Each year more than 75 million women worldwide experience an unintended

Transcription

1 Inside Pregnancy Diagnostics... 7 OUT Feature Article New Approaches to Early Abortion Each year more than 75 million women worldwide experience an unintended pregnancy. 1 For many of these women, contraception was not available or easily accessible. Others may have been unable to negotiate use of a method with their partner, were a victim of rape, or were one of the estimated 8 to 30 million women each year who experience contraceptive failure. 2 About two-thirds of these unintended pregnancies end in abortion. 3 Although some 61 percent of women live in countries where abortion is permitted on request or for socioeconomic reasons, 4 abortion often is not easily accessible or affordable in these countries, and women rely on alternate and often unsafe measures to terminate pregnancy. Where access to safe, legal abortion is severely restricted, for example in much of Latin America, unsafe abortion is common. Some 20 percent of maternal deaths in Latin America and the Caribbean are due to unsafe abortion, a higher proportion than in any other region. Limited data suggest that some 20 million unsafe abortions take place each year, resulting in close to 80,000 maternal deaths and many more injuries (see Table 1). 5 Recognizing that most abortion-related deaths are preventable, governments participating in the 1994 International Conference on Population and Development (ICPD)* called for: Access to compassionate, quality services for the management of complications arising from abortion; Postabortion counseling, education, and family planning services to reduce recourse to repeat abortion; and Where abortion is legal, access to safe induced-abortion services. 6 Safe Motherhood programs in several countries recognize the impact of unsafe abortion on women s health and are beginning to incorporate postabortion care and other efforts into their program activities (see Outlook, Volume 16, Special Issue). * EDITOR S NOTE: The 1994 ICPD Programme of Action stated that abortion should not be promoted as a method of family planning. UNFPA fully subscribes to this, works to prevent abortion through family planning, and does not provide support for the provision of abortion services. Volume 16 October Number

2 Table 1. Estimated Mortality from Unsafe Abortion Deaths Percent of maternal Unsafe from unsafe deaths due to Region abortions abortions unsafe abortions Africa 5,000,000 34, Asia 9,900,000 38, Europe 900, Latin America 4,000,000 5, North America Oceania 30, Total 20,000,000 78, Does not include Japan, Australia, and New Zealand. No estimates shown as incidence is negligible. Source: WHO, A number of newer approaches and/or technologies for uterine evacuation promise to make legal induced abortion and treatment of incomplete abortion safer and more widely accessible. These include manual vacuum aspiration (MVA) and several nonsurgical abortion (also called medical abortion) methods. This article will describe these options and their implications for women and service providers in low-resource settings. Options for Early Abortion For women who choose to terminate their pregnancies, several options for early abortion are becoming more widely available. These options may offer advantages to both women and service providers. In addition, at least one of the technologies manual vacuum aspiration is useful in treating incomplete induced or spontaneous abortion (see box, page 3). Manual Vacuum Aspiration (MVA). MVA involves using a hand-held syringe attached to a cannula to suction the contents of the uterus. It can be used to induce abortion in women up to 12 weeks gestation (some experienced providers use it for pregnancies up to 16 weeks). MVA completely evacuates the uterus in more than 98 percent of women and generally can be performed on an outpatient basis using local anesthesia. Studies repeatedly have shown that MVA results in significantly fewer complications than dilation and curettage (D and C). For a more complete description of MVA, see Outlook, Volume 12, Number 1. While not a new technology, experts believe increased access to MVA could significantly contribute to the safety and availability of legal induced abortion as well as the prompt treatment of complications from incomplete abortion. