- Email: [email protected]
Physicians' approaches to post-abortion care in Manila, Philippines
International Journal of Gynecology and Obstetrics 109 (2010) 216–218
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Physicians' approaches to post-abortion care in Manila, Philippines Catherine Cansino a,⁎, Junice Lirza Melgar b, Anne Burke a a b
Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA Likhaan, Quezon City, Philippines
a r t i c l e
i n f o
Article history: Received 28 September 2009 Received in revised form 13 December 2009 Accepted 21 January 2010 Keywords: Induced abortion Manual vacuum aspiration Misoprostol Philippines Post-abortion care Sharp curettage
a b s t r a c t Objective: To assess the knowledge and practice of health professionals in Manila, Philippines, regarding methods used for uterine evacuation in post-abortion care (PAC), including the use of misoprostol. Methods: A purposive sample of physicians providing PAC services completed questionnaires anonymously about PAC practices. Results: Among 45 survey respondents, the primary methods used for first-trimester uterine evacuation in PAC included sharp curettage (n = 45, 100%) and manual vacuum aspiration (MVA; n = 38, 84.4%), which was consistent with their preferences. Misoprostol was prescribed for first-trimester postabortion uterine evacuation by 55.6% (n = 25) of respondents; dosing regimens ranged from 50 to 200 µg as a single dose or repeated every 4–24 hours. Of the respondents, 91.1% (n = 41) prescribed misoprostol for obstetric indications, including labor induction and postpartum hemorrhage. Conclusions: Most respondents used sharp curettage and MVA for first-trimester post-abortion uterine evacuation, and did not express a clear preference for either method. Despite the unregistered status of misoprostol, it was used in obstetrics and PAC by a majority of study respondents. The doses of misoprostol used for post-abortion uterine evacuation are lower than those recommended by evidence-based studies. The results indicate the need to disseminate evidence-based information about safe and effective use of MVA and misoprostol for PAC to physicians in Manila, Philippines. Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction On the basis of indirect estimates, 3.4 million pregnancies occur annually in the Philippines [1]. These pregnancies result in induced abortion (17%, approximately 578 000 per year), unwanted birth (14%), mistimed birth (16%), and spontaneous abortion and planned birth (combined 53%) [1,2]. Owing to the legal restrictions on abortion and the availability of unsafe abortion practices, two-thirds of Filipino women who attempt an induced abortion experience complications [1,2]. In 2008, approximately 90 000 hospitalizations and 1000 deaths occurred secondary to complications from induced abortion [1]. Recognizing the individual and public health impact of complications due to spontaneous and induced abortions, the Department of Health issued the Prevention and Management of Abortion and its Complications (PMAC) policy in May 2000 [3]. The policy stipulated “quality and humane post-abortion care services by competent, compassionate, objective and non-judgmental service providers in a wellequipped institution, complemented by a supportive environment” [3]. The policy was initiated at 8 pilot hospitals in Greater Metro Manila, the region with the highest abortion rate in the country (52 per 1000 women aged 15–44 years) [2]. In the pilot program, over 100 physicians
⁎ Corresponding author. 6100 4th St NW, no. 301, Albuquerque, New Mexico 87107, USA. Tel.: +1 443 465 9340. E-mail address: [email protected] (C. Cansino).
were trained in the clinical course (family planning curriculum and manual vacuum aspiration skills training) and 428 staff members were trained in counseling (E. Bautista, personal communication, January 2008). These programs reviewed clinical algorithms for the treatment of post-abortion complications, including use of manual vacuum aspiration, emphasizing “humane” and “compassionate” treatment of patients. PMAC training and services expanded to 18 hospitals in 2003 (E. Bautista, personal communication, January 2008). Limited documentation is available to review implementation of the PMAC policy and to assess its impact on rates of post-abortion complications and changes in the quality of post-abortion care (PAC) services. Despite inclusion in the World Health Organization Model List of Essential Medicines [4], misoprostol is considered an “unregistered drug product” by the Philippine Bureau of Food and Drugs (BFAD). This product status means that the distribution, sale, and use of misoprostol are reportable to BFAD and police authorities. This aim of the present study was to assess the knowledge and practice of health professionals regarding methods used for uterine evacuation in PAC, including the use of misoprostol. 2. Materials and methods The highly sensitive nature of abortion in the Philippines limited our ability to recruit a representative sample of the study population. Therefore, we conducted a descriptive study with purposive sampling to study PAC services in this prohibitive setting. A purposive sample
0020-7292/$ – see front matter. Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. doi:10.1016/j.ijgo.2010.01.005
C. Cansino et al. / International Journal of Gynecology and Obstetrics 109 (2010) 216–218
analyses were performed using Stata Statistical Software version 9.0 (Stata Corp, College Station, TX, USA).
