Improving technologies to reduce abortion-related morbidity and mortality

Transcription

1 International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 Improving technologies to reduce abortion-related morbidity and mortality K. Rogo* The World Bank, J8-805, 1818 H Street NW, Washington, DC 20433, USA Abstract This article reviews the technologies used to diagnose pregnancy and manage abortion in developing countries. The author discusses methods of diagnosing pregnancy including physical examination, laboratory and home testing, and ultrasound as well as methods for performing safe abortions. Due to manual vacuum aspiration (MVA) advances, vacuum aspiration has become safer and more feasible in low-resource settings. The discussion of medical abortion includes the advantages and limitations of mifepristone, misoprostol-only regimens, methotrexate, and other methods. The author stresses the importance of post-abortion care and post-abortion contraception and, in the conclusion, identifies six areas in which technology can reduce abortion-related morbidity and mortality: pregnancy prevention, early diagnosis of pregnancy, accurate assessment of gestation, standardization and supply of MVA technology, and simple and affordable regimens for medical abortion International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Keywords: Abortion; Pregnancy test; Manual vacuum aspiration; Medical abortion; Developing country 1. Introduction The World Health Organization (WHO) estimates that, of the pregnancy-related deaths that occur globally each year, (13%) result from complications of abortion w1,2x. In Latin America and sub-saharan Africa, the proportion of abortion-related deaths is higher (21% and up to 50%, respectively) w3,4x. In the developed world, abortion-related mortality has significantly diminished, as liberalization of abortion laws and use of safer technologies have improved both access to and quality of care. These differences in abortion-related outcomes are paralleled within many developing countries, where income, resi- *Tel.: q ; fax: address: Krogo@worldbank.org (K. Rogo). dence, social status, and restricted access to services have turned abortion morbidity into a true burden of the poor woman w5x. This article reviews some of the technologies used in the diagnosis of pregnancy and the management of abortion. Because both spontaneous and induced abortions may lead to severe morbidity and mortality, appropriate management including proper timing, provider skills, facilities, and equipment is essential. Much also depends on the procedure a woman has undergone prior to arriving at a skilled provider s service. 2. Magnitude of the problem Accurate information on the global magnitude of abortion especially in parts of the world where laws are restrictive does not exist. Among all /03/$ International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi: /j.ijgo

2 S74 K. Rogo / International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 Fig. 1. Relation of restriction of abortion laws to maternal mortality w10x. pregnancies, an estimated 15% are spontaneously aborted within the first few weeks, and another 22% end with induced abortion. Each year, an average of 35 per 1000 women of childbearing age have an abortion, making abortion one of the most common health events in women s lives w6,7x. The legal environment around abortion is a significant factor in determining how a woman will end an unwanted pregnancy and how safe the procedure will be, but it does not affect the incidence of abortion w8,9x. A study by the International Federation of Gynecology and Obstetrics (FIGO) of abortion laws and attitudes in 156 countries demonstrated a striking correlation between high maternal mortality and restrictive abortion laws (Fig. 1). Although member societies supporting restrictive laws argue that prohibition protects the lives of women, the study results indicate that a greater proportion of women die from abortion and other pregnancy-related causes in countries where abortion restrictions are severe w10x. In all countries, certain restrictions also impact a woman s access to care: Gestational age. Laws usually stipulate how late in the pregnancy a termination can be performed. Gestational age is limited to the first trimester in 36 countries, weeks in eight countries, and 24 weeks or fetal viability in six countries w8x. Some countries with liberal laws impose extra requirements for terminations beyond the first trimester. Consent and counseling requirements. Consent of another family member, including the husband, is required in some countries. In other countries, minors who cannot obtain parental consent must obtain court approval. Counseling is also a precondition for abortion in a few countries. A waiting period between counseling and termination of pregnancy is sometimes mandatory. Facilities and provider training. In nearly all countries, the laws attempt to provide specifications on the facilities and types of providers permitted to perform abortion procedures. For many years, only physicians were allowed to perform abortions in most countries, as physicians were assumed to have the necessary technical competence. Laws are changing, however. Increasingly, nurses are permitted to perform first-trimester procedures. Second-trimester terminations must still be performed by physicians. Equipment and medicines. Laws sometimes prescribe certain pregnancy-termination methods, but

