Analysis of failure in medical abortion

Abstract

Medical abortion opens a new choice to women wishing to terminate a pregnancy. Increasingly, providers in the developing and developed world will begin to offer this option. Yet, the nomenclature and concepts used for measuring failure of surgical abortion are not directly adaptable because of important differences inherent in the method and in the way it is offered in a given setting. We propose that failures in medical abortion should be defined as a surgical intervention (whether vacuum aspiration or dilatation and curettage) performed for any reason. Such instances may be further classified into three types: user choice interventions, provider choice or error interventions, and true drug failures requiring intervention. Further description and examples of each type are given.

PIP: This article recommends that failure of medical abortion, as distinguished from surgical abortion, be defined very specifically and further distinguished by whether the abortion was due to user choice, provider choice or error in intervention, or true drug failures requiring intervention. Surgical abortion is distinguished from a medical abortion in that it is a mechanical event, scheduled at a specific time. Medical abortion refers to drug ingestion over a period of time before expulsion can occur. When surgical abortion requires reaspiration, it is considered as one abortion and one intervention for complications rather than two abortion procedures. Medical abortion requires a new measure of efficacy that includes records of repeat visits, counseling sessions, the drug regimen, and failure rates. The advantages of better reporting of medical abortion include the improved information for client choice, the improved information for provider selection of a suitable method, the service statistic record, and comparative records of different drug regimes. The proposed definition of medical abortion failure is one that involves dividing the number of women requiring surgical intervention by the number of women undergoing the medical procedure in the trial. The total failure rate includes user choices, provider choices or errors, and true drug failures. Each of the failure types is described and examples are given of each type of failure. Recent evidence suggests that true drug failures accounted for only about 50% of the surgical interventions. It is suggested that the failure rate of mifepristone and misoprostol may be as low as 2%. Failures in user choice can be reduced with improved counseling. Failures due to provider error can be reduced with improved training and experience.