Table 1 Sociodemographic characteristics of post-abortion care providers. Characteristics Age, y ≤35 35–50 ≥51 Sex Male Female Institutional affiliation Public Private University-affiliated Professional experience, y ≤5 6–10 11–20 ≥21 Type of current practice Obstetrics Gynecology Family planning Post-abortion care services
217
No. (%) (n = 45)
3. Results 26 (57.8) 15 (33.3) 4 (8.9) 2 (4.4) 43 (95.6) 36 (80.0) 5 (11.1) 4 (8.9) 26 (57.8) 7 (15.6) 6 (13.3) 6 (13.3) 44 41 40 42
(97.8) (91.1) (88.9) (93.3)
was obtained using the snowball technique to identify potential participants. The snowball technique identifies a core group of study participants, and those who participate are asked to refer other potential study participants. The technique has been implemented successfully to investigate the off-label use of misoprostol for reproductive health indications [5]. The snowball technique facilitated study participation among a group of trusted and well-respected health professionals, enabling us to build trust among those they referred, and thereby encouraging their participation. In January 2008, we recruited potential participants beginning with a core of 4 physicians identified from a group of providers who had undergone clinical training in PMAC in the initial pilot program and who continued to provide PAC services in Greater Metro Manila. These physicians were then asked to provide referrals of other PAC providers who might be willing to participate. We aimed to recruit as many participants as possible during a 2-month recruitment period. The core group of physicians and the referred physicians completed self-administered written anonymous questionnaires regarding their PAC practices. The questionnaire was developed by the authors to document therapeutic regimens used in PAC, including misoprostol dosing regimens. Study participation and responses were kept confidential. Study participation ended upon completion of the questionnaire. Our study was approved by the Johns Hopkins Medicine Institutional Review Board and the Philippine National Ethics Committee. The sociodemographic profile of study participants was analyzed using descriptive statistics (χ2 for categorical data). Statistical
Forty-five obstetrician–gynecologists from Greater Metro Manila, Philippines, completed the self-administered anonymous, written questionnaires between January and February 2008. Table 1 shows the sociodemographic characteristics of the study participants. The majority of respondents were young (≤35 years old) and female. They worked in a public hospital and had fewer than 5 years of professional experience. They also provided a wide range of services including obstetrics, gynecology, and family planning. Among physicians surveyed, 93.3% reported that they provided PAC services. Respondents performed first-trimester uterine evacuation using sharp curettage (n= 45, 100%), manual vacuum aspiration (MVA; n = 38, 84.4%), electric vacuum aspiration (n= 16, 35.6%), and prostaglandins (n= 27, 60.0%) (Fig. 1). Commonly reported pain regimens for surgical intervention included ibuprofen, nalbuphine, promethazine, diazepam, and midazolam. A total of 6.8% of respondents reported that they performed surgical uterine curettage without analgesia. When asked to state which methods they preferred to use for postabortion uterine evacuation, most respondents reported preferences for sharp curettage and MVA (Fig. 1). Many respondents reported more than 1 preference. The participants who reported previous formal training in MVA were more likely to report use (97.1% [n= 33] vs 45.4% [n= 5], P b 0.001) and preference (79.4% [n= 27] vs 45.4% [n= 5], P b 0.05) for this method compared with participants who did not report formal MVA training. Although 80% (n= 36) of MVA users primarily used the device for treatment of incomplete abortion, other reported uses included evacuation of blighted ovum, missed abortion, septic abortion, molar pregnancy, retained products of conception, and endometrial biopsy. A total of 83.0% (n= 25) of respondents who reported using medications for first-trimester post-abortion uterine evacuation prescribed misoprostol, representing 55.6% of all respondents. Dosing regimens ranged from 50 to 200 µg, prescribed as a single dose or repeated every 4–24 hours. Misoprostol tablets were administered orally, rectally, or vaginally. Forty-one (91.1%) of all respondents and 24 (96.0%) of the respondents who reported using misoprostol for first trimester uterine evacuation said they also used misoprostol for obstetric indications. Prescribed doses for labor induction ranged from 50 to 200 µg every 4–8 hours, primarily administered vaginally. Prescribed doses for prevention or treatment of postpartum hemorrhage ranged from 200 to 800 µg as a single dose or repeated every 6–12 hours, primarily administered rectally or vaginally. In addition to misoprostol, other medications used for uterine evacuation included methylergonovine, oxytocin, hyoscine butylbromide (an antispasmodic agent that blocks acetylcholine at parasympathetic sites in smooth muscle), and evening primrose oil (a natural herb rich in omega-6 fatty acids).
