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Choosing between surgical abortions and medical abortions induced with methotrexate and misoprostol
ELSEVIER
Choosing Between Surgical Abortions and Medical Abortions Induced with Methotrexate and Misoprostol Ellen R. Wiebe Women phoning to request an abortion at a free-standing abortion clinic who were less than 46 days from the last menstrual period were given a choice between a surgical abortion and a medical abortion induced with methotrexate and misoprostol. Twenty-six percent (116 of 405 women) chose a medical abortion. Younger women were more likely to choose a surgical abortion. There were no other significant differences in the two groups in terms of gestational age, race, or prior pregnancies. The reasons most women listed as ‘very important” when making the decision to have a medical abortion were the timing (being able to have the abortion before 7 weeks), the privacy of aborting at home, and fear of surgery. The women who chose surgery gave the reasons of fear of experimental medications, the lack of emotional support at home, and wanting to avoid the extra visits and blood tests. 0 1997 Elsevier Science, Inc. All rights reserved. CONTRACEPTION 1997;55:67-71 KEY WORDS:
acceptance of surgical abortion, medical abor-
tion
Introduction edical abortions induced with methotrexate and misoprostol were first reported by Creinin and Darney in 1993.’ Subsequently, there have been more reports of this method and it has been found to be safe, effective, and acceptable to most women.2-10 Medical abortions induced with mifepristone (which is not available in North America), followed by a prostaglandin have become common in some European and Asian countries and there are several reports of how women chose between surgical and medical abortions in those settings.“-l6 Winikoff” has extensively reviewed the
M
Department of Family Practice, University of British Columbia, Vancouver, Canada Name and address for correspondence: Ellen R. Wiebe, M.D., Suite 1310-750 West Broadway, Vancouver, B.C. Canada V5Z lJ3. Tel: 604/873-8303: Fax: 6041873-8304 Submitted for publication May 21, 1996 Revised November 1, 1996 Accepted for publication November 4, 1996
0 1997 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
acceptability of medical abortions. She states, “Not only is medical abortion acceptable, but for some it is markedly preferable.” Information about how women choose between medical and surgical abortions is important to physicians planning abortion services. In 1991, Tang and colleagues’ reported on 42 Chinese women in Hong Kong who were offered a choice between surgical abortion and medical abortion induced with RU486 (mifepristone, an anti-progestin) and ON0 802 (a prostaglandin). In 1993,r2 they reported on a further 144 women; 67.7% chose medical abortions. In 1992, Bachelot and colleagues13 reported on 488 women in France who were offered a choice between surgical abortions with either local or general anesthesia and medical abortions induced with mifepristone and sulprostone (a prostaglandin); 62% chose medical abortions. The women who chose medical abortions were more likely to be younger, with higher educational and socio-professional levels and of “Western cultural background.” Henshaw and colleagues’4-‘6 reported on 363 women in Scotland who were offered surgical abortion or medical abortion induced with mifepristone and gemeprost (a prostaglandin). Of these, 20% chose medical abortions, 26% chose surgical abortions, and 54% agreed to be randomized to either medical or surgical abortions. There were no differences between the groups in terms of age, gestational age, or history of prior pregnancies. There have been no reported comparisons between abortions induced with mifepristone and those induced with methotrexate, and there are no reports of how women choose between medical and surgical abortions in North America. Not only is the North American setting different, but the experience of a medical abortion induced with methotrexate is different from one induced by mifepristone. The most important difference is that the mifepristone abortions
occurred in clinics,
while methotrexate
abortions
curred in the women’s own homes. Methotrexate
an anti-metabolite pristone, which
ocis
and works more slowly than mifeis an anti-progesterone.
The usual
ISSN OOlO-7824/97/$17.00 PI I SO01 O-7824(96)00274-0
68
Wiebe
Contraception 1997;55:67-71
protocols involve having the prostaglandin administered 48 h after mifepristone but 3-7 days after methotrexate. It is important that physicians planning to offer medical abortions induced with methotrexate and misoprostol know how many women are likely to choose this method and understand more about the choices they make.
