First trimester abortion protocols by facility type in Switzerland and potential barriers to accessing the service

Abstract

Simplified first-trimester abortion protocols are well established. However, data on the use of medical or surgical abortion protocols across Switzerland is lacking. We report protocol characteristics in abortion care for two different facility types, hospital vs private practices (office-based) in Switzerland. Furthermore, we investigate an association between protocol characteristics and the likelihood of following through with the abortion at the same facility. We also report abortion outcomes of an office-based cohort where doctors use simplified abortion protocols. This study consists of two parts. (i) Between April and July, 2019, we collected data regarding medical and surgical abortion protocols of institutions offering abortions, in a nationwide survey. We assessed whether the proportion of patients who followed through with the abortion (primary outcome) after first appointment was associated with predefined protocol characteristics, considered to complicate access to abortion services, using generalised estimating equations. (ii) We analysed abortion outcomes of six selected office-based facilities from January, 2008, to December, 2018, using simplified abortion protocols in accordance with the Worlds Health Organisation (WHO) guidelines. (i) We included a total of 39 institutions. Hospitals showed more protocol-based barriers to abortion access compared with office-based facilities. The odds of undergoing an abortion after the first appointment were increased using protocols with minimal barriers. Overall, office-based facilities applied higher gestational age limits, required fewer appointments, and administered mifepristone more often after the first visit than did hospitals. (ii) We included a total of 5274 patients with an incidence of complications requiring surgery of 2.5% in line with rates reported in published literature. Only a few hospitals provide abortion care with easy access to medical and surgical abortion, whereas most office-based facilities do. Access to abortion services is generally crucial, and should be provided in a single visit whenever clinically permissible.

Figure 1

Study flow chart—Nationwide survey. Methodical selection process of appropriate institutions. *Swiss Institute of Medical Education. ^†General Practitioners. ^‡Swiss Working Group for Abortion and Contraception.

Figure 2

Association between protocol characteristics and the proportion of patients who followed through with the abortion at the same facility. Odds ratios were estimated by single variable GEE models (referred to as single-variable models in the text).

Figure 3

Association between protocol characteristics and the proportion of patients who followed through with the abortion at the same facility. Odds ratios were estimated by a multivariable variable GEE model (referred to as full model in the text).