3 K. Rogo / International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 S75 they do so in general terms. Surgical termination which has historically referred to dilatation of the cervix and removal of products of conception via curettage, either sharp or blunt is the method most often referred to by law. Suction curettage has been used for decades, but was for many years restricted to larger facilities that could afford electrical or foot-pumped suction machines. With the advent of manual vacuum aspiration (MVA), suction curettage has become more applicable to smaller, remote facilities and to non-physicians. Although medical abortion has been practiced for centuries, it has only recently been accepted in modern medical practice. Today, pharmacological methods of abortion are rapidly evolving and changing abortion practices, including the way the surgical option is used w10x. 3. Early diagnosis of pregnancy and determination of gestation 3.1. History and examination In most parts of the developing world, providers rely on patient history and physical examination to diagnose a pregnancy. Experienced providers can confirm pregnancy and estimate gestation from as early as 6 weeks. A soft cervix and enlarged uterus are the more reliable signs, especially when linked to a woman s history of amenorrhea, morning sickness, breast engorgement and tenderness, and frequent urination. Physical examination may also raise suspicion of incomplete abortion, ectopic pregnancy, or multiple gestations. In many programs, training in technological diagnosis of pregnancy is emphasized at the expense of training in physical examination. This is particularly unfortunate for parts of the world where these technologies are less accessible. Professional organizations such as FIGO and the International Federation of Midwives should work to reverse this trend Laboratory and home testing Laboratory confirmation is not always needed to confirm pregnancy, and may even be discouraged in some settings. This has special significance in countries where menstrual regulation is practiced, since menstrual regulation presumes that there is no pregnancy. Laboratory testing is useful when the woman is unsure of her menstrual history or presents with atypical signs of pregnancy. Testing may also help distinguish a molar pregnancy from a normal one. The reliability of the tests and consequences of false-negative results could hinder early diagnosis and delay uterine evacuation, however. In most developing countries, laboratory reagents do not go through the high level of scrutiny and mandatory registration that is applied to drugs. The tests, therefore vary in their sensitivity, specificity, and the gestation at which they become effective. Although it is possible that existing pregnancy tests may have reached their maximum level of accuracy, several factors may affect the actual performance of test kits, including type of hcg measured (whole or sub-units), urinary dilution, and user errors w11 13x. Adolescents and young women who are frequent users of test kits are especially prone to false test results because they are at a higher risk of anovulation. In addition, a wide variety of substandard and counterfeit pregnancy test kits have entered the market simply because they are cheaper. In one clinic in Africa, the provider routinely performs three tests before confirming the results. This is clearly a waste of meager resources. Better regulation and standardization of test quality are needed. Women s and reproductive rights activists have hailed the development of home-based pregnancy tests because they empower women to determine their pregnancy status independently, rapidly, and confidentially. In a survey of 600 females aged years in urban clinics, the prevalence of home pregnancy test use was 34% among the 474 sexually experienced youth. Of these, 77% had received at least one negative pregnancy test result, and 48% took no further action w11x. If homebased pregnancy kits are to benefit poor women in the developing world, manufacturers must provide clearer instructions to reduce user error Ultrasound Despite widespread debate, ultrasonography in early pregnancy has been deemed safe. The Royal

4 S76 K. Rogo / International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 Fig. 2. Recommended abortion methods, by gestation. College of Obstetricians and Gynaecologists has indicated that ultrasound scanning is not necessary for the provision of early abortion care, but this technology has been increasingly applied where it is readily and cheaply available, especially in the developed world w12x. Ultrasound scanning may be used to assess gestation and to confirm that the uterus has been completely evacuated. In addition, ultrasound scanning is useful in detecting ectopic pregnancies, determining fetal viability, and confirming missed abortion. Many professionals argue, however, that the margin of error in ultrasound estimation of gestational age in early pregnancy is similar to that of skilled physical examination, and, therefore scanning is not worth the extra cost. Ultrasound scanning has also generated a new controversy in Islamic countries where abortion is allowed in the first trimester. The Koran allows abortion on the basis that life has not yet been breathed on the fetus before the mother detects any movements. Ultrasound detection of independent fetal heart activity as early as 4 6 weeks raised the debate on the Koranic definition of when fetal life begins at a meeting on Islam and abortion attended by the author in Syria in Whether or not the benefits of ultrasound outweigh the costs, its use in the developing world is constrained by cost, a lack of reliable electricity and adequately trained personnel in some settings. 4. Abortion methods Abortion methods are generally classified as surgical or medical, although dual applications are not uncommon. The correct choice of an appropriate abortion method is a major determinant of safety and outcome. Both gestational age and provider skills are important considerations w13,14x. WHO and others have recently provided a summary of the most appropriate methods for different gestations, based on established protocols used worldwide w15x (Fig. 2).