Fig. 1. Proportion of the 45 respondents who used and preferred each method of first trimester uterine evacuation. Abbreviations: MVA, manual vacuum evacuation; EVA, electric vacuum aspiration; PGs, prostaglandins.
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C. Cansino et al. / International Journal of Gynecology and Obstetrics 109 (2010) 216–218
4. Discussion In response to the high rates of complications resulting from induced and spontaneous abortions in the Philippines, the federal government adopted the PMAC policy and offered guidance to healthcare professionals on the provision of PAC services. The present study assessed the impact of this guidance. Despite greater pain [6] and the higher rates of complications [7] associated with sharp curettage, most physicians surveyed in the present study reported the use of and preference for this procedure in first-trimester uterine evacuation. Fewer respondents reported use of MVA or electric vacuum aspiration. Formal training in the use of MVA and, presumably, recent increased availability were significantly associated with higher reported MVA use and preference. The comparatively low reported use of electric vacuum aspiration may be due to prohibitive logistical issues including financial costs, availability of electricity, and waiting time for the operating room. Many respondents identified more than 1 preferred method for post-abortion uterine evacuation. This finding may indicate that clinicians were comfortable performing the procedure using more than 1 method, including the use of MVA after formal training. Hence, access to medical resources, such as the availability of MVA supplies, may be the limiting factor concerning which method is used. Our study also identified a small percentage of respondents who reported using no analgesia during surgical uterine evacuation, with sharp curettage, MVA, or electric vacuum aspiration. It is not clear from our study whether this was related to patient choice, lack of availability of medications, prohibitive costs, or other reasons. However, Singh et al. [2] reported that women who received PAC services mentioned that analgesics and anesthesia were withheld by “disapproving doctors and nurses.” Despite the unregistered status of misoprostol, many respondents reported using the medication for obstetric indications and PAC services. The low preference for use of misoprostol in first-trimester uterine evacuation may be related to the BFAD advisory on the drug, lack of availability of clear guidelines for use, or possibly to perception of low effectiveness, which in turn may be a consequence of lack of experience with the drug. Respondents who reported misoprostol use for first-trimester uterine evacuation prescribed 50 to 200 µg of misoprostol, either as a single dose or repeated every 4–24 hours. Current evidence-based recommendations for first-trimester uterine evacuation stipulate 600 µg of oral misoprostol for incomplete abortion and 800 µg of vaginal misoprostol for missed abortion [8]; these recommendations differ from the regimens used by our respondents in practice. Similarly, our study identified use of various misoprostol dosing regimens for obstetric indications. Respondents reported that they prescribed misoprostol for labor induction and used doses that ranged from 50 to 200 µg every 4–8 hours, primarily administered vaginally. Prescribed doses for prevention or treatment of postpartum hemorrhage ranged from 200 to 800 µg as a single dose or repeated every 6–12 hours, primarily administered rectally or vaginally. The doses reported by respondents differ substantially from the evidence-based regimens recommended for term labor induction (vaginal misoprostol 25 µg every 3 to 6 hours) [9,10] and for treatment of postpartum hemorrhage (800–1000 µg rectally) [11–13]. The main strength of our study is the documentation of knowledge and practice about PAC services, which is a sensitive and little-studied topic in the Philippines. We also identified incorrect use of medications, including misoprostol, for PAC. A further strength is that the study focused on clinicians trained in PMAC and, as such, provides some insight into the effect that training has had on the perceptions about use of MVA specifically and PAC in general. We also consider that the confidential environment in which the survey was completed fostered the provision of honest responses.
