Safety, efficacy and acceptability of mifepristone-misoprostol medical abortion in Vietnam

Context: In developing countries where the demand for abortion services is high, such as Vietnam, the need for safe and effective alternatives to surgical abortion is great. Medical abortion using mifepristone and misoprostol may be an appropriate option in some of these countries.

Methods: In a comparative study of the safety, efficacy and acceptability of medical and surgical abortion, 393 women at two urban clinics chose between a mifepristone-misoprostol medical regimen and the standard surgical procedure offered in each clinic.

Results: Success rates for both methods were extremely high (96% for medical abortion and 99% for surgical abortion). Medical abortion patients reported many more side effects than women obtaining surgical procedures (most commonly, cramping, prolonged bleeding and nausea), but none of these side effects represented a serious medical risk. Nearly all women, regardless of the method they chose, were satisfied with their abortion experience. Additionally, among women who had previously undergone surgical abortion, those who selected medical abortion were more likely than those who chose surgery to say that their study abortion was more satisfactory than their earlier one (32% vs. 4%).

Conclusions: Mifepristone-misoprostol abortion is safe, effective and acceptable for urban Vietnamese women who are given a choice of methods. If similar results are observed for rural areas, the regimen could help meet the need for abortion services nationwide.

International Family Planning Perspectives 1999, 25(1):10-14 & 33

In the past decade, several nonsurgical options have been developed for women seeking to terminate pregnancies. To date, however, medical methods of abortion have been officially approved only in several European countries and China. Although women in developed countries benefit from these new options, women in the developing world have a greater need for safe and effective alternatives to surgical abortion: Nearly all of the estimated 70,000 deaths each year due to unsafe abortion occur in developing countries.1

The administration of mifepristone, a powerful antiprogestin, coupled with a prostaglandin is a highly effective medical method of terminating pregnancy.2 Of the most widely used prostaglandins, gemeprost and misoprostol, the latter shows the greater promise for use in developing countries. Misoprostol can be administered orally and is inexpensive, stable at ambient temperatures and widely available. By contrast, gemeprost is expensive, not widely available and provided in a vaginal suppository that requires refrigeration. In 1993, a large French trial confirmed the safety and efficacy of a regimen consisting of mifepristone and oral misoprostol.3 This regimen, with a success rate of 96%, has been used extensively in France and may be available in the United States by the end of 1999. Only two studies, however, have focused on the potential use of mifepristone and misoprostol for medical abortion in developing countries,4 and only one of these measured the method's acceptability to clients.5 Given the potential of medical abortion to improve conditions for women in developing countries, these women's perceptions of the method in general and of the mifepristone-misoprostol regimen in particular is critical to its acceptability. Patients' attitudes, expectations and tolerance of side effects influence surgical intervention rates; ultimately, for the method to work successfully, women must complete the regimen and wait while the treatment takes its course.

In Vietnam, the number of pregnancy terminations has risen steadily over the past 15 years and is now estimated at more than one million per year;6 since the early 1990s, the annual number of abortions has exceeded the annual number of births.7 A 1994 nationwide survey found that 13% of women have had at least one abortion.8 Moreover, in 1992, the total abortion rate was estimated as 2.5 lifetime abortions per woman, the highest in Asia and the thirdhighest in the world.9

Additionally, the surgical abortion services available in Vietnam are marked by a number of safety and quality problems.lo For example, sterilization of instruments is inadequate in some clinics, and management of pain requires improvement. Indeed, while some women receive no pain medication, others are medicated beyond the point of conscious sedation and are consequently unable to respond to physical or verbal stimuli.

Vietnamese officials have responded to this situation by committing themselves to offering a broader range of contraceptives. They have also increased efforts to improve the quality of abortion services, including investigating the addition of alternatives to surgical abortion.

In this article, we describe a study exploring the safety, efficacy and acceptability of mifepristone-misoprostol medical abortion among women attending two clinics in Vietnam. We address three important questions: First, is medical abortion as effective as surgical abortion for women who choose the method? Second, how do the safety, risks and side effects of medical abortion compare with those of surgical abortion? Third, do women who choose mifepristone-misoprostol abortion find the method acceptable? Answers to these questions can help policymakers and providers in Vietnam, as well as in other developing countries, determine if medical abortion is a feasible and desirable alternative method of pregnancy termination.