Women's satisfaction with medical abortion with RU486

Introduction

Following approval from the Therapeutic Goods Administration in March 1994, the World Health Organization selected Monash University and Family Planning Victoria to participate in an international multicentre, double-blind, randomised controlled trial to test the efficacy and side effects of two doses of mifepristone (600 mg or 200 mg) followed by 400 mg of misoprostol 48 hours later for the termination of early pregnancy. Ethical approval to conduct the trial was obtained from the ethics committee of Family Planning Victoria.

We thought it would be useful to know if the Australian women who participated in this WHO trial considered medical abortion an acceptable primary treatment and if their level of pain was acceptable. For women who had had a previous surgical termination, we were interested in how they felt the methods compared.  

Clinical record

According to the trial protocol, participants attended the clinic to receive mifepristone and returned after 48 hours to receive misoprostol. Women were offered paracetamol (500 mg) for mild to moderate pain or pethidine (50 mg intramuscularly) for severe pain. Analgesic preparations known to interfere with prostaglandin metabolism, such as salicylates and mefenamic acid, were not dispensed and women were advised not to take these. Patients returned for follow-up two weeks and six weeks after abortion.

Five women were withdrawn from the trial because they needed surgical intervention. Four women who had a successful termination of pregnancy failed to attend for assessment at six weeks and were lost to follow-up. Thirty-eight of the remaining 41 women who completed the protocol agreed to complete a self-administered questionnaire to assess their satisfaction with medical abortion.

The questionnaire included two visual analogue scales on which:

• All women were asked to score their degree of satisfaction with the medical abortion (Box 1a); and

• Women who had previously had a surgical abortion were asked to compare medical abortion with the surgical procedure (Box 1b).

Further, the questionnaire included questions about cost, avoidance of anaesthesia, whether the procedure was considered more natural, and whether the pain and discomfort were acceptable. Women were also invited to make personal comments about why they chose a medical abortion and how they rated their experience.

Results

The level of pain and discomfort was regarded as acceptable by 34 participants; 19 women experienced only mild discomfort, while one woman was pain free. Seventeen of these 20 women did not require analgesia. Only one patient required pethidine for severe pelvic cramping. The remaining women who required analgesia were satisfied with paracetamol.

Cost was an important factor in the choice for seven of the 38 participants. There were no costs involved for trial patients. As public hospitals in Victoria are able to service only a small number of patients, most women seeking termination must attend private abortion clinics, so that cost becomes a factor in their choice of provider. The wish to avoid anaesthesia was important for 19 women, while 25 regarded medical abortion as more natural.

Other factors in women's decisions to choose medical termination included preferring a less clinical atmosphere and finding research staff to be very supportive at a stressful time (nine women), considering a medical termination to be more emotionally acceptable (nine women), and fear of surgical operation (six women). Other factors included more autonomy (expressed as "a need to be in control of the situation") and the desire for a less invasive procedure. One woman stated: "I was much more able to cope with my decision to have a medical termination as I was conscious the whole time and did not feel that my body was invaded." Six women reported that the associated pain and the duration of bleeding was a drawback for medical abortion, but all six rated the procedure as acceptable.  

Discussion

Satisfaction with medical termination of pregnancy among the 38 women was evident. The factors involved in their choice of medical abortion were complex. Overall, medical abortion provided women with a more active role in the process, thus allowing them to achieve a certain degree of autonomy. Most of the women surveyed described the medical approach as more natural, and two women likened the procedure to having a miscarriage.

The requirements for a medical abortion differ in many respects from those for a surgical abortion. In particular, partners, friends or family could be present at any time, and patients were not required to fast during the three hours they remained in the clinic after being given misoprostol. Many of the women who participated in the trial commented on the friendly, non-clinical approach, which they considered psychologically beneficial at a time when anxiety levels were increased. Similar psychological benefits of medical abortion have been noted by Henshaw and colleagues.²

Medical abortion as an alterative to surgical abortion has gained acceptance in countries in which it has become available. In a British study of 363 women undergoing first-trimester abortion, 20% of women chose medical abortion, 26% chose the surgical technique, and the remainder agreed to be randomised to either method.³ This finding concurs with earlier studies in France where one-fifth of women chose medical abortion.⁴ In a Chinese study, women who were likely to accept medical abortion were single, young, nulliparous and employed; these women were reportedly fearful of "trauma to the body" from surgical abortion.⁵ Significantly, all women who answered the questionnaire in that study said that they would choose medical termination again.⁵

As Baird⁶ has suggested, more studies are needed to establish the acceptability of mifepristone (RU486) for termination of pregnancy in different countries and different cultures. A further follow-up study in Australia with a larger sample of women would be useful in this regard.  

Acknowledgements

References

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2. Henshaw RC, Naji SA, Russell IT, Templeton AA. Psychological responses following medical abortion (using mifepristone and gemeprost) and surgical vacuum aspiration. Acta Obstet Gynecol Scand 1994; 73: 812-818.
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