Despite the strategic study design, our investigation is restricted by the small sample size and non-random sampling. In addition, our targeted study cohort in Greater Metro Manila does not represent physicians practicing outside this region. Findings do not provide detailed information about the full spectrum of post-abortion management including infection prevention and treatment, family planning, provision of humanistic care, and details of complications encountered by the respondents. Because of the sensitive nature of our study objectives, study participants may have been reluctant to refer other potential participants. Among those who participated, reporting bias may have influenced their responses. Respondents who did not trust the confidentiality of their participation may not have provided accurate responses. The present study provides important information on the impact of the PMAC policy on physicians' knowledge and scope of clinical practice in post-abortion care. Availability of formal training in use of MVA and high rates of MVA use and preference for this method among study respondents are consistent with World Health Organization recommendations, which call for a shift of practice from sharp curettage to vacuum aspiration [14] to address the universal problem of unsafe abortion. Because our study focused on physicians trained in PMAC, the reportedly high use of sharp curettage and lack of analgesia use among a small percentage of study respondents probably underestimate the negative impact of such practices. Dissemination of evidence-based information about post-abortion management, including MVA and misoprostol use, in line with current legislative and medical policies, would help many physicians who provide PAC services. Such information will improve the health of women as adoption of the PMAC policy reaches younger generations of physicians and those working outside Greater Metro Manila. Conflict of interest The authors have no conflict of interest to report. References [1] Darroch JE, Singh S, Ball H, Guttmacher Institute, Cabigon JV, University of the Philippines Population Institute. Meeting women's contraceptive needs in the Philippines, in brief, vol. 1. New York: Guttmacher Institute; 2009. [2] Singh S, Juarez F, Cabigon J, Ball H, Hussain R, Nadeau J. Unintended Pregnancy and Induced Abortion in the Philippines: Causes and Consequences. New York: Guttmacher Institute; 2006. [3] Romualdez Jr A. Prevention and management of abortion and its complications (PMAC) policy. Manila: Office of the Secretary, Republic of the Philippines Department of Health; 2000. [4] World Health Organization. WHO model list of essential medicines. 16th ed. Geneva: WHO; 2009. [5] Clark S, Blum J, Blanchard K, Galvao L, Fletcher H, Winikoff B. Misoprostol use in obstetrics and gynecology in Brazil, Jamaica, and the United States. Int J Gynecol Obstet 2002;76(1):65–74. [6] Grimes D, Schulz KF, Cates W, Tyler CW. The joint program for the study of abortion/ CDC – a preliminary report. In: Hern W, Andrikipolous B, editors. Abortion in the Seventies. New York: National Abortion Federation; 1977. p. 41–6. [7] Cates W, Grimes DA, Schulz KF. Abortion surveillance at CDC: creating public health light out of political heat. Am J Prev Med 2000;19(Supp 1):12–7. [8] Consensus Statement: Instructions for Use – Misoprostol for Treatment of Incomplete Abortion and Miscarriage. Expert Meeting on Misoprostol sponsored by Reproductive Health Technologies Project and Gynuity Health Projects. June 9, 2004. New York. [9] Wing DA, Rahall A, Jones MM, Goodwin TM, Paul RH. Misoprostol: an effective agent for cervical ripening and labor induction. Am J Obstet Gynecol 1995;172(6):1811–6. [10] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Induction of Labor; 1999. [11] Dildy GA, Clark SL. Postpartum hemorrhage. Contemp Obstet Gynecol 1993;38(8): 21–9. [12] Nasr A, Shahin AY, Elsamman AM, Zakherah MS, Shaaban OM. Rectal misoprostol versus intravenous oxytocin for prevention of postpartum hemorrhage. Int J Gynecol Obstet 2009;105(3):244–7. [13] ACOG Practice Bulletin. Clinical Management Guidelines for ObstetriciansGynecologists Number 76; postpartum hemorrhage. Obstet Gynecol 2006;108(4): 1039–47. [14] World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva: WHO; 2003. p. 33.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Physicians' approaches to post-abortion care in Manila, Philippines Catherine Cansino a,⁎, Junice Lirza Melgar b, Anne Burke a a b
Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA Likhaan, Quezon City, Philippines
a r t i c l e
i n f o
Article history: Received 28 September 2009 Received in revised form 13 December 2009 Accepted 21 January 2010 Keywords: Induced abortion Manual vacuum aspiration Misoprostol Philippines Post-abortion care Sharp curettage
