Examining impacts of approval of home use of misoprostol in England on access to medical abortion

ObjectivesTo assess the impact of the December 2018 approval of home administration of misoprostol in England on access to medical abortion. DesignTime series analysis SettingBritish Pregnancy Advisory Service (BPAS), independent-sector abortion provider in England Participants145,529 abortions carried out by BPAS across England between 2018 and 2019. InterventionApproval of home administration of misoprostol in early medical abortions (EMA) in December 2018 Main outcome measureGestational age at abortion and EMAs as a proportion of all abortions. The analysis was stratified by key sociodemographic characteristics to assess differential impacts of the approval Results99,008 abortions took place in the period before the approval or during its implementation phase (January 2018 - June 2019) and 46,521 took place after (July 2019 - Dec 2019). Compared to if former trends had continued, the actual proportion of EMAs was 4.2% higher in December 2019 and the mean gestational age 3.4 days lower. ConclusionFollowing the approval of home use of misoprostol, we saw an acceleration in the trends towards increasing proportion of all abortions that were EMAs and decreasing gestational age at abortion, especially in more deprived areas of England. Some inequities remain across race/ethnicity groups that require further investigation. Policymakers should take the positive results of this study into consideration when reviewing rules for home management of medical abortions, including with home use of mifepristone. What is already known on this topicIn 2018 in England, a womans "home" was designated as a class of place where misoprostol could be used to induce abortion up to 10 weeks gestation following administration of mifepristone in a medical facility. This model of abortion care has been shown in numerous international studies to be highly effective, safe, and preferred by women over in-clinic use. Existing data anticipated positive clinical and acceptability outcomes with implementation of home use, but whether or how the change would impact access particularly in relation to barriers such as area-level deprivation, race/ethnicity, and disability was uncertain. What this study addsThe approval of home use of misoprostol as part of a medical abortion regimen in England was associated with material and equitable improvements in abortion access as evidenced by a higher proportion of medical abortions provided, lower gestational age at treatment, and higher odds of having a medical abortion across all racial/ethnic groups and socioeconomic groups. Pre-approval trends toward greater uptake of medical abortion and declining gestational age were accelerated post-approval and were greatest in the most deprived quintiles but not across all racial/ethnic groups. Patient and Public Involvement StatementThis study was a quantitative data analysis of existing clinical data and patients were not directly involved in the research. Authors note on terminologyThe authors would like to note that abortions are experienced not only by cis-women, but also by trans, non-binary and intersex people, who should be recognised and treated as equal recipients of abortion care. The term women will be used in this project for simplicity and in acknowledgment of the fact that the majority of the patients identify as women.