Managing early stages of abortion at home cuts hospital stay: trial

An international trial involving 435 women has found that 71% of patients who managed early stages of abortion at home after 12 weeks of pregnancy spent fewer than nine hours in hospital, compared to 46% of patients who took the first step at hospital.

A medical abortion involves taking two types of pills to end a pregnancy: mifepristone, which blocks the hormone progesterone and therefore causes the lining of the uterus to break down, and misoprostol, which makes the womb contract.

In this trial, all patients received the first dose of mifepristone in the clinic as usual, but some patients then took the first dose of misoprostol at home. Previous studies indicate that most medical abortions after 12 weeks of pregnancy are completed eight to 12 hours after the first misoprostol dose and require an average of two to three misoprostol doses, with some patients needing to stay overnight in hospital.

“Currently, most abortions after 12 weeks of pregnancy take place in hospitals and may require an overnight stay, which some women find stressful and isolating. Our trial results show that taking the first dose of misoprostol at home decreases the average time women spent in hospital, enabling them to leave the hospital within nine hours after admission and without an overnight stay,” said Dr Johanna Rydelius, from the Sahlgrenska Academy at the University of Gothenburg, who was an author of the paper published in The Lancet.

“Offering the choice to take the first dose of misoprostol at home provides a safe and effective alternative to taking all misoprostol doses at hospital and enables women to self-manage some of the process, potentially leading to feelings of autonomy during a time where women can feel extremely vulnerable,” Rydelius said.

“Our study found 1% of the women who took misoprostol at home completed the abortion before attending hospital for the next dose. Previous studies suggest a 1% complete abortion rate within two hours after the misoprostol first dose, and women who took misoprostol at home were made aware of this risk when choosing to take part in the trial and provided with a number to call if they had any concerns. It’s extremely important that women who are given the choice to take the first dose of misoprostol at home are clearly informed about the very small risk of the abortion occurring before attending the hospital.”

The study took place at six hospitals in Sweden between January 2019 and December 2022. All participants were given mifepristone oral pills at an outpatient clinic and provided with a time to return. Women between 12 and 22 weeks pregnant planning to undergo a medical abortion and who chose to take part in the trial were randomised to either receive their first dose of misoprostol at home or at the hospital.

Women in the home treatment group administered the first dose of misoprostol vaginally at home and returned to hospital two hours later for the remaining treatment. Women in the hospital group self-administered the first dose of misoprostol upon arrival at the hospital. All participants then took repeated doses of misoprostol under the tongue every three hours until the abortion occurred.

The patients were asked to complete a follow-up survey two to four weeks after the abortion. Five out of six participants in both trial arms (171/200 of those in the home treatment group and 152/188 of those in the hospital treatment group) said they were very satisfied with the care they received.

When asked ‘if you were to choose, where would you prefer to take the first dose of misoprostol?’, 78% of women in the home group and 51% of women in the hospital group said they’d prefer to take the first dose of misoprostol at home.

“Every patient who seeks abortion care must navigate a unique set of personal and medical circumstances. The choice of self-administering the first dose of misoprostol at home may provide some patients with a sense of autonomy and comfort during what can be a very overwhelming time in their lives. In addition, providing the option of the first dose of misoprostol at home would enable more abortion clinics with no overnight facilities to provide medical abortions for women who are over 12 weeks pregnant, something particularly important for locations where access to abortion care is limited,” said author Professor Kristina Gemzell Danielsson, from Sweden’s Karolinska Institutet.

The authors acknowledge some limitations of the study, including that the researchers were advised by the Data and Safety Monitoring Board to end the trial early due to a lower-than-expected enrolment and slow progress towards the trial’s target of 784 participants. However, trial site feedback suggests the enrolment rate was not due to reluctance to take misoprostol at home but rather due to patients feeling overwhelmed by the overall situation.

Image credit: iStock.com/FatCamera