Material
and Methods
Approval for this study was granted by the Clinical Screening Committee for Research Involving Human Subjects of the University of British Columbia. Women phoning to request an abortion at a free-standing abortion clinic were screened by the telephone staff and those less than 46 days from the last menstrual period (LMP) and who could understand a consent form were given a choice between a surgical abortion and a medical abortion. If they expressed interest in a medical abortion, they were referred to a nursecounselor who gave them detailed information including the need for at least three office visits and at least two blood tests, the approximately 10% possibility of requiring a surgical aspiration, and the fact that the abortion would occur later in the woman’s own home. The surgical abortions were performed at the clinic, but the women having medical abortions were seen at the investigator’s primary care office. Three groups of women were compared: women who had called the office directly and requested a medical abortion; women who had called the clinic first, were offered a choice and had medical abortions; and the women who called the clinic first, were offered a choice and chose surgical abortions. The women who were given a choice between medical and surgical abortions were tracked when they arrived at the clinic or the office. After the women had been given detailed information and signed the consent forms for the procedures, they were given self-administered questionnaires asking about the reasons they made their choice. They were also given a symptom log to fill in at home and hand in at the follow-up visit. On this, they charted their bleeding with a daily pad count, their pain using an 11 -point numeric pain scale (the same pain scale used in the investigator’s previous studies on pain control in surgical abortions’8r19) and other symptoms such as diarrhea. The surgical group were given self-addressed stamped envelopes and told to mail the log if they did not return to the clinic for follow-up. Demographic information was collected from the charts and compared. This survey was conducted between February 1 and August 15, 1995. During that time period, 1217 abortions were performed at the clinic that participated in
this survey, and a total of 5238 were performed in the two free-standing clinics and the two hospitals in the city (hospital and clinic records). There were no other medical abortions available. Surgical abortions were performed after 7 weeks from the LMP under local anesthesia at the clinic. Pre-operative lorazepam and ibuprofen were offered. The wait list at the clinic was approximately 2 weeks. The 352 women having medical abortions were part of a randomized controlled trial comparing two doses of misoprostol or a cohort study comparing two doses of methotrexate as described elsewhere.” They each received an injection of methotrexate 50 mg/m’ or 60 mg/m’ on Day 1 and then inserted 500 or 750 mcg of misoprostol on Days 4 or 5. A second dose of misoprostol was given on Day 8 if they had not aborted. The women were followed with serial HCGs. Two weeks after the abortion, women returned for a pelvic examination to ensure a non-tender, nonpregnant uterus and handed in their questionnaire. Statistical
Analysis
The three groups of women-medical abortions via office, medical abortions via clinic, and surgical abortions-were compared with respect to outcomes measures (pregnancy terminated vs. continuing, pain, days of bleeding, side effects) and demographic variables using one-way analysis of variance for interval data and chi-square tests of independence of categoric data. “Reasons for choice” variables were assessed using chi-square tests to compare the three groups with respect to the percentage rated “very important.” Where differences among the three groups were detected, follow-up pair-wise comparisons were performed. Analysis was carried out using SPSS statistical software.
Results There were 405 women who were offered a choice between medical and surgical abortions when they called the clinic; 116 had medical abortions and 149 had surgical abortions at the clinic. The other 140 women either continued their pregnancies or had surgical abortions at one of the other clinics or hospitals. There were also 236 women who requested medical abortions directly through the office. Therefore, during this time period, a total of 352 women had medical abortions. The success rate of the 352 medical abortions, i.e., the percentage who aborted without surgical aspiration, was 91.8%. The mean worst pain on the llpoint numeric pain scale was 6.27 (SD 2.951, and the mean total days of bleeding was 12.3 days (SD 5.5). Other side effects, including vomiting and diarrhea,
Choice of Medical or Surgical Abortion
Contraception 1997;55:67-71
occurred in 50.9%. 83.5% of all the women who had successful abortions and 80.4% of the 82 women who had had both surgical and medical abortions said they would choose medical abortion if faced with the same choice. Younger women were more likely to choose a surgical rather than a medical abortion (p-value 0.0049), but there were no significant differences among the three groups in terms of gestational age, previous pregnancies, or race (Table 1). When asked about the reasons for their choice, 80.9% of the women who had medical abortions rated the timing, i.e., that they could have the abortion before 7 weeks as “very important.” The expected privacy of aborting at home and the emotional support they had were rated as “very important” by 71.3 % and 61 .O%, respectively. Fear of surgery and anesthetics were rated as “very important” by 44.7%. Of the women who chose surgical abortion, 75.0% said that lack of emotional support at home was “very important,” 65.4% said the fear of experimental medications,. and 48.1% said the number of office visits and blood tests required for the medical abortions were “very important” (Table 2).