5 K. Rogo / International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 S77 Table 1 Comparison of vacuum aspiration and D&C Vacuum aspiration Uses plastic or metal cannulae Usually requires only mild sedation, analgesia, andyor local anesthesia Easily performed on an outpatient basis and wellsuited to primary point of care, making it more convenient for patients and providers Typically associated with lower rates of complications (uterine hemorrhage, infection, and perforation) Costs per procedure significantly lower than sharp curettage Greenslade w17x Vacuum aspiration WHO recommends that manual and electric vacuum aspiration replace dilatation and curettage (D&C) as the safer standard methods of surgical abortion w22x. Manual and electric aspiration are deemed equally effective w16x. Compared to D&C, vacuum aspiration use is associated with fewer complications and reduced need for pain management. Vacuum aspiration procedures can be performed in a variety of ambulatory settings, saving the cost of hospital admissions and general anesthesia (Table 1). Vacuum aspiration can also be used safely and effectively by a wider range of mid-level providers, which is an important consideration in the developing world w17x. Manual vacuum aspiration. Introduction of MVA has facilitated the use of vacuum aspiration. MVA requires less up-front capital investment and does not require electricity. The MVA technology consists of a plastic cannula connected to a manual vacuum syringe. MVA can be used for a variety of clinical conditions, including menstrual regulation; early pregnancy termination; treatment of missed abortion, incomplete abortion, and molar pregnancy; and endometrial biopsy. It can also serve as backup for medical abortion. A study of experienced users of MVA equipment in Kenya identified important considerations for MVA design. These included cost, reusability, ease of sterilization, durability of markings, cannula integrity, and fit with the syringes w18x. As the number of manufacturers of MVA instruments has D&C Requires a sharp curette Generally performed under heavy sedation or general anesthesia Typically requires operating room and overnight hospital stay Typically associated with higher rate of complications Costs per procedure significantly higher than vacuum aspiration increased, products vary widely in quality and cost. Currently, there are no regulatory standards to guide buyers of MVA products. Girvin and Ruminjo s study of MVA equipment by eight manufacturers explored durability, quality, safety, and usability of MVA instruments. Data were obtained from manufacturers device specifications, technical evaluation, and field evaluation in the Dominican Republic w19x. Although the investigators acknowledged some limitations of the evaluation, the study raised several important technical issues, including problems related to cleaning, sterilization, and reuse; disassembly of syringes; number of parts; presence of valves; durability of markings; and stability of vacuum. More specifically, the study found that: The high temperatures used to sterilize equipment for reuse compromised their durability. The design of equipment made proper cleaning difficult. The majority of providers experienced difficulty assembling and dismantling MVA devices. The language used in MVA instruction manuals was often too advanced for mid-level practitioners. The lack of compatibility of cannulae and syringes as well as variable cost and quality of equipment were major concerns for users. The authors concluded that no current brand of MVA equipment is perfectly suited for every setting.

