Part 1 nationwide survey
Taking into account discrepancies between straightforward international abortion guidelines1,9,11 and the Swiss guidance4,5, we compared nationwide first-trimester abortion protocols regarding medical and surgical abortion in hospitals as opposed to office-based settings, as the latter were hypothesised to be more straightforward and easier to access. Furthermore, we investigated associations between protocol characteristics and the proportion of patients who followed through with the abortion at the same facility.
Our results indicate that less complex protocol characteristics, which are more common among office-based facilities, are associated with higher odds of following through with the abortion at the same facility. By contrast, more complex abortion protocols, which are more common in hospitals, appear to decrease the odds that a patient will follow through with the abortion at the same facility. Office-based settings were characterised by fewer clinical visits requiring the involvement fewer staff members, no mandatory reflection period, a higher proportion applying a gestational age limit of more than 63 days, the availability of medical abortion medication for home use, and a higher proportion of telemedicine follow-up in conjunction with a semiquantitative urine human chorionic gonadotropin test.
Repeated assessments and counselling may cause delays in accessing abortion services and are not recommended by several guidelines, including those of the WHO1,6,7,8,9,11. Furthermore, reduced waiting times and fewer clinical visits decrease distress and improve patient experience7,8,19,23,24. However, an argument in favour of repeated assessments may be that more time is needed to determine the patient’s needs in terms of somatic or psychological comorbidities. Nevertheless, most women have already decided on abortion before their first contact with the care provider, and they are aware of contraceptive methods and how to use them. Hence, the imposition of a requirement for further counselling or a mandatory reflection period seems unethical and results in unnecessary barriers restricting access to this service.
Our results indicate that the gestational age limit appears to be an important protocol characteristic affecting the number of those who follow through with a medical abortion at the same facility when the service is offered up to a limit of 63 days or beyond. Hospitals were found to be more restrictive regarding the gestational age limit compared with GPs. Consequently, patients were not permitted to choose between a medical or surgical abortion and were obliged undergo a suction evacuation. This fact may have led to a decreased proportion of patients following through with an abortion at the same facility. Multiple studies have shown the safety and effectiveness of medical abortions up to 70 days of pregnancy with a regimen of 200 mg mifepristone followed by a single dose of misoprostol1,12,13,14,25,26,27. A systematic review conducted by Abbas et al. showed an overall success rate of 92.3% and an overall ongoing pregnancy rate of 3.1% between 64 and 70 days. No statistically significant difference in success rate could be demonstrated compared with a gestational age up to 63 days after LMP (93.9%)14.
Regarding home use of medical abortion medication, in the single-variable model (Fig. 2), the odds of following through with an abortion at the same facility were increased when offered (OR 5.55, 95% CI 3.15 to 9.79). In contrast, the full model (Fig. 3) suggests the opposite (OR 0.20, 95% CI 0.07 to 0.55). The reason for this discrepancy (and others) between single-variable models (which ignore all other explanatory variables) and the full model is that ORs estimated by the full model are adjusted for all other explanatory variables in the model. The full model estimates the OR for home use of medical abortion medication by patients in the same category for all other explanatory variables. Home use of medical abortion medication was permitted more often by institutions which required fewer clinical visits, and by facilities which did not impose a mandatory reflection period or which allowed for the administering of mifepristone at the first appointment. Thus, these variables partly explain the same variation, and the adjusted OR estimate for home use of medical abortion medication (independently of the other variables) is reversed. However, home use is safe and effective, showing that health professionals are no longer obliged to directly dispense the medication to patients12,24,28,29,30. Clinicians can prescribe mifepristone, misoprostol, and pain medications for home use, which may enhance patient experience and increase satisfaction and privacy, the latter of which is pivotal in abortion care. Another argument in favour of home use of abortion medication is the similarity of the situation compared with that of patients suffering from a first-trimester miscarriage, who are less prepared and who may even endure the process without relying on painkillers, despite experiencing comparable somatic and psychological pain.
