Shorter time interval treatments for Early Medical Abortions: A Mixed Methods Research Approach By Dr. Sheethal Madari

A thesis submitted to the University of Birmingham for the degree of DOCTOR OF MEDICINE

Doctor of Medicine School of Clinical & Experimental Medicine

University of Birmingham

May 2017

University of Birmingham Research Archive

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Abstract

Purpose This dissertation focuses at assessing the efficacy of shorter time intervals in the treatment of medical abortions along with the use of various follow up methods.

Methods This initial part of dissertation was carried out as an extensive study of literature, followed by observational study on shorter time intervals and follow up methods for the feasibility of the study. The main dissertation met its research aims through an RCT of 121 women comparing shorter to standard time intervals and assessing the various follow up methods at the end of 2 weeks. The qualitative component of the study was achieved by conducting in-depth interviews of women undergoing medical abortion on various aspects of medical abortions with emphasis on shorter time intervals and follow up.

Findings This research produced a number of key findings: the RCT showed that both treatments have equal efficacy and acceptability with minor differences in their side effects however the sample size was small to generalise the findings; the follow up methods showed varied responses with preference to confirmatory investigations at 2 weeks follow up.

Conclusions

The main conclusions drawn from this research were that shorter time intervals can be offered as an alternative to standard treatment intervals in well informed women, however a larger RCT is needed. In order to provide these treatments as outpatient robust follow up methods will need to be incorporated into the abortion services.

Acknowledgements

I am truly indebted and thankful to my supervisors Professor Janesh Gupta and Professor Sheila Greenfield for the support and guidance they showed me throughout my dissertation writing. I am sure it would not have been possible without their help.

I would like to thank the staff at the Calthorpe clinic for helping me in successfully carrying out the research at their clinic.

I am obliged to the Wilma Arnold (medical secretary at Birmingham Women’s Hospital) and Katherine Lapsworth (medical secretary at Calthorpe Clinic) for their assistance in transcribing the interviews, without whose help the qualitative study would not have been possible. I am also grateful to Derek Yates (Librarian at Birmingham Women’s Hospital), Lee Middleton (Senior Medical Statistician at the Birmingham Clinical Trials Unit) and Melanie Calvert (Professor of Outcomes Methodology at Institute of Applied Health Research, University of Birmingham) for their advice.

I am grateful to Professor Christian Fiala and Dr Helena von Hertzen for their time and input as external advisors.

I would like to sincerely extend my gratitude to all the women who took part in the study, who made the study possible.

Finally, I would like to thank my mother who boost my morale and kept me going to complete the thesis.

TABLE OF CONTENTS

Forward: Why research Early Medical Abortions? 1 Introduction: Structure and overview of the thesis 3

Part 1: LITERATURE REVIEW: WHAT DO WE KNOW ABOUT MEDICAL ABORTIONS

1.1 History of Medical A