a b s t r a c t Objective: To assess the knowledge and practice of health professionals in Manila, Philippines, regarding methods used for uterine evacuation in post-abortion care (PAC), including the use of misoprostol. Methods: A purposive sample of physicians providing PAC services completed questionnaires anonymously about PAC practices. Results: Among 45 survey respondents, the primary methods used for first-trimester uterine evacuation in PAC included sharp curettage (n = 45, 100%) and manual vacuum aspiration (MVA; n = 38, 84.4%), which was consistent with their preferences. Misoprostol was prescribed for first-trimester postabortion uterine evacuation by 55.6% (n = 25) of respondents; dosing regimens ranged from 50 to 200 µg as a single dose or repeated every 4–24 hours. Of the respondents, 91.1% (n = 41) prescribed misoprostol for obstetric indications, including labor induction and postpartum hemorrhage. Conclusions: Most respondents used sharp curettage and MVA for first-trimester post-abortion uterine evacuation, and did not express a clear preference for either method. Despite the unregistered status of misoprostol, it was used in obstetrics and PAC by a majority of study respondents. The doses of misoprostol used for post-abortion uterine evacuation are lower than those recommended by evidence-based studies. The results indicate the need to disseminate evidence-based information about safe and effective use of MVA and misoprostol for PAC to physicians in Manila, Philippines. Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction On the basis of indirect estimates, 3.4 million pregnancies occur annually in the Philippines [1]. These pregnancies result in induced abortion (17%, approximately 578 000 per year), unwanted birth (14%), mistimed birth (16%), and spontaneous abortion and planned birth (combined 53%) [1,2]. Owing to the legal restrictions on abortion and the availability of unsafe abortion practices, two-thirds of Filipino women who attempt an induced abortion experience complications [1,2]. In 2008, approximately 90 000 hospitalizations and 1000 deaths occurred secondary to complications from induced abortion [1]. Recognizing the individual and public health impact of complications due to spontaneous and induced abortions, the Department of Health issued the Prevention and Management of Abortion and its Complications (PMAC) policy in May 2000 [3]. The policy stipulated “quality and humane post-abortion care services by competent, compassionate, objective and non-judgmental service providers in a wellequipped institution, complemented by a supportive environment” [3]. The policy was initiated at 8 pilot hospitals in Greater Metro Manila, the region with the highest abortion rate in the country (52 per 1000 women aged 15–44 years) [2]. In the pilot program, over 100 physicians
⁎ Corresponding author. 6100 4th St NW, no. 301, Albuquerque, New Mexico 87107, USA. Tel.: +1 443 465 9340. E-mail address: [email protected] (C. Cansino).
were trained in the clinical course (family planning curriculum and manual vacuum aspiration skills training) and 428 staff members were trained in counseling (E. Bautista, personal communication, January 2008). These programs reviewed clinical algorithms for the treatment of post-abortion complications, including use of manual vacuum aspiration, emphasizing “humane” and “compassionate” treatment of patients. PMAC training and services expanded to 18 hospitals in 2003 (E. Bautista, personal communication, January 2008). Limited documentation is available to review implementation of the PMAC policy and to assess its impact on rates of post-abortion complications and changes in the quality of post-abortion care (PAC) services. Despite inclusion in the World Health Organization Model List of Essential Medicines [4], misoprostol is considered an “unregistered drug product” by the Philippine Bureau of Food and Drugs (BFAD). This product status means that the distribution, sale, and use of misoprostol are reportable to BFAD and police authorities. This aim of the present study was to assess the knowledge and practice of health professionals regarding methods used for uterine evacuation in PAC, including the use of misoprostol. 2. Materials and methods The highly sensitive nature of abortion in the Philippines limited our ability to recruit a representative sample of the study population. Therefore, we conducted a descriptive study with purposive sampling to study PAC services in this prohibitive setting. A purposive sample
0020-7292/$ – see front matter. Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. doi:10.1016/j.ijgo.2010.01.005
C. Cansino et al. / International Journal of Gynecology and Obstetrics 109 (2010) 216–218
analyses were performed using Stata Statistical Software version 9.0 (Stata Corp, College Station, TX, USA).
