprostol through informal networks.…”