These data present yet another example of how misoprostol can be successfully incorporated into standard post-abortion care services
[2–4, 6, 7]. The difference in side effects between the two groups is also comparable to what has been shown in similar studies
[4, 5, 8]. Of note, the success rates for misoprostol at three of the sites were much higher after the first month of use. This “learning curve” for the clinicians offering misoprostol provides an excellent example of what may occur when misoprostol is first made available as a method of uterine evacuation in new settings.
The majority of surgical interventions in our study were initiated by women’s concerns over the amount and/or duration of bleeding; it is certainly possible that at least some of the interventions would not have been carried out by a more experienced misoprostol provider. Given that most interventions were carried out in the early stages of the study, providers may also have been less comfortable with the new method. And providers’ lack of comfort may have translated to women’s unease with the process. Indeed, it is not uncommon to see success rates improve over time when misoprostol is first introduced; providers who have not previously used misoprostol for treating incomplete abortion (or for medical abortion) need to become accustomed to the process, particularly the bleeding patterns, in order not to intervene prematurely. For example, in a recent study of misoprostol for incomplete abortion in Ghana
, all failures occurred in the first half of the study (J. Taylor, personal communication, September 20, 2011). In Turkey, a study with a low rate of success with medical abortion was followed by a second study with a much higher completion rate after more extensive provider education and experience were provided
[10, 11]. And in our study, Burkina Faso had the highest success rate both at the beginning of the study and overall, and was the only country to have previous experience with the method. This pattern suggests that when introducing misoprostol into new settings, additional focus should be placed on provider training as well as on provider follow-up and support to ensure that clinicians are fully comfortable with both the amount and duration of side effects, especially bleeding.
As in many studies addressing abortion and/or post-abortion care in settings with limited legal access to safe abortion care, some women were lost to follow-up. High rates of loss to follow-up are common with incomplete abortion treatment, particularly where cost and distance to care are substantial factors, as well as in settings where abortion is illegal
[2, 5]. Moreover, cultural norms in some settings discourage seeking care when it is not necessary, suggesting that women with complications are more likely to return and those not returning are more likely to have had no further problems
. One proposed solution to poor in-clinic follow-up is to develop an at-home assessment tool with a symptom checklist to help women determine whether or not they need to return for further care
. Telephone follow-up could also be established to reduce the need for in-person assessment
While the sites in this study were all secondary and tertiary level hospitals, the findings suggest a great potential for use of misoprostol at lower-level facilities where physicians are less available. As demonstrated in 4 of the 6 sites, physicians are not needed to provide PAC services: both counseling and provision of the medications were successfully provided by other clinicians such as nurses or midwives trained in treatment protocols. However, more attention to training in how to avoid unnecessary intervention would be beneficial. The option of a first line treatment at out-patient clinics could reduce the burden on higher-level settings where case loads are high and also increase access for women who may have difficulties reaching higher level care. This would facilitate task shifting and reduce the human resource burden in many countries.
This study supports previous research showing that ultrasound is not necessary for outcome assessment when treating incomplete abortion with misoprostol
[13–15]. The majority of misoprostol cases were successfully evaluated without the use of ultrasound. And in Senegal, where ultrasound use was required, its use decreased substantially over the course of the study (as providers likely became more comfortable with the process), and clinicians relied more on clinical assessment alone. Misoprostol may be very appropriate in places where ultrasound is not available and/or where providers are not trained in ultrasound use.
There were limitations to this study including small sample size across different sites, the mandated use of ultrasound in Senegal, and the differences in standard of care at each location. However, regardless of these limitations, this research gives us a good overview of what service provision of misoprostol for treatment of incomplete abortion might be like in these settings.