Discussion The main findings were that about one-third of women presenting for abortion were eligible for medical abortions (less than 46 days from LMP), and 28.6% of these chose medical abortions. In comparison, 69% of Tang’s Hong Kong Chinese women,9r’2 62% of Bachelot’s French women,13 and 20% of Henshaw’s Scottish women14-16 chose medical abortions. At the Table
1. Characteristics
time of this study, medical abortions were still offered only on research protocol and were not a widely accepted practice. If medical abortions become more accepted in North America, the percentage of women choosing medical abortions may rise. As the other authors have reported, it is not possible to predict which women will choose medical abortions on the basis of demographics. Tang and colleagues9f12 found that in their Hong Kong Chinese sample, single women were more likely to choose medical abortions, but it was too difficult to interpret marital status in this sample to make a similar comparison. An attempt to compare marital status, as Tang had done, was unsuccessful because women’s answers varied and were difficult to interpret; for example, “common-law,” “separated,” or “divorced,” and, unlike Tang’s subjects, many single women had children. Bachelot13 found that women of “Western cultural background” were more likely to choose medical abortions. The “non-Western” women in their sample would have been mostly North African and black African. In this study, approximately twothirds of the women were white Caucasian and onethird Asian (about 10% Chinese and about 10% East Indian) and there were no differences in how they chose between medical or surgical abortions. In this study younger women were more likely to opt for a surgical abortion, and this may be because they were less likely to have the necessary emotional support at home. The main difficulty with this survey was the low rate of valid questionnaire data, especially in the surgical group. Only 52 out of 149 women in the surgery
of women choosing between medical and surgical abortions
Maternal age in years (mean * SD) Gestational age in weeks (mean * SD) Gestational age at surgical procedure (mean * SD) Total pregnancies (mean f SD)
Medical Abortions Via Office
Medical Abortions Via Clinic
Surgical Abortions
27.3 (6.2)
27.8 (5.9)
25.6 (6.2)
5.8 (0.6)
5.7 (0.7)
5.8 (0.8)
F-stat = 5.45 p-value = 0.0049 F-stat = 2.56
p-value = 0.080 7.8 (0.9) 2.4 (1.4)
2.6 (1.5)
2.4 (1.7)
F-stat = 0.58 p-value
= 0.56
Previous births (mean + SD)
0.7 (1.0)
0.7 (0.9)
0.7 (1.0)
F-stat = 0.13 p-value = 0.88
Previous
0.6 (0.8)
0.7 (0.9)
0.5 (0.8)
F-stat = 1.19 p-value = 0.3 1
TAs (mean f SD)
Race Caucasian Chinese East Indian Other Total
69
159 24 27 26 236
(67.4) (10.2) (11.4) (Il.01
83 9 18 6 116
(71.6) (7.8) (15.5) j5.2)
109 14 18 6 149
(73.1) (9.4) (12.1) (5.4)
chi-square p-value
= 7.18 = 0.3 1
70
Wiebe
Contraception 1997:55:67-71
Table
2. Reasonsfor choosing between medical and surgical abortions-number (%] rated “very important”
Abortion site: home or clinic Abortion timing: before or after 7 wk Number of visits and blood tests Expected pain
MedicalAbortions Via Office
MedicalAbortions Via Clinic
Surgical Abortions
76 (44.4)
30 (33.0)
30 (57.7)
139(81.3)
69 (80.2)
24j46.2)
39(22.8)
19 (20.9)
25 (48.1)
70 (40.9)
29 (31.9)
21 (40.4)
Privacy
123(71.9)
58 (63.7)
35 (67.3)
Emotional support
103 (60.2)
50 (54.9)
39(75.0)
Fear of surgery or anesthetics Fear of experimental medications Other
76 (44.4)
38 (41.8)
16 (30.8)
39 (22.8)
27 (29.7)
34 (65.4)
10 (5.8)
2 (2.2)
9 (17.3)
Total
171
91
52
group handed in the first questionnaire asking about reasons for choice, and 23 mailed in the second questionnaire about symptoms and preference. Of the 352 women having medical abortions, 262 handed in the choice questionnaire and 299 the symptoms and preference questionnaire. Therefore, a comparison between the surgical and medical groups with respect to reasons for choice, symptoms, and preference is impossible. There is, however, enough information from the women who had medical abortions to examine their reasons for choice. The reasons for choice given by the 262 women having medical abortions (Table 2) give us some insight into which issues they considered important when making the choice between medical and surgical abortions. This may be helpful when counseling women who are facing this choice. Since these abortions occur in the privacy of the women’s own homes, the level of emotional support they have at home is very important. Young women, especially those not informing their parents, often have less support, and this may be why more chose surgical abortions. Since women now often diagnose their pregnancies very early at home with pregnancy test kits, many have made their decision to abort before 5 weeks since their LMP. This is probably why so many listed the timing of the abortion as “very important.” In their written comments, many mentioned that it felt better emotionally to abort the pregnancy as early as possible. “Expected pain” was very important to 39.3% of women having medical abortions and 40.4% of women having surgical abortions. The mean worst pain scale rating of 6.3 compares unfavorably with the 4.3 previously reported in 220 women having surgical
