|  There
is no debate about the fact that every abortion needs medical
supervision– pontaneous or induced andmedical or surgical
abortion.
Can women use medical abortion without medical supervision?
Medical abortion offers a new option to women seeking to
terminate their pregnancies, in particular mifepristone-misoprostol
combination consists of simple pills and it is potentially
suitable for self administration. Yet access to and administration
of this method of abortion remains tightly controlled.
In this, strict control is medically necessary. This is to
identify the seven steps that women would need to accomplish
in order to use this mifepristone – misoprostol regime
without medical supervision.
Which are the seven steps, women would be incapable of controlling
if such pills are given to her without medical supervision?
1. Recognize that they are pregnant (Delayed menses,lactational
amenorrhoea, ectopic pregnancy, intrauterine pregnancy, irregular
menses, gestation not known, etc have to be ruled out).
2. Estimate the duration of pregnancy to be sufficiently short
so that she is an ideal case for a particular method.
3. Select mifepristone – misoprostol regime appropriately
(rule out corticosteroid therapy, contraindication to PGs,
previous cesarean)
4. Adhere to the correct protocol
5. Manage adverse reactions and seek care for those that warrant
medical attention.
6. Possibly, notice and cope with expulsion of embryo.
7. Recognize complete abortion
As evident not only women from developing countries but also
from developed countries need medical supervision, as they
are incapable of controlling these 7 steps. There the several
other advantages of having medical supervision. Thorough check-up
can be done and contraceptive advice can be given in the same
sitting. Patients can be counseled to use some other regular
method of contraception.
You also examine her, thus any co-existing problem can be
identified and treated simultaneously. |  Medical
Methods of early abortion differ from surgical methods, in
that women, themselves, can potentially administer the regimens.
As currently researched and offered, however, the main regimen
used for medical abortion, mifepristone - misoprostol is highly
medicalized, involving several clinic visits and extensive
physician involvement. Other drugs in use are methotrexate,
tamoxifen, gemeprost etc.
In scientific terms, medical supervision is a preventive
strategy and not a treatment. Its aim is to detect complications
early and have proper selection of the client. The recommended
medical supervision for medical abortion, at present, is a
three-visit clinic-based administration of drug. The aim is
to detect the complications and problems early.
Evidence suggests that most women can handle most steps of
the medical abortion process themselves, effectively and safely.
The utility of clinic visits to ingest mifepristone and misoprostol
is questionable. For many women, even the follow-up visits
could, perhaps, be replaced by telephone follow-up, combined
with home pregnancy tests.
Visible complications of medical abortion that can be detected
by the patient herself if known to her, include pain, headache,
gastro-intestinal symptoms, bleeding, incomplete abortion,
severe hemorrhage (< 1%) and failure (< 1%). The patient
can go to the doctor and seek advice.
Invisible complications can be missed ectopic or a congenital
malformation in case of a continuing pregnancy. These can
hardly be detected by medical supervision. Ectopic pregnancy
is seen in 0.1% of cases, and can be diagnosed by per vaginal
examination in a symptomatic patient in 10% cases only. Therefore,
to detect only 1 case of ectopic pregnancy by medicalsupervision,
10,000 women will be kept under supervision.
Also, the incidence of failure or incomplete abortion rate
is not reduced by medical supervision. The client has to visit
the doctor for surgical abortion in both the cases.
The success of medical abortion depends on the regimen used,
dosage schedule, route of administration and gestational age.
Life-threatening complications (severe haemorrhage) are seen
in < 1% of patients, but they cannot be prevented by medical
supervision. Life can only be saved if patient goes to the
doctor or hospital for management. Haemorrhage can occur at
any time. Therefore, the recommended three-visit supervision
is not enough. It needs hospitalization for 2 weeks or a minimum
of 3 days, which is neither cost-effective nor convenient.
Clinic visits, especially in less-developed countries where
women can ill afford time lost from work or childcare and
associated transport costs, are
burdensome and inconvenient, and should be eliminated, if
not needed, to safeguard women’s health.
Clinic visits also compromise privacy which is essential
in places where abortion is stigmatized. Substantial clinician
involvement in the abortion process, if not warranted medically,
is wasteful in countries where medical attention is scarce,
physician skills and attention spread is thin, and clinics
overburdened.
Patients undergoing medical abortion require only a partial
medical supervision. It includes first visit at registration
for proper client-selection, to rule out ectopic gestation,
explain the risk of complications and failure rate and congenital
malformation and establish proper linkage in case of emergency.
What is needed is:
• An educated and well-informed client
• Good initial guidelines in regional language and product-insert
with the drug
• Identified back-up emergency access facilities and
their telephone numbers
MTP Act has to be modified to take full benefit of medical
abortion and to resolve social, legal and ethical issues. |