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. ICPD Programme of Action (Cairo, 1994) Use of mid-level providers can be an important means of increasing access to MVA (and many other reproductive health services) at the primary health care level. Mid-level providers, including midwives and other non-physician providers, can use MVA successfully. In Bangladesh, for example, female paramedics perform MVA for menstrual regulation (early uterine evacuation in the absence of pregnancy confirmation) as safely and effectively as physicians. In one study, female paramedics reported less client noncooperation/shyness (17 percent) than physicians (26 percent); they also reported supplying more clients with a postabortion contraceptive (95 percent) than did physicians (70 percent). 7 In the United States, MVA is being used in conjunction with ultrasound for very early abortion (sometimes even before a missed menstrual period). Planned Parenthood of Houston and Southeast Texas has treated 2,399 women of between three and six weeks gestation using early MVA. Complete abortion occurred in over 99 percent. 8 One advantage of using MVA over electric vacuum aspiration is that with MVA the gestational sac is more likely to remain intact, thus facilitating confirmation of complete evacuation. The effectiveness of this protocol in the absence of ultrasound confirmation of gestational age has not been studied, however. Nonsurgical Methods. Mifepristone plus prostaglandin. Mifepristone is an antiprogestin used in conjunction with a prostaglandin to induce abortion in women of gestation 49 days or less (some protocols extend use up to 63 days gestation). Varying doses of mifepristone are used. In several European countries, mifepristone is registered for use in a 600 mg oral dose. Recent data suggest that 200 mg doses are equally effective. 9 A prostaglandin (typically 1 mg gemeprost administered vaginally or 200 mcg misoprostol administered orally or up to 800 mcg vaginally) is taken 36 to 48 hours after the mifepristone. A review of nine studies using various mifepristone plus prostaglandin regimens found an overall complete abortion rate of 94 percent. 10 Common side effects of the mifepristone plus prostaglandin treatment include nausea, vomiting, cramps, diarrhea, and prolonged bleeding. While it has been promoted as having the potential to increase access to abortion services, the standard mifepristone/prostaglandin protocol can be difficult to follow in some settings. In particular, the requirement that women return to the treatment facility on several 2 OUT/Volume 16, Number 2

3 MVA for Treating Incomplete Abortion Manual vacuum aspiration has proven to be an important tool for providing emergency care for women with incomplete induced or spontaneous abortion. MVA can be used to treat incomplete abortion in women up to at least 12 weeks gestation. It has been used successfully for this purpose by a range of medical providers. For example, in Ghana, the Ministry of Health is collaborating with the Ghana Registered Midwives Association and Ipas to train midwives to provide emergency uterine evacuation for abortion complications using MVA. In addition, the midwives are trained to provide family planning counseling and services at the same time as they provide postabortion care (see box, page 6). Between January and October 1997, 162 MVA procedures were done at the 29 project sites; 86 percent of these were done by midwives. Nearly 60 percent of all women treated by midwives selected a method of contraception to use following the procedure. 11 Project results suggest the expansion of midwives treatment authority in Ghana has strengthened referral networks between midwives and physicians and improved postabortion clients access to family planning services. occasions (for initial evaluation, drug and prostaglandin administration, and follow up) may be impractical where women have difficulty accessing services. In addition, many protocols require that women be observed for several hours following prostaglandin administration, necessitating the availability of adequate rest and toilet facilities. The possibility of incomplete abortion and severe or prolonged bleeding also may pose problems in areas where prompt follow up may not always be available. Availability of mifepristone also has been an obstacle to its widespread use. After the product developer, Roussel Uclaf, stopped production of the drug in 1997, a small French company, Exelgyn, took over manufacture, marketing, and distribution of the drug in Europe (where it is available in France, Sweden, and the United Kingdom). Factories in the People s Republic of China manufacture an equivalent product but are not yet distributing it internationally. In the United States, efforts to bring a product to market have been delayed by the lack of a supplier; the drug may be available in the United States in China is the only developing country where mifepristone has been widely introduced into the health care system. The State Family Planning Commission oversees mifepristone service delivery; it has issued medical guidelines and certifies facilities that provide the method. Few serious complications have been reported since the product was registered for pregnancy termination (in 1988). In one study, a majority of women surveyed indicate that they were satisfied with the method and would use it again, if needed. 