chi-square = 8.44 p-value = 0.015 chi-square = 25.76 p-value = ~0.0001 chi-square = 15.13 p-value = 0.0005 chi-square = 2.19 p-value = 0.33 chi-square = 1.92 p-value = 0.38 chi-square = 5.73 p-value = 0.057 chi-square = 3.08 p-value = 0.21 chi-square = 33.58 p-value = ~0.0001 chi-square = 12.53 p-value = 0.0019
abortions in the same clinic using the same pain scale.‘* Fear of surgery and anesthetics was rated as “very important” by 44.7% of the women having medical abortions, and in the written and verbal comments it was obvious that for some women this fear was overwhelming and that they were very highly motivated to avoid surgery. The majority of women in the medical abortion group said they would choose this method again. This was despite the uncertainty of when or whether they would abort, the bleeding, and the pain. This method of abortion is highly desired by some women and, therefore, should be offered. In conclusion, when planning abortion services, we can expect at least one-quarter of eligible North American women given the option to choose medical abortions induced with methotrexate and misoprostol. We can expect most women having medical abortions to find this method highly acceptable. More research is needed to compare the experience of women having abortions induced with mifepristone and methotrexate and to look at how women in different settings choose between medical and surgical abortions.
Acknowledgments The Vancouver Foundation study and the Department
provided of Family
funding for this Practice helped
with planning the study. I thank the staff of Every-
woman’s Health Centre, my dedicated office staff, and Drs. Beata Byczko and Mollie Rawling for their help with this study. Dr. Jonathan Berkowitz provided statistical support.
Contraception 1997;55:67-71
References 1. Creinin MD, Damey PD. Methotrexate and misoprosto1 for early abortion. Contraception 1993;48:339-48. 2. Creinin MD. Methotrexate for abortion at ~42 days gestation. Contraception 1993j48:519-25. 3. Creinin MD, Vittinghoff E. Methotrexate and misoprostol vs misoprostol alone for early abortion. JAMA 1994j272:1190-5. 4, Creinin MD. Methotrexate and misoprostol for abortion at 57-63 days gestation. Contraception 1994j50: 511-5. 5. Hausknecht RU. Methotrexate and misoprostol to terminate early pregnancy. N Eng J Med 1995j333:337-40. 6. Schaff E, Eisinger SH, Franks P, Kim SS. Combined methotrexate and misoprostol for early induced abortion. Arch Fam Med 1995j4:774-9. 7. Creinin MD, Vittinghoff E, Galbraith S, Klaisle C. Methotrexate and misoprostol for early abortion: a randomized trial comparing misoprosto13 days and 7 days following methotrexate. Am J Obstet Gynecol 1995; 173:137-43. 8. Wiebe ER. Abortion induced with methotrexate and misoprostol. Can Med ASSOC J 1996;154:165-70. 9. Tang GWK. A pilot study of RU486 and ON0 802 in a Chinese population. Contraception 1991j44152332. 10. Schaff E, Eisinger SH, Franks P, Kim SS.Methotrexate and misoprostol for early abortion. Fam Med 1996j28: 196-99. 11. Schaff EA, Wortman M, Eisinger SH, Franks P. Methotrexate and misoprostol when surgical abortion fails. Obstet Gynecol 1996j87:450-2. 12. Tang GWK, Lau OWK, Yip P. Further acceptability
Choice of Medical or Surgical Abortion 71
evaluation of RU486 and ON0 802 as abortifacient agentsin a Chinese population. Contraception 1993j48: 267-76. 13. Bachelot A, Cludy L, Spira A. Conditions for choosing between drug-induced and surgical abortions. Contraception 1992j45:547-59. 14. Henshaw RC, Naji SA, Russell IT, Templeton AA. Comparison of medical abortion with surgical vacuum aspiration: women’s preferences and acceptability of treatment. Brit Med J 1993j307:714-7. 15. Henshaw RC, Naji SA, Russell IT, Templeton AA. A comparison of medical abortion (using mifepristone and gemeprost) with surgical vacuum aspiration: efficacy and early medical sequelae.Hum Reprod 1994j9: 2167-72. 16. Henshaw RC, Naji SA, Russell IT, Templeton AA. Psychological responsesfollowing medical abortion (using mifepristone and gemeprost)and surgical vacuum aspiration. Acta Obstet Gynecol Stand 1994j73:812-5. 17. Winikoff B. Acceptability of first trimester medical abortion. In: Baird DT, Grimes DA, Van Look PFA, eds. Modem methods of inducing abortion. London: Blackwell Science, 1995. 18. Wiebe ER. Comparison of the efficacy of different local anesthetics and techniques of local anesthesiain therapeutic abortions. Am J Obstet Gynecol 1992;167:131-4. 19. Wiebe ER, Rawling M. Pain control in abortion. Int J Gynecol Obstet 1995j50:41-6. 20. Wiebe ER. Abortion induced with methotrexate and misoprostol: A comparison of various protocols, in press.
