Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries

Objective: Abortion-related complications remain one of the leading causes of maternal morbidity and mortality worldwide. Nearly half of all abortions are unsafe, and the vast majority of these occur in low and middle-income countries. The use of mifepristone with misoprostol for medical abortion has been proposed and implemented to improve abortion safety. Data Sources: A systematic review of the literature was conducted in PubMed, Embase, Cochrane, and CINAHL. Study Selection: Criteria for study inclusion were first-trimester abortion, use of mifepristone with misoprostol, and lowor middle-income country status as designated by the World Health Organization. Data Extraction: Results for effectiveness, safety, acceptability, and qualitative information were assessed. Data Synthesis: The literature search resulted in 181 eligible articles, 52 of which met our criteria for inclusion. A total of 34 publications reported effectiveness data on 25 385 medical abortions. The average effectiveness rate with mifepristone 200 mg and misoprostol 800 mg was 95% up to 63 days gestation. A sensitivity analysis was performed to assume that all women lost to follow-up failed treatment, and the recalculated effectiveness rate remained high at 93%. The average continuing pregnancy rate was 0.6%. A total of 22 publications reported safety and acceptability data on 17 381 medical abortions. Only 0.8% abortions required presentation to hospital, and 87% of patients found the side effects of treatment acceptable. Overall, 95% of women were satisfied with their medical abortion, 94% would choose the method again, and 94% would recommend this method to a friend. A total of 16 publications reported qualitative results and the majority supported positive patient experiences with medical abortion. Conclusions: Mifepristone and misoprostol is highly effective, safe, and acceptable to women in lowand middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.