12 While the introduction experience generally has been positive, several aspects of service delivery have presented challenges. Some doctors surveyed thought the mifepristone regimen was more time consuming and less convenient than surgical abortion. Another challenge has been regulating the private clinics that offer mifepristone. These clinics often are not certified by the government, advertise the service inappropriately (such as quick, pain-free abortion ), and do not have follow-up capabilities to deal with bleeding complications. In parts of China, mifepristone is available through primary health facilities. This poster advertises mifepristone Xiyin as modern, safe, and convenient. OUT/October

4 In India, studies of mifepristone use outside of hospitals or specialty research clinics suggest the method can be provided safely and effectively in other settings. One study tested the use of mifepristone at a rural health facility in the village of Vadu Budhruk. A variety of health workers, including auxiliary nurse-midwives and multipurpose village workers, have been trained to provide abortion counseling and mifepristone treatment and follow-up under a doctor s supervision. The project proactively addressed some of the potential problems associated with mifepristone service delivery by ensuring that only early gestations were treated, providing adequate counseling about what to expect, identifying back-up facilities, and excluding remote villages from the service area. The project also reduced the number of clinic visits to three (one to diagnose pregnancy and administer mifepristone, a second to administer misoprostol, and a third follow-up visit two weeks later). Interim results suggest that services provided in this setting are safe, effective, and highly acceptable to women. 13 Methotrexate plus prostaglandin. Methotrexate, an antimetabolite that interferes with cell division, has been used for many years as a treatment for ectopic pregnancy with effectiveness rates of 90 percent or higher; it is now being used by some to induce early abortion (see Outlook, Volume 14, Number 2 and Volume 14, Number 3). In women 49 days gestation or less, methotrexate generally is administered intramuscularly, 50 mg/per square meter of body surface area, followed 5 to 7 days later by vaginal administration of 800 mcg of misoprostol. This regimen is 90 percent effective. 14 A recent study evaluated use of 50 mg oral methotrexate followed 3 to 5 days later by 800 mcg vaginal misoprostol among 315 women. This regimen was 91 percent effective; no significant difference was found among women who received misoprostol three, four, or five days after administration of methotrexate. 15 Side effects of these regimens include bleeding, cramping, nausea, vomiting, and diarrhea. One concern about methotrexate has been that the elapsed time between methotrexate administration and completion of abortion can be extended (up to 30 days in some studies). The Misoprostol and Missed Abortion recent study of oral methotrexate plus vaginal misoprostol 15 did not find this, however; all women in the study aborted within 24 hours of misoprostol administration. While some researchers believe that the methotrexate regimen should be made more widely available (primarily because the drugs used in the regimen are low cost and readily available in many settings), others disagree. Because methotrexate is a known teratogen, a WHO Toxicology Panel has recommended against its use due to the potential for birth defects in infants born after treatment failure 16 (see Outlook, Volume 14, Number 3). Given that up to ten percent of methotrexateinduced abortion attempts fail, and follow-up with surgical termination cannot be ensured in some settings, WHO scientists feel that the method cannot be recommended. Misoprostol. In addition to being used as a part of mifepristone or methotrexate regimens, misoprostol alone has been studied for induction of first and second trimester abortion as well as for treatment of missed abortion (see box below). Self-medication with misoprostol to induce abortion appears to be a common practice in some countries, 17, 18 although dosages vary widely and there have been reports of misoprostol-associated heavy bleeding in some cases. While its low cost (approximately US$ per 800 mcg), widespread availability, and stability at room temperature (similar drugs require refrigeration) make it an attractive option, regimens studied to date are not as effective as other medical abortion choices. A study of 141 Cuban women of 10 weeks or less gestational age found that 83 percent aborted after a single treatment with misoprostol, though nearly half of these women had remaining uterine tissue that was surgically evacuated. 