Choosing Between Surgical Abortions and Medical Abortions Induced with Methotrexate and Misoprostol Ellen R. Wiebe Women phoning to request an abortion at a free-standing abortion clinic who were less than 46 days from the last menstrual period were given a choice between a surgical abortion and a medical abortion induced with methotrexate and misoprostol. Twenty-six percent (116 of 405 women) chose a medical abortion. Younger women were more likely to choose a surgical abortion. There were no other significant differences in the two groups in terms of gestational age, race, or prior pregnancies. The reasons most women listed as ‘very important” when making the decision to have a medical abortion were the timing (being able to have the abortion before 7 weeks), the privacy of aborting at home, and fear of surgery. The women who chose surgery gave the reasons of fear of experimental medications, the lack of emotional support at home, and wanting to avoid the extra visits and blood tests. 0 1997 Elsevier Science, Inc. All rights reserved. CONTRACEPTION 1997;55:67-71 KEY WORDS:
acceptance of surgical abortion, medical abor-
tion
Introduction edical abortions induced with methotrexate and misoprostol were first reported by Creinin and Darney in 1993.’ Subsequently, there have been more reports of this method and it has been found to be safe, effective, and acceptable to most women.2-10 Medical abortions induced with mifepristone (which is not available in North America), followed by a prostaglandin have become common in some European and Asian countries and there are several reports of how women chose between surgical and medical abortions in those settings.“-l6 Winikoff” has extensively reviewed the
M
Department of Family Practice, University of British Columbia, Vancouver, Canada Name and address for correspondence: Ellen R. Wiebe, M.D., Suite 1310-750 West Broadway, Vancouver, B.C. Canada V5Z lJ3. Tel: 604/873-8303: Fax: 6041873-8304 Submitted for publication May 21, 1996 Revised November 1, 1996 Accepted for publication November 4, 1996
0 1997 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
acceptability of medical abortions. She states, “Not only is medical abortion acceptable, but for some it is markedly preferable.” Information about how women choose between medical and surgical abortions is important to physicians planning abortion services. In 1991, Tang and colleagues’ reported on 42 Chinese women in Hong Kong who were offered a choice between surgical abortion and medical abortion induced with RU486 (mifepristone, an anti-progestin) and ON0 802 (a prostaglandin). In 1993,r2 they reported on a further 144 women; 67.7% chose medical abortions. In 1992, Bachelot and colleagues13 reported on 488 women in France who were offered a choice between surgical abortions with either local or general anesthesia and medical abortions induced with mifepristone and sulprostone (a prostaglandin); 62% chose medical abortions. The women who chose medical abortions were more likely to be younger, with higher educational and socio-professional levels and of “Western cultural background.” Henshaw and colleagues’4-‘6 reported on 363 women in Scotland who were offered surgical abortion or medical abortion induced with mifepristone and gemeprost (a prostaglandin). Of these, 20% chose medical abortions, 26% chose surgical abortions, and 54% agreed to be randomized to either medical or surgical abortions. There were no differences between the groups in terms of age, gestational age, or history of prior pregnancies. There have been no reported comparisons between abortions induced with mifepristone and those induced with methotrexate, and there are no reports of how women choose between medical and surgical abortions in North America. Not only is the North American setting different, but the experience of a medical abortion induced with methotrexate is different from one induced by mifepristone. The most important difference is that the mifepristone abortions
occurred in clinics,
while methotrexate
abortions
curred in the women’s own homes. Methotrexate
an anti-metabolite pristone, which
ocis
and works more slowly than mifeis an anti-progesterone.