6 S78 K. Rogo / International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 Recent advances. Recognizing these concerns, product developers have designed a new generation of MVA cannulae and syringes to withstand the rigor of frequent disinfection and reuse. The Ipas EasyGrip cannulae, introduced in 2003, are available in sizes 4 12 mm and use permanently affixed bases, which eliminate the need for adapters to connect to the aspirator, which in turn results in fewer parts to lose and more efficient procedure preparation. The bases are color-coded by size for rapid differentiation and are constructed with wings to facilitate easy insertion and removal from the aspirator. The new cannulae may be processed by most standard methods, including steam autoclave, resulting in increased efficiency and a lower per-procedure cost. This is a good example of how technological advancements can ease the problems of managing abortion in lowresource settings. Ongoing challenges. Despite the new developments, MVA equipment will still be marketed and labeled for single use. Given that reusability is common and an important part of the cost-reduction strategy in the developing world, the disparity between recommended and actual use must be resolved. Indeed, without reuse, MVA equipment would be too costly and unlikely to gain popular use in the public sector. Additional impediments to wider use of MVA equipment include poor marketing and the lack of sustainable supply systems. Governments and most multilateral organizations do not consider MVA equipment to be an essential reproductive health commodity. Availability on the private market is also limited due to the narrow profit margin for distributors in low-volume markets, which results in high unit costs. As the recommended standard for abortion care in limited resource settings, these issues merit urgent attention Medical abortion Recent technology developments, proof of greater safety, and improved predictability have increased the use of medical abortifacients w20x and influenced the way abortion is managed w21,22x. The safety of modern medical regimens for abortion is now well established w15,23x. Mifepristone. Mifepristone, an antiprogestin, is the mainstay of most medical-abortion regimens w22,24,25x. It acts by binding progesterone receptors, inhibiting the action of progesterone, and, therefore interrupting continuation of pregnancy. Addition of a synthetic prostaglandin analogue (such as misoprostol or gemeprost) augments the process by initiating uterine contractions, which lead to expulsion of the products of conception. Misoprostol is now preferred over gemeprost because it is cheaper and does not require refrigeration w15x. Below 10 weeks from the last menstrual period, mifepristone-misoprostol combinations have an efficacy of up to 98% w26x. Upto 5% of women on this regimen will still require surgical evacuation of the uterus for incomplete abortion or for ongoing pregnancy. The optimal dose and administration route continue to be explored. Currently, the recommended regimen is 200 mg of oral mifepristone followed by 800 mg of vaginal misoprostol w15x. Actual regimens differ widely, however, w18,24x. Research on how regimens should be tailored to specific circumstances for example, whether the woman is kept under observation or returns home is ongoing. In the developing world, hospital admission, use of an operation theatre, and anesthesia drive the cost of safe, good-quality abortion care beyond the reach of poor women. Medical abortion that requires neither admission nor anesthesia is an appealing possibility that could revolutionize practice and dramatically improve access to women in need. Misoprostol-only regimens. Misoprostol has also been successfully used alone to terminate both first- and second-trimester abortions w27x. The 800- mcg vaginal regimen is preferred for first-trimester abortions, and is associated with complete abortion of up to 94% w28x. In the second trimester, misoprostol regimens based on initial vaginal doses of 200 mcg, for a total of 600 mcg, have been associated with success rates approaching 90%, although half of the abortions are incomplete w29x. While not as efficacious as the mifepristonemisoprostol regimen, misoprostol-only methods are affordable and easily available. In Brazil, misoprostol s availability and low cost led to widespread and ill-informed use w30x. In Africa,

