IS SELF-USE OF MEDICALMEDICAL ABORTIONABORTION A VIABLE OPTION? A systematic review of global evidence with a special focus on India MARCH 2018 Ipas Development Foundation (IDF) is dedicated to preventing and managing unwanted pregnancies. At IDF we believe that no woman should have to risk her life or her health because she lacks reproductive health care, and every woman must have the opportunity to manage her fertility. Ipas Development Foundation (IDF) is registered as a company under section 25 of the Indian Companies Act, 1956 (Now known as section 8 of Companies Act, 2013) Ipas Development Foundation (IDF) E-63, Vasant Marg, Vasant Vihar New Delhi 110 057, India Phone: 91-11-4606-8888 Fax: 91-11-4166-1711 E-mail: [email protected] ©2018 Ipas Development Foundation Suggested citation: Banerjee Sushanta K, Shveta Kalayanwala, Vinoj Manning, Kathryn L. Andersen, Ritu Raj, and Arpita Das (2018). Is self-use of medical abortion a viable option?: A systematic review of global evidence with a special focus on India, New Delhi, Ipas Development Foundation, India Graphic Deisgn: Impression Communication Produced in India Sushanta K. Banerjee Shveta Kalyanwala Vinoj Manning Kathryn L. Andersen Ritu Raj Arpita Das March 2018 Ipas Development Foundation ii Is self-use of medical abortion a viable option?: A systematic review of global evidence with a special focus on India Contents Chapter 1 Background and Methodology ................................................................................................................1 1.0 Context ...........................................................................................................................................................1 1.1 Methodology ....................................................................................................................................................2 1.1.1 Search strategy and parameters ...................................................................................................2 1.1.2 Inclusion/exclusion criteria ..........................................................................................................3 1.1.3 Selection of studies and flow of analysis ...................................................................................3 Chapter 2 Safety and efficacy of MA among women who used mifepristone at clinic and misoprostol at home ....................................................................................................................................6 2.0 Global Scenario ...........................................................................................................................................................6 2.1.1 Efficacy and acceptability of home use and clinic use of misoprostol ..................................................6 2.1.1.1 Intervention design ........................................................................................................................7 2.1.1.2 Study outcomes ..............................................................................................................................7 2.1.2 Acceptability and satisfaction of self-administration of misoprostol ....................................................8 2.1.3 Efficacy of home use of misoprostol without a comparison group ......................................................9 2.1.3.1 Study outcomes ..............................................................................................................................9 2.1.4 Acceptability of home use of misoprostol ...............................................................................................10 2.2 Use of Misoprostol at home: Indian evidence .....................................................................................................10 2.2.1 Implementation design .................................................................................................................................11 2.2.2 Study outcomes .............................................................................................................................................12 2.2.3 Acceptability of home use of misoprostol ...............................................................................................13 2.3 Conclusion from global and Indian evidence .......................................................................................................14 Chapter 3 Self-administration of mifepristone and misoprostol with clinical guidance .........................15 3.0 Context .........................................................................................................................................................15 3.1.1 Intervention design: ......................................................................................................................................16 3.1.2 Study outcome ...............................................................................................................................................17 3.1.3 Acceptability of home use of mifepristone and misoprostol ................................................................17 3.2 Conclusion .........................................................................................................................................................18 Is self-use of medical abortion a viable option?: A systematic review of global evidence with a special focus on India iii Chapter 4 Self-use of MA through pharmacy, online, telemedicine, and other informal channels......19 4.0 Evidence of using MA through pharmacists: Global .........................................................................................19 4.1 Operation research to assess the efficacy of self-use of MA through pharmacies: ...........................19 4.1.1 Operation Research study in Nepal: 2015 ................................................................................19 4.1.2 Operation Research study in Nepal: 2017 ................................................................................20 4.1.3 Research Study in Bangladesh: 2016 .........................................................................................20 4.1.4 Outcome of the study conducted in Bangladesh: 2017 .........................................................21 4.2 Evidence of using MA through informal channels: India ......................................................................21 4.3 Off label use of misoprostol alone ............................................................................................................23 4.4 Evidence of using MA online: Hotlines, SMS, and telemedicine ..........................................................23 4.5 Community-based interventions .................................................................................................................25 4.6 Challenges and concerns of ensuring safe abortion through pharmacists and other informal channels .........................................................................................................................................................26 4.6.1 Women’s ability to assess gestation age.....................................................................................26 4.6.2 Ability of women to self-administer MA drugs as per instructions ....................................27 4.6.3 Ability of women to assess the medical abortion outcome (completeness of pregnancy termination) ...............................................................................27 4.6.4 Ability of women to identify complications and seek care if needed .................................27 4.6.5 Cost of treating complications after self-use of MA .............................................................28 4.6.6 Ability of pharmacist to ensure safe access to MA ................................................................28 4.6.7 Serious adverse events associated with self-use of MA drugs ..............................................29 4.6.8 Quality of MA drugs ...................................................................................................................29 4.7 Conclusion ......................................................................................................................................................29 Chapter 5 Summary and discussions .......................................................................................................................31 5.0 Summary and discussions ........................................................................................................................................31 5.1 The way forward: Filling the evidence gaps ..........................................................................................................41 References .........................................................................................................................................................42 List of Tables Table 1: Search terms used for the literature review .................................................................................................2 Table 2: Ranks of evidence ...........................................................................................................................................4 Table 3: Types of published and unpublished documents reviewed for this study ............................................5 Table 4: The best and worst features of using MA at home and in clinic as reported by women ..................18