title: Clinical Outcomes and Women's Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa.
abstract: OBJECTIVE
  To document clinical outcomes and women's experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only.
  
  
  METHODS
  Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2-4 weeks after discharge for the 2014 cohort.
  
  
  RESULTS
  The 2014 cohort received 200 mg mifepristone, which was self-administered 24-48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3-4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts.
  
  
  CONCLUSIONS
  The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.
authors: Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.|Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors: Deborah
authors: http://orcid.org/0000-0002-7176-9963
authors: D
authors: Constant
authors: Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors: Jane
authors: J
authors: Harries
authors: Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.|Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors: Thokozile
authors: T
authors: Malaba
authors: Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors: Landon
authors: L
authors: Myer
authors: Department of Obstetrics & Gynaecology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
authors: Malika
authors: M
authors: Patel
authors: Department of Obstetrics & Gynaecology, University of Cape Town and New Somerset Hospital, Cape Town, South Africa.
authors: Gregory
authors: G
authors: Petro
authors: Ibis Reproductive Health, Oakland, California, United States of America.
authors: Daniel
authors: D
authors: Grossman
mesh_terms: D000019:Abortifacient Agents / Q000008:administration & dosage*; D000028:Abortion, Induced / Q000523:psychology*; D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D015735:Mifepristone / Q000008:administration & dosage*; D011247:Pregnancy; D011262:Pregnancy Trimester, Second; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000019:Abortifacient Agents; D015735:Mifepristone