Integrating medical abortion into safe abortion services in South Africa Jennifer Moodley Margaret Hoffman

Abortion in South Africa Choice on Termination of Pregnancy Act, 1996 < 12 weeks abortion available on request weeks -Fetus not viable -Rape or incest -Danger to woman’s physical or mental health -Affect woman’s socio-economic status

Abortion in South Africa Designated facility: public, NGO or private 1 st trimester- trained registered nurse or physician 2 nd trimester- physician only Consent irrespective of age Health worker may refuse to perform, but obliged to inform women of rights and refer

Abortion in South Africa Achievements 90% reduction deaths associated with unsafe abortions Decrease in morbidity associated with abortions Challenges in implementation Lack of designated facilities Shortage of trained personnel

Abortion in South Africa 1997 National guidelines for implementation of TOP stated: “Once medical abortifacients become available in South Africa they should be introduced into the health services to further decentralise services in a safe and effective manner”

Medical abortion in South Africa Lobby group: academics, NGOs, providers, policy makers established 1998 MCC approved mifepristone in 2001 –Gestational age less than 56 days –Day 1: 600 mg mifepristone –Day 3: 400 mcg oral misoprostol (offered home or clinic use) –Day 15: Follow-up and final evaluation Medical abortion is available in private sector; not available in public sector

Research Studies: SA Feasibility study –profile of TOP clients, the accuracy of gestational age estimation by clinicians and clients compared to ultrasound measurements, the acceptability of medical TOP to clients and providers Operations research –Medical TOP provided and the following were assessed: outcome, side effects, rates of follow-up, and acceptability of medical abortion to women and health care providers Costing studies Private sector use

Research studies: key findings Feasibility 22% of TOP clients attended service within 56 days 82% interested in trying medical TOP 77% lived < 1 hour from health service, but rural women travelled for longer Generally policymakers and providers favourable attitudes Gestational age - mean provider estimates were 2 days fewer than u/s estimates. D Cooper et al RHM 2005 K Blanchard et al. BJOG 2007

Research studies: key findings Operations research 90% returned for follow-up visit 93% of women had a complete abortion Majority opted to use misoprostol at home Side-effect – no serious, 66% pain, 67% heavy bleeding 96% women satisfied with procedure Providers satisfied, felt it would decrease their workload and recommended introduction of medical TOP M Kawonga et al J Fam Plann Reprod Health are 2008

Research studies: key findings Costing Main cost drivers are:  Dosage – cost increased by 84% when 600mg vs 200mg  Level of health care facility – cost increased by 39% when secondary vs primary level facility  Category of provider – cost increased by 10% for physician vs nurse Cost of nurse providing MVA at primary level similar to the cost of providing medical abortion with 200 mg mifipristone H De Pinho WHRU, UCT 2000 L CUllingworth et al WHRU, UCT 2002

Research studies: key findings Private Majority of providers also provided surgical abortion, 11.3% were not providing surgical abortion and had incorporated medical TOP into their services Range of regimes used – 84% mifipristone- misoprostol regimes. Of these, 54% used 200 mg mifipristone and 43% used 600 mg. 94% reported that their clients were satisfied with medical TOP K Blanchard et al European Society of Contraception 2006

Current situation MCC approved mifepristone 2001 Available in private sector  300 – 400 packs (3 x 200mg) mifegyn sold per week. Cost R1020 per pack = R340 per 200 mg tablet. Local research has shown that medical abortion can be integrated into the SA public health care sector Provider training guidelines have been developed and are available Providers have been trained

Current situation Draft policy guidelines for the implementation of medical TOP have been developed and submitted to NDOH in 2007  Set standards and norms for provisions of medical TOP  Guiding principles with regards to clients, providers and service sites  Describe MTOP counseling  Provide information on provider training  Provide indicators for monitoring and evaluation 2009 – NOT available in public sector

Introducing medical abortion into public health sector Advocacy and education Responding to anti-abortion lobby Responding to news media Change protocol – mifipristone 200mg Challenges

Conclusion Medical abortion can and should be integrated into public sector abortion services in South Africa