7 K. Rogo / International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 S79 misoprostol has been registered in only a handful of countries, including South Africa w29x. In developing countries where misoprostol is not yet registered, it is available in the black market and sells at cost that is four to ten times of what the price would be if legally imported. Furthermore, misoprostol s availability is vulnerable to political pressures placed on manufacturers. These issues highlight the need to develop and disseminate standard regimens for misoprostol use in the first two trimesters of pregnancy, and expand misoprostol s registration and marketing to ensure that good-quality products are available at an affordable price w31x. To ensure affordable and sustainable supplies, additional manufacturers must be encouraged to produce and distribute misoprostol. Methotrexate. Methotrexate, an antimetabolite used for the treatment of gestational trophoblastic disease, is used in some settings where mifepristone is not available. Like mifepristone, methotrexate is used in early pregnancy to stop fetal growth; it is followed by misoprostol, which causes contractions of the uterus. Despite an overall efficacy rate of 92% with 50 mg of methotrexate followed by 800 mcg of vaginal misoprostol a week later, WHO has discouraged the use of methotrexate due to concerns about teratogenicity w32x. Other methods. Other technologies for inducing second-trimester abortion include intra-amniotic injection of hypertonic saline or urea, intra- or extra-amniotic administration of prostaglandin analogues, and use of oxytocin w15x. Although these methods have been less thoroughly researched, they have been condemned due to their invasive nature. Unfortunately, they are still widely used in the developing world because they are cheaper and more available than other methods. This has created a major dilemma for researchers of technologies: Should the methods be studied with a view to improve their safety, or be ignored completely? This is a complex but important issue, since safer abortion technologies are spreading to the developing world at a snail s pace, and they are not affordable to poor people. Given these circumstances, it may be prudent to study lesser-known methods in an effort to influence practice and increase safety. 5. Post-abortion care Post-abortion care (PAC) is an approach for reducing morbidity and mortality from incomplete and unsafe abortion and its resulting complications. As such, PAC can improve women s sexual and reproductive health and lives. The PAC Consortium has recently revised their guidelines to emphasize five PAC elements w33x: Partnerships of community and service providers for preventing unwanted pregnancies and unsafe abortion, mobilizing resources (to help women receive appropriate and timely care for complications from abortion), and ensuring that health services reflect and meet community expectations and needs. Counseling to identify and respond to women s emotional and physical health needs and other concerns. Treatment of incomplete and unsafe abortion and complications that are potentially life threatening. Contraceptive and family planning services to help women prevent unwanted pregnancies or practice birth spacing. Reproductive and other health services that preferably are provided on-site or via referrals to other accessible facilities in providers networks. The technologies used to manage incomplete abortion complications are the same as those used to induce abortion. Managing infection or hemorrhage from abortion complications is similar to managing them during more advanced pregnancy and delivery, and is covered elsewhere in this series w34,35x. Most perforations do not require surgical intervention and can be managed conservatively; laporotomy or laporoscopy can be used to diagnose and manage internal injury. Prophylactic antibiotics for women undergoing surgical abortion may reduce the risk of post-abortion sepsis and should be provided where possible w36x. In most developing country settings, however, routine coverage

8 S80 K. Rogo / International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 for all patients undergoing termination under aseptic conditions is not always feasible; local protocols must be established and adhered to. In cases of incomplete abortion where the circumstances of the initial procedure and duration are unknown, universal broad-spectrum antibiotic cover is necessary and recommended. Clearly, stringent application of infection-control measures is costeffective and more likely to reduce post-abortion sepsis than mere use of routine antibiotic prophylaxis. 6. Post-abortion contraception Most women who experience abortion especially those who induce abortion do not desire to get pregnant immediately. In some circumstances, immediate pregnancy is contraindicated on medical grounds. Post-abortion family planning is, therefore an integral part of comprehensive abortion care. A recent evaluation of post-abortion care services worldwide confirmed that family planning is a weak component of postabortion care w37x. In general, all contraceptive methods can be used after termination of pregnancy, but individualized contraindications limit the use of certain methods. WHO recently summarized the contraceptive methods and limitations of their use after abortion w15x. For example, all hormonal contraceptives and condoms can be used immediately after abortion unless there are contraindications unrelated to the event. Tubal ligation can be done simultaneously, and IUDs can be inserted unless there is pelvis sepsis. WHO recommends waiting 6 weeks before fitting a diaphragm or cervical cap after a second-trimester abortion. Whatever the contraceptive method, adequate counseling and informed decision-making should be guaranteed before the method is given. Given the rapid return of fertility and the wide variety of issues involved in the choice of appropriate contraception after abortion, programs must have good supplies of all methods or be able to refer clients promptly and effectively. 7. The way forward Any effort to reduce abortion-related mortality must begin by determining why so many intelligent women risk their lives to terminate pregnancy and what the direct causes of abortion-related deaths are Why do women choose abortion? Many women want small families but do not want abortion w38x. Yet women seek abortion for a range of reasons, including a desire to stop or postpone childbearing for socioeconomic reasons, problems in their relationships, concerns about their age (too young or too old), health reasons, and coercion from others. These reasons are universally applicable. Often, more than one contributes to their circumstances Why do women die from abortion? Women die due to complications sustained in the abortion process, particularly sepsis, hemorrhage, physical injury, and anesthetic accidents How can technology reduce abortion-related morbidity and mortality? For technology to decrease abortion-related morbidity and mortality, women s motivations and abortion-related complications must be carefully considered. Only then can technological improvement support programmatic and legal efforts to save the lives of women from these preventable catastrophes. In this context, six issues are critical to the choice of technologies for improvement: Prevention of pregnancy. Preventing pregnancy is a priority intervention. Beyond regular contraceptive technologies, advances in and greater access to emergency contraception are a welcome addition to current efforts to prevent unintended pregnancy, especially for women who live in coercive or abusive environments. Early diagnosis of pregnancy. Because terminating pregnancy in the first trimester is much safer, early diagnosis of pregnancy is important. Technological developments are critical to making services safer. Self-testing and rapid pregnancy diagnostic test kits offer advantages only if they are reliable and followed by appropriate action,

