Self-assessment of the outcome of first trimester medical abortion compared to routine clinic follow-up: A systematic review

Background: Home self-administration of misoprostol for medical abortion has been suggested as safe, efficient, feasible and acceptable. However, it remains inaccessible for many women especially in low-resource settings. Administration of misoprostol at home and self-assessment by urine pregnancy tests (UPTs) to confirm complete termination of pregnancy with follow-up by home visits or telephone call after 12-15 days after the intake of mifepristone helps to de-medicalize abortion and provides privacy to women. Objective: To assess the effectiveness, safety, and acceptability of self-assessment of the outcome of medical abortion in a non-inferiority comparison with routine clinic follow-up after medical abortion at home. Methodology: A systematic review for randomized controlled trials (RCTs) of self-assessment of the outcome of medical abortion compared with routine clinic follow-up was conducted. The systematic review followed the Cochrane Handbook of Systematic Reviews for Intervention. A thorough search was performed in databases such as Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, CINAHL, British Nursing Index and Archive, Scopus and Google Scholar. Searches were also done in ClinicalTrials.Gov and WHO-ICTRP for ongoing studies. The population was women of reproductive age, 15 years or above, who had a confirmed pregnancy and who had requested a medical termination of pregnancy up to 9 weeks (63 days) of gestation age, which they performed at home. The intervention, self-assessment of outcome done by UPTs by women themselves at home combined with a follow-up by telephone call or home visit to confirm the complete termination of pregnancy, was compared with assessment of the outcome of medical abortion performed by medical/health care personnel during routine clinic follow-up visits. The primary outcome was effectiveness of self-assessment of the outcome of medical abortion compared to routine clinic follow-up, while its safety and acceptability were the secondary outcomes. Risk of bias (RoB) assessment was performed for each included RCT in accordance with the criteria in the Cochrane Handbook for Systematic Reviews of Interventions. The outcomes were analysed as risk ratios (RR) with 95% confidence intervals (CI). Review Manager 5.3 (RevMan 2014) was used to pool the data (meta-analysis) and to generate forest plots to display the results. A GRADE (Grading of Recommendations Assessment, Development, and