Original research articleMifepristone-misoprostol abortion: a trial in rural and urban Maharashtra, India☆
Introduction
Mifepristone medical abortion offers a safe and acceptable non-surgical alternative to women seeking early pregnancy termination [1], [2]. In Europe alone, where the method has been available in three countries (France, Sweden, and UK) for nearly 10 years, more than 750,000 women have used it. Recent mifepristone approvals in several additional European countries and introduction in the US in 2000 should lead to a large increase in the number of developed-country women with access to this method of abortion.
In the developing world, however, where nearly all of the 70,000 estimated deaths each year because of unsafe abortion occur [3], mifepristone is readily available in only a single country, China. In recent years, policymakers and women’s health advocates have called for the increased availability of medical methods of abortion in developing countries, and Ministries of Health from several such countries have expressed interest in their introduction [4], [5]. While recent studies have explored the use of this method in other developing countries [6], [7], [8], four key questions about the method’s use in such settings remain unanswered: (1) Can mifepristone abortion be offered safely and effectively in existing urban family planning clinics? All previous studies were conducted in research settings. (2) Can the method be provided in a rural setting? While 63% of developing-country women live in rural areas [9] where access to abortion services is particularly difficult, no study has documented the use of mifepristone in such settings. (3) Is mifepristone-misoprostol as acceptable to rural women as to urban women? Given socioeconomic and cultural differences between rural and urban women, results of studies conducted in urban environments may not be applicable to rural ones. (4) Is the method safe, effective, and acceptable up to 9 weeks gestation? To date, the studies conducted in developing countries have assessed the method’s safety, efficacy, and acceptability up to 8 weeks gestation. Given the logistic delays women encounter when seeking abortions in many developing countries, if safe, effective, and acceptable, extending the gestational age cut-off by 1 week would greatly increase access to the method. We conducted a study of mifepristone-misoprostol abortion in two urban and one rural setting in India to address these questions.
Abortion has been legally available in India since 1972. Nonetheless, access to legal abortion services there remains difficult. In 1996, with population estimates exceeding 900 million, only approximately 8500 facilities were approved to provide abortion [10]. In certain states, such as Uttar Pradesh, there were only 3.4 approved centers per million population. While the approved facility-to-population ratio was higher in other states, many centers in those states lacked the necessary equipment or trained personnel to provide consistent abortion services. Indeed, in 1996 less than 5% of the 1646 approved centers in Maharashtra state were functioning [10]. Additionally, abortion services in rural areas are particularly short-changed. Finally, many of the surgical abortion services in India are marked by a number of quality problems. Ultimately, complications of abortion account for approximately 12% of all maternal deaths in India [11].
Section snippets
Methods
We conducted a prospective study from August 1995 to September 1998 in the outpatient family planning departments of two urban hospitals (Pune and Mumbai) and one rural hospital (Vadu) in the Indian state of Maharashtra. While Pune and Mumbai are large metropoles, Vadu is a village of 56,000 located 30 kilometers from Pune. As part of a larger project to increase access to healthcare in the rural areas surrounding Pune, the Vadu hospital serves women from a well delineated rural area. The two
Sample characteristics
The sample included 900 women, 300 at each of the three study sites (Table 1). Vadu women were the youngest (Vadu 23.8 years, Pune 26.7 years, Mumbai 26.4 years), shortest (Vadu 151.1 cm, Pune 155.4 cm, Mumbai 152.1 cm), and weighed the least (Vadu 44.3 kg, Pune 51.9 kg, Mumbai 49.6 kg). The rural women also averaged fewer years of schooling than urban women, although even between the two urban sites, there was a significant difference in education levels (Vadu 8.4 years, Pune 13.0 years,
Discussion
Our findings suggest that mifepristone-misoprostol abortion can be safely, effectively, and acceptably offered in urban family planning departments and rural health settings in India. While highest in the rural hospital, perfect-use success rates exceeded 91.0% in the two urban facilities where women up to 9 weeks gestation participated. When user failures were considered as well, efficacy rates changed minimally, suggesting that both urban and rural women can adhere to a medical abortion
Acknowledgements
The authors are extremely grateful to Andrea Eschen for valuable assistance at the initiation of the study, and Sunil Patel for extensive efforts on data entry and cleaning. The authors also thank Elizabeth Pearlman for her assistance with preliminary table preparation.
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This study was funded by an anonymous donor.