Table 1 Sociodemographic characteristics of post-abortion care providers. Characteristics Age, y ≤35 35–50 ≥51 Sex Male Female Institutional affiliation Public Private University-affiliated Professional experience, y ≤5 6–10 11–20 ≥21 Type of current practice Obstetrics Gynecology Family planning Post-abortion care services
217
No. (%) (n = 45)
3. Results 26 (57.8) 15 (33.3) 4 (8.9) 2 (4.4) 43 (95.6) 36 (80.0) 5 (11.1) 4 (8.9) 26 (57.8) 7 (15.6) 6 (13.3) 6 (13.3) 44 41 40 42
(97.8) (91.1) (88.9) (93.3)
was obtained using the snowball technique to identify potential participants. The snowball technique identifies a core group of study participants, and those who participate are asked to refer other potential study participants. The technique has been implemented successfully to investigate the off-label use of misoprostol for reproductive health indications [5]. The snowball technique facilitated study participation among a group of trusted and well-respected health professionals, enabling us to build trust among those they referred, and thereby encouraging their participation. In January 2008, we recruited potential participants beginning with a core of 4 physicians identified from a group of providers who had undergone clinical training in PMAC in the initial pilot program and who continued to provide PAC services in Greater Metro Manila. These physicians were then asked to provide referrals of other PAC providers who might be willing to participate. We aimed to recruit as many participants as possible during a 2-month recruitment period. The core group of physicians and the referred physicians completed self-administered written anonymous questionnaires regarding their PAC practices. The questionnaire was developed by the authors to document therapeutic regimens used in PAC, including misoprostol dosing regimens. Study participation and responses were kept confidential. Study participation ended upon completion of the questionnaire. Our study was approved by the Johns Hopkins Medicine Institutional Review Board and the Philippine National Ethics Committee. The sociodemographic profile of study participants was analyzed using descriptive statistics (χ2 for categorical data). Statistical
Forty-five obstetrician–gynecologists from Greater Metro Manila, Philippines, completed the self-administered anonymous, written questionnaires between January and February 2008. Table 1 shows the sociodemographic characteristics of the study participants. The majority of respondents were young (≤35 years old) and female. They worked in a public hospital and had fewer than 5 years of professional experience. They also provided a wide range of services including obstetrics, gynecology, and family planning. Among physicians surveyed, 93.3% reported that they provided PAC services. Respondents performed first-trimester uterine evacuation using sharp curettage (n= 45, 100%), manual vacuum aspiration (MVA; n = 38, 84.4%), electric vacuum aspiration (n= 16, 35.6%), and prostaglandins (n= 27, 60.0%) (Fig. 1). Commonly reported pain regimens for surgical intervention included ibuprofen, nalbuphine, promethazine, diazepam, and midazolam. A total of 6.8% of respondents reported that they performed surgical uterine curettage without analgesia. When asked to state which methods they preferred to use for postabortion uterine evacuation, most respondents reported preferences for sharp curettage and MVA (Fig. 1). Many respondents reported more than 1 preference. The participants who reported previous formal training in MVA were more likely to report use (97.1% [n= 33] vs 45.4% [n= 5], P b 0.001) and preference (79.4% [n= 27] vs 45.4% [n= 5], P b 0.05) for this method compared with participants who did not report formal MVA training. Although 80% (n= 36) of MVA users primarily used the device for treatment of incomplete abortion, other reported uses included evacuation of blighted ovum, missed abortion, septic abortion, molar pregnancy, retained products of conception, and endometrial biopsy. A total of 83.0% (n= 25) of respondents who reported using medications for first-trimester post-abortion uterine evacuation prescribed misoprostol, representing 55.6% of all respondents. Dosing regimens ranged from 50 to 200 µg, prescribed as a single dose or repeated every 4–24 hours. Misoprostol tablets were administered orally, rectally, or vaginally. Forty-one (91.1%) of all respondents and 24 (96.0%) of the respondents who reported using misoprostol for first trimester uterine evacuation said they also used misoprostol for obstetric indications. Prescribed doses for labor induction ranged from 50 to 200 µg every 4–8 hours, primarily administered vaginally. Prescribed doses for prevention or treatment of postpartum hemorrhage ranged from 200 to 800 µg as a single dose or repeated every 6–12 hours, primarily administered rectally or vaginally. In addition to misoprostol, other medications used for uterine evacuation included methylergonovine, oxytocin, hyoscine butylbromide (an antispasmodic agent that blocks acetylcholine at parasympathetic sites in smooth muscle), and evening primrose oil (a natural herb rich in omega-6 fatty acids).