In this study, only 8% of hospitals and 29% of GPs gave women the opportunity for post-abortion follow-up through self-assessment in conjunction with a semiquantitative urine human chorionic gonadotropin test instead of a routine clinical visit. In Switzerland, the distance between a patient’s place of residence and an abortion provider is generally short, and insurance companies reimburse the costs for an ultrasound assessment. However, guidelines no longer endorse in-person visits with routine clinical follow-up, since remote and self-assessment along with a telephone call are viable alternatives to in-person follow-up7,8,28. Oppegaard et al. demonstrated that self-assessment in conjunction with a semiquantitative urine human chorionic gonadotropin test and standardised assessment of women’s symptoms were not inferior to standard clinical follow-up in terms of complication rates15,31. Self-assessment and telemedicine are especially valuable in resource-poor settings and sparsely populated regions, and they also proved their worth during the COVID-19 pandemic15,32. Experience has shown that many patients do not return to in-person follow-up after medical abortions in Switzerland, despite the fact that the costs are reimbursed. Hence, self-assessment could be an appropriate alternative, which is currently still underrepresented15. These arguments are supported by the fact that ongoing pregnancies are low at around 0.4–3% in early medical abortions using a standard regimen with mifepristone and misoprostol10,16,33,34,35. More importantly, patients undergoing ultrasound assessment frequently receive unnecessary interventions following a medical abortion, such as suction evacuation for misinterpreted residual abortion material caused by inexperienced providers15. The failure rate of surgical abortion is approximately the same as that of medical abortion, and an in-person follow-up visit is not required for the latter procedure9.
Cost-efficiency of surgical abortion has only been confirmed by 40% of hospitals compared to 77.8% among GPs, which might be directly related to more complicated protocols. However, amid growing concerns regarding cost reimbursement, hospitals should be encouraged to adjust their abortion protocols, as safety and effectiveness are seemingly uncompromised10.
The first part of the present study has several limitations. Firstly, the variables were self-reported by a representative of each institution based on questionnaires. Secondly, the response rate was low (53%), accounting for 34–41% of all abortions in Switzerland within the years 2014–2018. The French speaking part was the least represented in this study. Thirdly, following through with the abortion at the same facility is not necessarily a proxy for patient acceptability as we did not include any direct patient perspective in this study. Fourthly, we did not statistically account for repeat abortions within the same patient in the analysis plan as this appeared to be a rare event within a period of 5 years.
Part 2 patient cohort from six GPs
Simultaneously, we aimed to analyse a considerable dataset, obtained from six specialist GPs in Zurich, in terms of complication rates requiring surgery. GPs are acknowledged for their simplified protocols. From 2008 to 2018, 5495 first-trimester abortions were performed. Of these (a total of 5495), 75% and 25% were performed by medical or surgical means, respectively. Despite simplified protocols, the overall complication rate requiring suction evacuation was at a low level of 2.5%. This rate is comparable to those of other studies investigating the same setting10,14,15,16,19,36. Major haemorrhage, ongoing pregnancies and the patient’s decision to refuse another dose of misoprostol were included in this 2.5% suction evacuation or reaspiration rate, respectively. The number lost to follow-up was low at 4.02%. There were similar complication rates compared to those reported in the literature14. In a retrospective cohort study conducted by Robertson et al. of more than 50,000 abortions, abortion-related morbidities and adverse events were compared by facility type (hospitals vs office-based settings). The overall proportion of patients with abortion-related morbidity or adverse events was 3.3%, which does not indicate a significant difference between the two facility types37.
The limitations of the second part of this study are as follows. Firstly, despite a complete dataset from six specialised GPs over a decade, it only represents a small cohort and is not nationwide. Secondly, the complication rates requiring surgery were not further specified. Retained tissue, abortion-related infection, haemorrhage, ongoing pregnancies, and missed ectopic pregnancies were not further specified. Therefore, the minor and major adverse events could not be differentiated.