9 K. Rogo / International Journal of Gynecology and Obstetrics 85 Suppl. 1 (2004) S73 S82 S81 however. The relatively low effectiveness of many home kits is a legitimate concern and should be addressed by manufacturers. Accurate assessment of gestation. For reasons stated above, accurate assessment of gestation makes it possible to determine the appropriate care and prevent complications and resulting morbidity. This is particularly important for care between the first and second trimesters, when the choice of technology and skills may not be easily determined before the procedure begins and the exact requirements are known. It is not unusual for a provider to go in convinced he is dealing with a 12-week procedure, only to find during examination under sedation or anesthesia a significantly more advanced or multiple pregnancy that requires a different technology or set of skills. Sadly, this often occurs too late for many women. Standardization and supply of MVA technology. The wide variation in quality of MVA equipment and poor cross-compatibility are causes for concern, especially in the developing world, where this technology holds so much promise. Purchasers and providers need regulatory guidelines to assist them in determining the best buy. MVA supply systems need to be strengthened if private- and public-sector providers are to continue to use this technology. Affordable, easy-to-administer regimens for medical abortion. Though safe and effective, medical abortion regimens are still not accessible where they are most needed in the developing world w39x. In many developing countries, these regimens are available only on the black market or through the back door. In addition, the regimens are still too dependent on providers and often require hospitalization. Technological advances, increased market competition, and better information dissemination to women can help achieve the dual aims of reducing both cost and unnecessary medicalization. In summary, the potential value of improved technologies in reducing abortion-related mortality and mortality cannot be denied. In addition to focusing on technologies themselves, researchers must also explore cost, marketing, and use issues. Ultimately, pragmatism should prevail over idealism. As a short- to medium-term measure in the real world, promoting a less-than-perfect abortion technology (like misoprostol alone in first trimester or saline infusion in the second trimester) that is more readily available and affordable to poor women in the developing world will save more lives than waiting to perfect technologies that will remain inaccessible due to cost or other factors. References w1x World Health Organization. Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA (WHOyRHRy01.9). Geneva: WHO, w2x World Health Organization. Unsafe abortion: global and regional estimates of incidence of and mortality due to unsafe abortion with a listing of available country data (WHOyRHTyMSMy97.16). Geneva: WHO, w3x Rogo KO. Induced abortion in sub-saharan Africa. East Afr Med J 1993;70: w4x Henshaw SK, Singh S, Haas T. The incidence of abortion worldwide. Int Fam Plann Perspect 1999;25(Suppl):S30 S38. w5x Berer M. Making abortion safe: a matter of good public health policy and practice. Bull World Health Organ 2000;78: w6x Bongaarts J, Porter RG. Fertility, biology and behavior: an analysis of proximate determinants. New York: Academic Press, w7x Alan Guttmacher Institute. Sharing responsibility: women, society and abortion worldwide. New York: AGI, w8x Rahman A, Katzin L, Henshaw SK. A global review of laws on induced abortion, Int Fam Plann Perspect 1998;24(2): w9x Cook RJ, Dickens BM, Bliss LE. International developments in abortion laws from 1988 to Am J Public Health 1999;89: w10x McKay HE, Rogo KO, Dixon DB. FIGO society survey: acceptance and use of new ethical guidelines regarding induced abortion for non-medical reasons. Int J Gynecol Obstet 2001;75: w11x Shew ML, Hellerstedt WL, Sieving RE, Smith AE, Fee RM. Prevalence of home pregnancy testing among adolescents. Am J Public Health 2000;90: w12x Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. Evidencebased guideline No.7. London: RCOG Press, w13x World Health Organization. Complications of abortion: technical and managerial guidelines for prevention and treatment. Geneva: WHO, w14x Hord CE, Baird TL, Billings DL. Advancing the role of midlevel providers in abortion and post-abortion care: a global review and key future actions. Issues in Abortion Care No. 6. Carrboro, NC: Ipas, 1999.

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