Fig. 1. Proportion of the 45 respondents who used and preferred each method of first trimester uterine evacuation. Abbreviations: MVA, manual vacuum evacuation; EVA, electric vacuum aspiration; PGs, prostaglandins.
218
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4. Discussion In response to the high rates of complications resulting from induced and spontaneous abortions in the Philippines, the federal government adopted the PMAC policy and offered guidance to healthcare professionals on the provision of PAC services. The present study assessed the impact of this guidance. Despite greater pain [6] and the higher rates of complications [7] associated with sharp curettage, most physicians surveyed in the present study reported the use of and preference for this procedure in first-trimester uterine evacuation. Fewer respondents reported use of MVA or electric vacuum aspiration. Formal training in the use of MVA and, presumably, recent increased availability were significantly associated with higher reported MVA use and preference. The comparatively low reported use of electric vacuum aspiration may be due to prohibitive logistical issues including financial costs, availability of electricity, and waiting time for the operating room. Many respondents identified more than 1 preferred method for post-abortion uterine evacuation. This finding may indicate that clinicians were comfortable performing the procedure using more than 1 method, including the use of MVA after formal training. Hence, access to medical resources, such as the availability of MVA supplies, may be the limiting factor concerning which method is used. Our study also identified a small percentage of respondents who reported using no analgesia during surgical uterine evacuation, with sharp curettage, MVA, or electric vacuum aspiration. It is not clear from our study whether this was related to patient choice, lack of availability of medications, prohibitive costs, or other reasons. However, Singh et al. [2] reported that women who received PAC services mentioned that analgesics and anesthesia were withheld by “disapproving doctors and nurses.” Despite the unregistered status of misoprostol, many respondents reported using the medication for obstetric indications and PAC services. The low preference for use of misoprostol in first-trimester uterine evacuation may be related to the BFAD advisory on the drug, lack of availability of clear guidelines for use, or possibly to perception of low effectiveness, which in turn may be a consequence of lack of experience with the drug. Respondents who reported misoprostol use for first-trimester uterine evacuation prescribed 50 to 200 µg of misoprostol, either as a single dose or repeated every 4–24 hours. Current evidence-based recommendations for first-trimester uterine evacuation stipulate 600 µg of oral misoprostol for incomplete abortion and 800 µg of vaginal misoprostol for missed abortion [8]; these recommendations differ from the regimens used by our respondents in practice. Similarly, our study identified use of various misoprostol dosing regimens for obstetric indications. Respondents reported that they prescribed misoprostol for labor induction and used doses that ranged from 50 to 200 µg every 4–8 hours, primarily administered vaginally. Prescribed doses for prevention or treatment of postpartum hemorrhage ranged from 200 to 800 µg as a single dose or repeated every 6–12 hours, primarily administered rectally or vaginally. The doses reported by respondents differ substantially from the evidence-based regimens recommended for term labor induction (vaginal misoprostol 25 µg every 3 to 6 hours) [9,10] and for treatment of postpartum hemorrhage (800–1000 µg rectally) [11–13]. The main strength of our study is the documentation of knowledge and practice about PAC services, which is a sensitive and little-studied topic in the Philippines. We also identified incorrect use of medications, including misoprostol, for PAC. A further strength is that the study focused on clinicians trained in PMAC and, as such, provides some insight into the effect that training has had on the perceptions about use of MVA specifically and PAC in general. We also consider that the confidential environment in which the survey was completed fostered the provision of honest responses.