The usual
ISSN OOlO-7824/97/$17.00 PI I SO01 O-7824(96)00274-0
68
Wiebe
Contraception 1997;55:67-71
protocols involve having the prostaglandin administered 48 h after mifepristone but 3-7 days after methotrexate. It is important that physicians planning to offer medical abortions induced with methotrexate and misoprostol know how many women are likely to choose this method and understand more about the choices they make.
Material
and Methods
Approval for this study was granted by the Clinical Screening Committee for Research Involving Human Subjects of the University of British Columbia. Women phoning to request an abortion at a free-standing abortion clinic were screened by the telephone staff and those less than 46 days from the last menstrual period (LMP) and who could understand a consent form were given a choice between a surgical abortion and a medical abortion. If they expressed interest in a medical abortion, they were referred to a nursecounselor who gave them detailed information including the need for at least three office visits and at least two blood tests, the approximately 10% possibility of requiring a surgical aspiration, and the fact that the abortion would occur later in the woman’s own home. The surgical abortions were performed at the clinic, but the women having medical abortions were seen at the investigator’s primary care office. Three groups of women were compared: women who had called the office directly and requested a medical abortion; women who had called the clinic first, were offered a choice and had medical abortions; and the women who called the clinic first, were offered a choice and chose surgical abortions. The women who were given a choice between medical and surgical abortions were tracked when they arrived at the clinic or the office. After the women had been given detailed information and signed the consent forms for the procedures, they were given self-administered questionnaires asking about the reasons they made their choice. They were also given a symptom log to fill in at home and hand in at the follow-up visit. On this, they charted their bleeding with a daily pad count, their pain using an 11 -point numeric pain scale (the same pain scale used in the investigator’s previous studies on pain control in surgical abortions’8r19) and other symptoms such as diarrhea. The surgical group were given self-addressed stamped envelopes and told to mail the log if they did not return to the clinic for follow-up. Demographic information was collected from the charts and compared. This survey was conducted between February 1 and August 15, 1995. During that time period, 1217 abortions were performed at the clinic that participated in
this survey, and a total of 5238 were performed in the two free-standing clinics and the two hospitals in the city (hospital and clinic records). There were no other medical abortions available. Surgical abortions were performed after 7 weeks from the LMP under local anesthesia at the clinic. Pre-operative lorazepam and ibuprofen were offered. The wait list at the clinic was approximately 2 weeks. The 352 women having medical abortions were part of a randomized controlled trial comparing two doses of misoprostol or a cohort study comparing two doses of methotrexate as described elsewhere.” They each received an injection of methotrexate 50 mg/m’ or 60 mg/m’ on Day 1 and then inserted 500 or 750 mcg of misoprostol on Days 4 or 5. A second dose of misoprostol was given on Day 8 if they had not aborted. The women were followed with serial HCGs. Two weeks after the abortion, women returned for a pelvic examination to ensure a non-tender, nonpregnant uterus and handed in their questionnaire. Statistical
Analysis
The three groups of women-medical abortions via office, medical abortions via clinic, and surgical abortions-were compared with respect to outcomes measures (pregnancy terminated vs. continuing, pain, days of bleeding, side effects) and demographic variables using one-way analysis of variance for interval data and chi-square tests of independence of categoric data. “Reasons for choice” variables were assessed using chi-square tests to compare the three groups with respect to the percentage rated “very important.” Where differences among the three groups were detected, follow-up pair-wise comparisons were performed. Analysis was carried out using SPSS statistical software.
