Integrating medical abortion into safe abortion services in South Africa

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Integrating medical abortion into safe abortion
services in South Africa
Jennifer Moodley Margaret Hoffman
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Abortion in South Africa

• Choice on Termination of Pregnancy Act 1996
• lt 12 weeks abortion available on request
• 13-20 weeks
• Fetus not viable
• Rape or incest
• Danger to womans physical or mental health
• Affect womans socio-economic status

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Abortion in South Africa

• Designated facility public NGO or private
• 1st trimester- trained registered nurse or
  physician
• 2nd trimester- physician only
• Consent irrespective of age
• Health worker may refuse to perform but obliged
  to inform women of rights and refer

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Abortion in South Africa

• Achievements
• 90 reduction deaths associated with unsafe
  abortions
• Decrease in morbidity associated with abortions
• Challenges in implementation
• Lack of designated facilities
• Shortage of trained personnel

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Abortion in South Africa

• 1997 National guidelines for implementation of
  TOP stated
• Once medical abortifacients become available in
  South Africa they should be introduced into the
  health services to further decentralise services
  in a safe and effective manner

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Medical abortion in South Africa

• Lobby group academics NGOs providers policy
  makers established 1998
• MCC approved mifepristone in 2001
• Gestational age less than 56 days
• Day 1 600 mg mifepristone
• Day 3 400 mcg oral misoprostol (offered home or
  clinic use)
• Day 15 Follow-up and final evaluation
• Medical abortion is available in private sector
  not available in public sector

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Research Studies SA

• Feasibility study
• profile of TOP clients the accuracy of
  gestational age estimation by clinicians and
  clients compared to ultrasound measurements the
  acceptability of medical TOP to clients and
  providers
• Operations research
• Medical TOP provided and the following were
  assessed outcome side effects rates of
  follow-up and acceptability of medical abortion
  to women and health care providers
• Costing studies
• Private sector use

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Research studies key findings

• Feasibility
• 22 of TOP clients attended service within 56
  days
• 82 interested in trying medical TOP
• 77 lived lt 1 hour from health service but rural
  women travelled for longer
• Generally policymakers and providers favourable
  attitudes
• Gestational age - mean provider estimates were 2
  days fewer than u/s estimates.
• D Cooper et al RHM 2005
• K Blanchard et al. BJOG 2007

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Research studies key findings

• Operations research
• 90 returned for follow-up visit
• 93 of women had a complete abortion
• Majority opted to use misoprostol at home
• Side-effect no serious 66 pain 67 heavy
  bleeding
• 96 women satisfied with procedure
• Providers satisfied felt it would decrease their
  workload and recommended introduction of medical
  TOP
• M Kawonga et al J Fam Plann Reprod Health are 2008

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Research studies key findings

• Costing
• Main cost drivers are
• Dosage cost increased by 84 when 600mg vs
  200mg
• Level of health care facility cost increased by
  39 when secondary vs primary level facility
• Category of provider cost increased by 10 for
  physician vs nurse
• Cost of nurse providing MVA at primary level
  similar to the cost of providing medical abortion
  with 200 mg mifipristone
• H De Pinho WHRU UCT 2000
• L CUllingworth et al WHRU UCT 2002

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Research studies key findings

• Private
• Majority of providers also provided surgical
  abortion 11.3 were not providing surgical
  abortion and had incorporated medical TOP into
  their services
• Range of regimes used 84 mifipristone-misoprost
  ol regimes. Of these 54 used 200 mg
  mifipristone and 43 used 600 mg.
• 94 reported that their clients were satisfied
  with medical TOP
• K Blanchard et al European Society of
  Contraception 2006

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Current situation

• MCC approved mifepristone 2001
• Available in private sector
• 300 400 packs (3 x 200mg) mifegyn sold per
  week. Cost R1020 per pack R340 per 200 mg
  tablet.
• Local research has shown that medical abortion
  can be integrated into the SA public health care
  sector
• Provider training guidelines have been developed
  and are available
• Providers have been trained

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Current situation

• Draft policy guidelines for the implementation of
  medical TOP have been developed and submitted to
  NDOH in 2007
• Set standards and norms for provisions of medical
  TOP
• Guiding principles with regards to clients
  providers and service sites
• Describe MTOP counseling
• Provide information on provider training
• Provide indicators for monitoring and evaluation
• 2009 NOT available in public sector

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Challenges

• Introducing medical abortion into public health
  sector
• Advocacy and education
• Responding to anti-abortion lobby
• Responding to news media
• Change protocol mifipristone 200mg

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Conclusion
Medical abortion can and should be integrated
into public sector abortion services in South
Africa