19 The women self-inserted 800 mcg misoprostol vaginally, then remained recumbent for three hours. Further doses were administered if abortion did not occur within 48 hours. The failure rate was higher for women of gestational age greater than nine weeks (17 percent) compared to women less than nine Misoprostol also has been investigated for the treatment of missed abortion fetal death without subsequent uterine evacuation. In a Thai study of 84 women with missed abortion, half received 200 mcg misoprostol vaginally and half received a placebo. Some 83 percent of women in the misoprostol group aborted spontaneously compared to 17 percent in the placebo group). 20 Abortion occurred an average of 12 hours after insertion in the misoprostol group. A second small study among U.S. women also found that vaginal administration of misoprostol in women may be effective in treating missed abortion. 21 Eight women with early fetal death (less than 8 weeks as confirmed by ultrasound) received 800 mcg vaginal misoprostol. If abortion did not occur within 24 hours, the misoprostol dose was repeated. Complete uterine evacuation occurred in seven of the eight women. The results of both of these studies suggest that greater use of misoprostol to manage missed abortion could reduce the need for curettage, which carries the risk of complications and requires specially trained staff. 4 OUT/Volume 16, Number 2

5 weeks (4 percent). Reported side effects included pelvic pain (93 percent), diarrhea (58 percent), chills (57 percent), fever (35 percent), vomiting (25 percent), nausea (24 percent), and dizziness (21 percent). All side effects except pain were of low intensity and duration, lasting one to two hours. A study in Mozambique found that misoprostol treatment caused abortion in 89 percent of cases, though in some cases several doses were needed. 22 Some 132 women with average gestational age 14.2 weeks (range 11 to 22 weeks) were given 800 mcg vaginal misoprostol; additional doses were administered if there was no evidence of cervical softening after 18 hours. The majority of women (80 percent) required only one dose to achieve abortion. There were no significant complications; 20 percent of women required a mild analgesic. Research results to date have raised several concerns about use of misoprostol to induce abortion. Rates of incomplete abortion following misoprostol treatment are high compared to other abortion techniques. In the research studies described above, women were carefully monitored using ultrasound and vaginal exams and additional misoprostol administered if needed. Still, a significant portion of women underwent surgical uterine evacuation. This level of follow-up is unlikely to be feasible in many low-resource settings. In addition, fetal exposure to misoprostol may lead to birth defects if the abortion is not successful. 16 There have been reports indicating various abnormalities in babies born following failed misoprostol abortion (including cranial nerve and limb defects). 23 Tracking of 29 Brazilian women who had attempted to induce abortion using misoprostol found no birth defects among 17 live births, however. 24 Some experts believe the benefits of misoprostol use may outweigh the risks in certain settings. As noted above, in some areas where women are self-administering misoprostol to induce abortion, there has been a noticeable drop in severe adverse health effects associated with self-induced abortion. 19 In one study, complications such as uterine infection were observed in about 32 percent of women who had used misoprostol compared with 63 percent of women who had visited an illegal abortionist. 17 Client Perspectives Early abortion technologies offer several advantages over conventional techniques to women seeking abortion services or treatment of incomplete abortion. Specifically, new options allow for: Greater choice: Studies have found that women choose different abortion methods for different reasons. For instance, women report choosing nonsurgical abortion to avoid surgery and general anesthesia and to have a more natural procedure; 25, 26 those choosing surgical abortion cite speed, simplicity, and effectiveness. Increased access: Because mid-level providers can provide these methods, they can be made more broadly accessible. Improved safety: Early abortions generally are associated with fewer complications than later abortions. 