Results There were 405 women who were offered a choice between medical and surgical abortions when they called the clinic; 116 had medical abortions and 149 had surgical abortions at the clinic. The other 140 women either continued their pregnancies or had surgical abortions at one of the other clinics or hospitals. There were also 236 women who requested medical abortions directly through the office. Therefore, during this time period, a total of 352 women had medical abortions. The success rate of the 352 medical abortions, i.e., the percentage who aborted without surgical aspiration, was 91.8%. The mean worst pain on the llpoint numeric pain scale was 6.27 (SD 2.951, and the mean total days of bleeding was 12.3 days (SD 5.5). Other side effects, including vomiting and diarrhea,
Choice of Medical or Surgical Abortion
Contraception 1997;55:67-71
occurred in 50.9%. 83.5% of all the women who had successful abortions and 80.4% of the 82 women who had had both surgical and medical abortions said they would choose medical abortion if faced with the same choice. Younger women were more likely to choose a surgical rather than a medical abortion (p-value 0.0049), but there were no significant differences among the three groups in terms of gestational age, previous pregnancies, or race (Table 1). When asked about the reasons for their choice, 80.9% of the women who had medical abortions rated the timing, i.e., that they could have the abortion before 7 weeks as “very important.” The expected privacy of aborting at home and the emotional support they had were rated as “very important” by 71.3 % and 61 .O%, respectively. Fear of surgery and anesthetics were rated as “very important” by 44.7%. Of the women who chose surgical abortion, 75.0% said that lack of emotional support at home was “very important,” 65.4% said the fear of experimental medications,. and 48.1% said the number of office visits and blood tests required for the medical abortions were “very important” (Table 2).
Discussion The main findings were that about one-third of women presenting for abortion were eligible for medical abortions (less than 46 days from LMP), and 28.6% of these chose medical abortions. In comparison, 69% of Tang’s Hong Kong Chinese women,9r’2 62% of Bachelot’s French women,13 and 20% of Henshaw’s Scottish women14-16 chose medical abortions. At the Table
1. Characteristics
time of this study, medical abortions were still offered only on research protocol and were not a widely accepted practice. If medical abortions become more accepted in North America, the percentage of women choosing medical abortions may rise. As the other authors have reported, it is not possible to predict which women will choose medical abortions on the basis of demographics. Tang and colleagues9f12 found that in their Hong Kong Chinese sample, single women were more likely to choose medical abortions, but it was too difficult to interpret marital status in this sample to make a similar comparison. An attempt to compare marital status, as Tang had done, was unsuccessful because women’s answers varied and were difficult to interpret; for example, “common-law,” “separated,” or “divorced,” and, unlike Tang’s subjects, many single women had children. Bachelot13 found that women of “Western cultural background” were more likely to choose medical abortions. The “non-Western” women in their sample would have been mostly North African and black African. In this study, approximately twothirds of the women were white Caucasian and onethird Asian (about 10% Chinese and about 10% East Indian) and there were no differences in how they chose between medical or surgical abortions. In this study younger women were more likely to opt for a surgical abortion, and this may be because they were less likely to have the necessary emotional support at home. The main difficulty with this survey was the low rate of valid questionnaire data, especially in the surgical group. Only 52 out of 149 women in the surgery
of women choosing between medical and surgical abortions
Maternal age in years (mean * SD) Gestational age in weeks (mean * SD) Gestational age at surgical procedure (mean * SD) Total pregnancies (mean f SD)
Medical Abortions Via Office
Medical Abortions Via Clinic
Surgical Abortions
27.3 (6.2)
27.8 (5.9)
25.6 (6.2)
5.8 (0.6)
5.7 (0.7)
5.8 (0.8)
F-stat = 5.45 p-value = 0.0049 F-stat = 2.56
p-value = 0.080 7.8 (0.9) 2.4 (1.4)
2.6 (1.5)
2.4 (1.7)
F-stat = 0.58 p-value
= 0.56
Previous births (mean + SD)
0.7 (1.0)
0.7 (0.9)
0.7 (1.0)
F-stat = 0.13 p-value = 0.88
Previous
0.6 (0.8)
0.7 (0.9)
0.5 (0.8)
