by Rebecca Finch
In October 2017, the Scottish government changed the law to allow women to self-administer misoprostol in their own homes. Misoprostol is the second of two drugs used in early medical abortion (EMA), and prior to this, was required by law to be administered on a licensed premises, such as in a hospital or clinic. As a result, women wishing to have EMA had to make two separate visits to abortion services within a 24-48 hour period in order to obtain each of the two drugs required for the procedure. This stipulation in the law was known to be inconvenient for women, particularly those who lived further from abortion services, as it meant they had to attend an additional appointment to be administered misoprostol, and then rush home before the drug took effect. Qualitative data in the form of interviews with women from rural and remote areas of Scotland revealed instances of distressing and often humiliating bleeding and/or pain for women on their journey home after receiving misoprostol. It was believed, therefore, that the change in legislation would be beneficial for women by reducing the process to a single clinic visit, and hopefully improving comfort and convenience during the procedure. Additionally and as a result of this change in law, the maximum gestation at which EMA could be performed was extended from 9 to 9+6 weeks owing to the fact that an additional dose of misoprostol could now be taken by women at home in cases where expulsion of the pregnancy had not occurred within 4 hours. This was previously not an option as women were not permitted to administer misoprostol at home.
In order to determine the impact of this change in legislation on abortion services and on the efficacy of the procedure, we conducted a quantitative study to compare the uptake and success rate of EMA before and after the introduction of the new protocol. In addition, due to the potential concern that provision of contraception might suffer as a result of the relative time constraints of a single clinic visit, we also wished to compare the uptake of effective contraception methods, in particular the long-acting reversible contraceptives (LARCs). A prospective observational cohort study was conducted to follow the outcomes of two cohorts of women in Edinburgh undergoing EMA in the six months prior to and six months following the introduction of home misoprostol administration. The women were followed up and data for the ‘clinic misoprostol’ and ‘home misoprostol’ cohorts were compared for the given variables.
Reassuringly, we found no change in the high success rate of EMA following the introduction of home misoprostol administration. Furthermore, uptake rates of EMA in fact increased following the change in legislation with 6.9% more women being treated as EMA. This increase can be largely attributed to the fact that women between 9 to 9+6 weeks gestation can now be treated at home, whereas previously they would have had no choice but to receive treatment in hospital as a day case procedure. These day case procedures require women to be admitted to a ward for up to 6 hours following misoprostol administration and their provision is thus limited by the availability of beds and staff on the ward. Finally, we reported no negative impact on provision of LARC to women undergoing abortion, despite them attending the clinic on less occasions than previously.
Health care services will benefit from the provision of home administration of misoprostol. It is likely to result in improved cost-efficacy by removing the need for an extra visit to the service, thus giving clinicians more time to see more patients, and reducing the proportion of women undergoing day case procedures which occupy hospital beds. More importantly, it allows women the opportunity to take responsibility for their own care in the comfort of their own home, where they can be in the company of a partner, relative or friend. The decision to terminate a pregnancy is clearly not an easy one and permitting women to take more control of this procedure themselves can be considered a positive move in health service delivery.