27 Early abortions also can lead to earlier detection of ectopic pregnancy, which can be life threatening. In areas where self-induction of abortion tends to be common, use of misoprostol or other nonsurgical techniques may be safer than common practices such as inserting catheters or other objects into the uterus. Earlier resolution of pregnancy: Early treatment eliminates a source of anxiety for many women and reduces the length of time women are subject to the effects of pregnancy. Some characteristics of early abortion technologies, particularly nonsurgical methods, may be less acceptable to women. For nonsurgical methods, the prolonged bleeding, nausea, vomiting, and the lack of control over when the abortion occurs can be unacceptable to some. 26 Some women also may find the multiple clinic visits needed for nonsurgical methods to be inconvenient, although recent protocol changes to allow women to self-administer the prostaglandin may help alleviate this concern. Program Implications As programs begin to introduce new technologies for early induced abortion or the treatment of incomplete abortion, they need to systematically consider a number of key issues related to the technologies used, service delivery requirements, and clients needs and perspectives. These include the following. Authorized providers. One of the key advantages of technologies for early abortion where medical resources are limited is that they can readily be provided by midlevel providers (although regulatory/policy changes may be necessary to allow non-physicians to provide new services). Training issues. Adequate training in technical skills and medical protocols is essential. Learning the basic protocols and techniques for the methods and understanding counseling needs are key. Special training issues include accurately assessing gestational age, recognizing signs of ectopic pregnancy, assessing whether abortion is complete, and dealing with complications. Modified protocols. As new information is gained from clinical research, changes in service delivery protocols may be warranted to allow earlier use of MVA or require fewer visits for nonsurgical methods. For instance, a study in the French West Indies and OUT/October

6 experience in Vietnam and Tunisia suggest that with the mifepristone plus misoprostol regimen, women can successfully self-administer the misoprostol at home. Some researchers believe that self administration of the entire regimen may be possible where proper instructional materials and access to follow-up care can be ensured. 13 Ensuring adequate follow-up. Ensuring that women who have undergone early abortion are adequately followed up is crucial to avoid serious complications, including undetected ectopic pregnancy. Where women use nonsurgical methods to self induce abortion, it is particularly important for health care facilities to make postabortion care (including emergency treatment for incomplete abortion, postabortion family planning services see box below, and referral to other reproductive health services as necessary) available at all times. Facilities and equipment needs. The facilities and equipment requirements for the early abortion methods generally are simple, although procedures for referral for abortion complications must be in place. Facilities must have a place for client counseling, a physical exam and/or procedure room, and, for nonsurgical procedures, a room for clients to rest while bleeding takes place. Facilities should have basic medical supplies, such as intravenous fluids and anesthesia, on hand. Ultrasound capability is useful but not necessary (ultrasound is officially required to confirm intrauterine pregnancy in China). Information needs. Provision of early abortion technologies must be accompanied by appropriate information. Women must be informed of the availability of early options and the need to seek treatment soon after a missed period. Women choosing early abortion need information and counseling about the procedures available, including what side effects to expect, signs of incomplete abortion or infection, pain management, and where to go for follow-up care. In areas where nonsurgical or alternative methods are used to self induce, women need to know when and where they can go for treatment of incomplete abortion. A qualitative study involving 14 women in Brazil who had self-administered misoprostol found that most did not know when to seek assistance in the case of complications. 