F-stat = 1.19 p-value = 0.3 1
TAs (mean f SD)
Race Caucasian Chinese East Indian Other Total
69
159 24 27 26 236
(67.4) (10.2) (11.4) (Il.01
83 9 18 6 116
(71.6) (7.8) (15.5) j5.2)
109 14 18 6 149
(73.1) (9.4) (12.1) (5.4)
chi-square p-value
= 7.18 = 0.3 1
70
Wiebe
Contraception 1997:55:67-71
Table
2. Reasonsfor choosing between medical and surgical abortions-number (%] rated “very important”
Abortion site: home or clinic Abortion timing: before or after 7 wk Number of visits and blood tests Expected pain
MedicalAbortions Via Office
MedicalAbortions Via Clinic
Surgical Abortions
76 (44.4)
30 (33.0)
30 (57.7)
139(81.3)
69 (80.2)
24j46.2)
39(22.8)
19 (20.9)
25 (48.1)
70 (40.9)
29 (31.9)
21 (40.4)
Privacy
123(71.9)
58 (63.7)
35 (67.3)
Emotional support
103 (60.2)
50 (54.9)
39(75.0)
Fear of surgery or anesthetics Fear of experimental medications Other
76 (44.4)
38 (41.8)
16 (30.8)
39 (22.8)
27 (29.7)
34 (65.4)
10 (5.8)
2 (2.2)
9 (17.3)
Total
171
91
52
group handed in the first questionnaire asking about reasons for choice, and 23 mailed in the second questionnaire about symptoms and preference. Of the 352 women having medical abortions, 262 handed in the choice questionnaire and 299 the symptoms and preference questionnaire. Therefore, a comparison between the surgical and medical groups with respect to reasons for choice, symptoms, and preference is impossible. There is, however, enough information from the women who had medical abortions to examine their reasons for choice. The reasons for choice given by the 262 women having medical abortions (Table 2) give us some insight into which issues they considered important when making the choice between medical and surgical abortions. This may be helpful when counseling women who are facing this choice. Since these abortions occur in the privacy of the women’s own homes, the level of emotional support they have at home is very important. Young women, especially those not informing their parents, often have less support, and this may be why more chose surgical abortions. Since women now often diagnose their pregnancies very early at home with pregnancy test kits, many have made their decision to abort before 5 weeks since their LMP. This is probably why so many listed the timing of the abortion as “very important.” In their written comments, many mentioned that it felt better emotionally to abort the pregnancy as early as possible. “Expected pain” was very important to 39.3% of women having medical abortions and 40.4% of women having surgical abortions. The mean worst pain scale rating of 6.3 compares unfavorably with the 4.3 previously reported in 220 women having surgical
chi-square = 8.44 p-value = 0.015 chi-square = 25.76 p-value = ~0.0001 chi-square = 15.13 p-value = 0.0005 chi-square = 2.19 p-value = 0.33 chi-square = 1.92 p-value = 0.38 chi-square = 5.73 p-value = 0.057 chi-square = 3.08 p-value = 0.21 chi-square = 33.58 p-value = ~0.0001 chi-square = 12.53 p-value = 0.0019
abortions in the same clinic using the same pain scale.‘* Fear of surgery and anesthetics was rated as “very important” by 44.7% of the women having medical abortions, and in the written and verbal comments it was obvious that for some women this fear was overwhelming and that they were very highly motivated to avoid surgery. The majority of women in the medical abortion group said they would choose this method again. This was despite the uncertainty of when or whether they would abort, the bleeding, and the pain. This method of abortion is highly desired by some women and, therefore, should be offered. In conclusion, when planning abortion services, we can expect at least one-quarter of eligible North American women given the option to choose medical abortions induced with methotrexate and misoprostol. We can expect most women having medical abortions to find this method highly acceptable. More research is needed to compare the experience of women having abortions induced with mifepristone and methotrexate and to look at how women in different settings choose between medical and surgical abortions.
Acknowledgments The Vancouver Foundation study and the Department
provided of Family
funding for this Practice helped
with planning the study. I thank the staff of Every-
woman’s Health Centre, my dedicated office staff, and Drs. Beata Byczko and Mollie Rawling for their help with this study. Dr. Jonathan Berkowitz provided statistical support.
Contraception 1997;55:67-71
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Choice of Medical or Surgical Abortion 71
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