Despite the strategic study design, our investigation is restricted by the small sample size and non-random sampling. In addition, our targeted study cohort in Greater Metro Manila does not represent physicians practicing outside this region. Findings do not provide detailed information about the full spectrum of post-abortion management including infection prevention and treatment, family planning, provision of humanistic care, and details of complications encountered by the respondents. Because of the sensitive nature of our study objectives, study participants may have been reluctant to refer other potential participants. Among those who participated, reporting bias may have influenced their responses. Respondents who did not trust the confidentiality of their participation may not have provided accurate responses. The present study provides important information on the impact of the PMAC policy on physicians' knowledge and scope of clinical practice in post-abortion care. Availability of formal training in use of MVA and high rates of MVA use and preference for this method among study respondents are consistent with World Health Organization recommendations, which call for a shift of practice from sharp curettage to vacuum aspiration [14] to address the universal problem of unsafe abortion. Because our study focused on physicians trained in PMAC, the reportedly high use of sharp curettage and lack of analgesia use among a small percentage of study respondents probably underestimate the negative impact of such practices. Dissemination of evidence-based information about post-abortion management, including MVA and misoprostol use, in line with current legislative and medical policies, would help many physicians who provide PAC services. Such information will improve the health of women as adoption of the PMAC policy reaches younger generations of physicians and those working outside Greater Metro Manila. Conflict of interest The authors have no conflict of interest to report. References [1] Darroch JE, Singh S, Ball H, Guttmacher Institute, Cabigon JV, University of the Philippines Population Institute. Meeting women's contraceptive needs in the Philippines, in brief, vol. 1. New York: Guttmacher Institute; 2009. [2] Singh S, Juarez F, Cabigon J, Ball H, Hussain R, Nadeau J. Unintended Pregnancy and Induced Abortion in the Philippines: Causes and Consequences. New York: Guttmacher Institute; 2006. [3] Romualdez Jr A. Prevention and management of abortion and its complications (PMAC) policy. Manila: Office of the Secretary, Republic of the Philippines Department of Health; 2000. [4] World Health Organization. WHO model list of essential medicines. 16th ed. Geneva: WHO; 2009. [5] Clark S, Blum J, Blanchard K, Galvao L, Fletcher H, Winikoff B. Misoprostol use in obstetrics and gynecology in Brazil, Jamaica, and the United States. Int J Gynecol Obstet 2002;76(1):65–74. [6] Grimes D, Schulz KF, Cates W, Tyler CW. The joint program for the study of abortion/ CDC – a preliminary report. In: Hern W, Andrikipolous B, editors. Abortion in the Seventies. New York: National Abortion Federation; 1977. p. 41–6. [7] Cates W, Grimes DA, Schulz KF. Abortion surveillance at CDC: creating public health light out of political heat. Am J Prev Med 2000;19(Supp 1):12–7. [8] Consensus Statement: Instructions for Use – Misoprostol for Treatment of Incomplete Abortion and Miscarriage. Expert Meeting on Misoprostol sponsored by Reproductive Health Technologies Project and Gynuity Health Projects. June 9, 2004. New York. [9] Wing DA, Rahall A, Jones MM, Goodwin TM, Paul RH. Misoprostol: an effective agent for cervical ripening and labor induction. Am J Obstet Gynecol 1995;172(6):1811–6. [10] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Induction of Labor; 1999. [11] Dildy GA, Clark SL. Postpartum hemorrhage. Contemp Obstet Gynecol 1993;38(8): 21–9. [12] Nasr A, Shahin AY, Elsamman AM, Zakherah MS, Shaaban OM. Rectal misoprostol versus intravenous oxytocin for prevention of postpartum hemorrhage. Int J Gynecol Obstet 2009;105(3):244–7. [13] ACOG Practice Bulletin. Clinical Management Guidelines for ObstetriciansGynecologists Number 76; postpartum hemorrhage. Obstet Gynecol 2006;108(4): 1039–47. [14] World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva: WHO; 2003. p. 33.