18 Conclusion New abortion technologies hold promise for expanding women s access to safe, legal services for early abortion. Expanded access to MVA also can play an continued on page 8 Postabortion Family Planning Services: A Critical Aspect of Care All abortion-related care should include postabortion family planning information, counseling, and, wherever possible, services. Postabortion women must understand: fertility returns rapidly following abortion, often before menses resume; safe and effective contraceptive methods can be used immediately to prevent pregnancy; and where they can go for ongoing contraceptive and reproductive health care. 28 Providing postabortion family planning care helps women to avoid future unplanned pregnancies, thereby reducing the likelihood they will seek future abortions. Women who have just undergone an induced abortion or received treatment for the complications of incomplete abortion may have special counseling and contraceptive needs. Some women may be upset by the abortion experience and/or have medical complications that influence their choice of method or timing of method initiation. Counseling for postabortion clients should be compassionate, nonjudgmental, and respectful and should not require acceptance of postabortion contraception. Women who have had an uncomplicated first trimester abortion can immediately initiate use of any method except periodic abstinence (which requires regular menstrual cycles), as long as they meet the standard eligibility criteria for the method. Providers should carefully counsel women considering sterilization to ensure informed consent and minimize the possibility of later regret; delaying the procedure may be advisable. Women with complications from first trimester abortion may consider using any method with the following exceptions: 28 Delay female sterilization and IUD insertion in women with postabortion sepsis or fever. Delay female sterilization and IUD insertion until trauma to genital tract has healed. If abdominal surgery is needed to repair trauma, sterilization may be performed concurrently if no additional risk is involved. Delay use of any method until hemorrhage is resolved. Delay female sterilization in women who may be anemic and unable to tolerate further blood loss. Consider an alternative to an IUD for women who are severely anemic. Whenever use of a specific method use is delayed, an interim method such as the condom, pill, or injectable should be suggested. 6 OUT/Volume 16, Number 2

7 Product News Pregnancy Diagnosis and Women s Health Care Early pregnancy diagnosis is an important component of efforts to improve the quality of reproductive health services. In settings where routine pregnancy testing is not feasible, women may face uncertainty and anxiety due to unknown pregnancy status, difficulties in initiating some contraceptive methods (for example, IUDs and some hormonal methods that must not be used during pregnancy), risks from undetected ectopic pregnancies, and the potential for undergoing unnecessary early pregnancy termination. 1 Currently available pregnancy tests allow a woman to confirm her pregnancy status as early as one week after fertilization, before the first missed menstrual period, and are easy to transport and store. Although pregnancy tests are easy-to-use, effective, and widely available, they are not routinely used in poorresource settings because of cost and other considerations (the average consumer price of a pregnancy test is about US$1). Yet some data suggest that use of pregnancy tests in some settings may actually save money overall. For example, a study in rural Vietnam found that as many as 17 percent of women seeking menstrual regulation were not pregnant. Given that some 800,000 menstrual regulation procedures are performed each year in Vietnam, 136,000 of these procedures may be unnecessary, and may cost the government and women in excess of nearly US$1.6 million. 2 In addition, women undergoing termination procedure needlessly are at risk of procedure-related morbidity (including hemorrhage, incomplete abortion, perforated uterus, etc.). Where making pregnancy tests available for routine use (e.g., prior to early abortion or initiating contraceptive use) is not feasible, alternative approaches based on standard clinical protocols should be considered (see box, this page). In some settings, use of a pregnancy test may be mandated only if a woman s pelvic examination is inconclusive and if she cannot return to the clinic at a later date, when pregnancy status can be clinically confirmed. 2 While the specific approaches to improving access to and quality of pregnancy diagnostic services will likely vary among countries depending on the resources available, all will be important steps to improving the overall quality of reproductive health services. 1. Stewart, F. Pregnancy testing and management of early pregnancy. In: Hatcher R.A. et al., eds. Contraceptive Technology. New York, NY: Ardent Media, Inc. pp (1998). 2. Trinh, H.V. et al. Health and cost impact of pregnancy diagnostic use in menstrual regulation services in Vietnam. International Family Planning Perspectives (forthcoming). 3. IPPF. Diagnosis of pregnancy. In: Huezo, C.M. and Carignan, C.S. (eds.).medical and Services Delivery Guidelines for Family Planning. London: IPPF Medical Publications, pp (1997). Clinical Diagnosis of Pregnancy Careful history taking and clinical examination can be quite effective in detecting the symptoms and signs of pregnancy. The most telling symptom is amenorrhea (eight to ten weeks) which, when accompanied by other symptoms, is highly suggestive of pregnancy. Pelvic examination is useful in the diagnosis of pregnancy after six weeks gestation. Listed below are the accepted symptoms and signs of pregnancy. Symptoms Amenorrhea (absence of menstruation) Nausea (with or without vomiting) and changes in appetite Persistent fatigue Breast tenderness and breast enlargement Increased frequency of urination Perception of fetal movements Source: IPPF, Clinical Signs Uterine softness, roundness and enlargement begins at 6 weeks gestation Uterine artery pulsations (felt on bimanual exam at less than 6 weeks) Fetal heartbeat can be heard with stethoscope at weeks Fetal movements can be felt by examiner at weeks OUT/October

8 New Approaches, cont. from page 6 important role in the treatment of abortion complications where unsafe abortion practices are common; MVA also is an important backup to incomplete medical or spontaneous abortion. Greater use of these new technologies, combined with efforts to reduce the number of unintended pregnancies through increased promotion of contraceptive services (including to postabortion clients), could contribute significantly to reducing the morbidity and mortality associated with unsafe abortion. 1. UNFPA. The State of World Population New York: UNFPA (1997). 2. Segal, S.J. and LaGuardia, K.D. Termination of pregnancy a global view. Bailliere s Clinical Obstetrics and Gynaecology 4(2): (1990). 3. WHO, Division of Reproductive Health. Prevent unwanted pregnancy. World Health Day: Safe Motherhood, 7 April Geneva: World Health Organization (1998). 4. Rahman, A. et al. A Global review of laws on induced abortion International Family Planning Perspectives 24(2):56-64 (June 1998). 5. WHO, Division of Reproductive Health. Unsafe Abortion: Global and Regional Estimates of Incidence and Mortality Due to Unsafe Abortion with Listing of Available Country Data, 3 rd Edition (WHO/RHT/MSM/97.16). Geneva: World Health Organization, United Nations. Population and Development, Volume 1: Programme of Action Adopted at the ICPD (1995). 7. Begum, S.F. et al. Evaluation of MR services in Bangladesh. Bangladesh Association of Prevention of Septic Abortion (1987). 8. Edwards, J. and Creinin, M.D. Surgical abortion for gestations of less than 6 weeks. Current Problems in Obstetrics, Gynecology, and Fertility 2(1):11-19 (January/February 1997). 9. WHO, Task Force on Post-ovulatory Methods of Fertility Regulation. Termination of pregnancy with reduced doses of mifepristone. British Medical Journal 307: (1993). 10. Grimes, D.A. Medical abortion in early pregnancy: a review of the evidence. Obstetrics and Gynecology 89(5, part 2): (May 1997). 11. Billings, D.L. et al. Operations Research with Midwives in Ghana: Ensuring the Delivery of Postabortion Care. Presented at the 43rd Annual Meeting of the American College of Nurse Midwives, May 22-28, San Francisco, CA. 12. Wu, S. et al. Situation analysis of mifepristone use for medical abortion in Beijing, Hunan, and Guangdong: Quantitative analysis. Report of Project 95- SMP SGP (November 14, 1997). 13. Coyaji, K.J. In: Stein K. et al. Abortion: Expanding Access and Improving Quality. Report of a Meeting. New York: Population Council (1998), pp Creinin, M.D. et al. Methotrexate and misoprostol for early abortion: a multicenter clinical trial. I. Safety and efficacy. Contraception 53: (1996). 15. Carbonell, J.L.L. et al. Oral methotrexate and vaginal misoprostol for early abortion. Contraception 57(2):83-88 (February 1998). 16. WHO. Methotrexate for the termination of early pregnancy: a review of its toxicology (April 18, 1997). 17. Coelho, H.L. et al. Misoprostol and illegal abortion in Fortaleza, Brazil. Lancet 341: (1993). 18. Barbosa, R.M. and Arilha, M. The Brazilian experience with Cytotec. Studies in Family Planning 24(4): (1993). 19. Carbonell, J.L.L. et al. The use of misoprostol for termination of early pregnancy. Contraception 55: (1997). 20. Herabutya, Y. and O-Prasertsawat, P. Misoprostol in the management of missed abortion. International Journal of Gynecology and Obstetrics 56 (3): (1997). 21. Creinin, M. et al. Misoprostol for medical evacuation of early pregnancy failure. Obstetrics and Gynecology 89 (5, Part I): (1997). 22. Bugalho, A. et al. Pregnancy interruption by vaginal misoprostol. Gynecological and Obstetrical Investigations 36: (1993). 23. Gonzalez, C.H. et al. Congenital abnormalities in Brazilian children associated with misoprostol misuse in first trimester of pregnancy. The Lancet 351: (May 30, 1998). 24. Schuler, L. et al. Teratogenicity of misoprostol. Lancet 339:437 (1992). 25. Winikoff, B. et al. The acceptability of medical abortion in China, Cuba, and India. International Family Planning Perspectives 23(2):73-78, 89 (June 1997). 26. Winikoff, B. et al. Acceptability and feasibility of early pregnancy termination by mifepristone-misoprostol. Archives of Family Medicine (July/August 1998). 27. WHO. Medical methods for termination of pregnancy. WHO Technical Report Series 871. Geneva: World Health Organization (1997). 28. WHO, Division of Reproductive Health. Postabortion Family Planning: a Practical Guide for Programme Managers. Geneva: World Health Organization (1997). The staff writers for this issue were Tuong Nguyen and Elisa Wells. Production assistants were Diane Lachman and Ginger Topel. In addition to selected members of Outlook s Advisory Board, the following individuals reviewed this issue: Dr. E. Ahman, Ms. K. Blanchard, Ms. B. Elu, Dr. P. Fajans, Ms. A. Gerhardt, Dr. D. Grimes, Ms. C. Hord, Ms. A. Leonard, Dr. P.F.A. Van Look, Dr. H. von Hertzen, and Dr. B. Winikoff. Outlook appreciates their comments and suggestions. ISSN: Outlook is published by PATH in English and French, and is available in Chinese, Spanish, Portuguese, and Russian. Outlook features news on reproductive health products and drug regulatory decisions of interest to developing country readers. Outlook is made possible in part by a grant from the United Nations Population Fund. Content or opinions expressed in Outlook are not necessarily those of Outlook s funders, individual members of the Outlook Advisory Board, or PATH. PATH is a nonprofit, international organization dedicated to improving health, especially the health of women and children. Outlook is sent at no cost to readers in developing countries; subscriptions to interested individuals in developed countries are US$40 per year. Please make checks payable to PATH. Editor: Jacqueline Sherris, Ph.D. PATH 4 Nickerson Street Seattle, Washington U.S.A. Phone: Fax: outlook@path.org URL: ADVISORY BOARD Giuseppe Benagiano, M.D., Director General, Italian National Institute of Health, Italy Gabriel Bialy, Ph.D., Special Assistant, Contraceptive Development, National Institute of Child Health & Human Development, U.S.A. Willard Cates, Jr., M.D., M.P.H., President, Family Health International, U.S.A. Lawrence Corey, M.D., Professor, Laboratory Medicine, Medicine, and Microbiology and Head, Virology Division, University of Washington, U.S.A. Horacio Croxatto, M.D., President, Chilean Institute of Reproductive Medicine, Chile Judith A. Fortney, Ph.D., Corporate Director for Scientific Affairs, Family Health International, U.S.A. John Guillebaud, M.A., FRCSE, MRCOG, Medical Director, Margaret Pyke Centre for Study and Training in Family Planning, U.K. Atiqur Rahman Khan, M.D., Country Support Team, UNFPA, Thailand Louis Lasagna, M.D., Sackler School of Graduate Biomedical Sciences, Tufts University, U.S.A. Roberto Rivera, M.D., Corporate Director for International Medical Affairs, Family Health International, U.S.A. Pramilla Senanayake, MBBS, DTPH, Ph.D., Assistant Secretary General, IPPF, U.K. Melvin R. Sikov, Ph.D., Senior Staff Scientist, Developmental Toxicology, Battelle Pacific Northwest Labs, U.S.A. Irving Sivin, M.A., Senior Scientist, The Population Council, U.S.A. Richard Soderstrom, M.D., Clinical Professor OB/GYN, University of Washington, U.S.A. Martin P. Vessey, M.D., FRCP, FFCM, FRCGP, Professor, Department of Public Health & Primary Care, University of Oxford, U.K. PATH (PROGRAM FOR APPROPRIATE TECHNOLOGY IN HEALTH), ALL RIGHTS RESERVED. 8 OUT/Volume 16, Number 2 Printed on recycled paper