Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review
Authors: Baraitser Paula , Free Caroline , Norman Wendy , Lewandowska Maria , Meiksin Rebecca , Palmer Melissa , Scott Rachel , French Rebecca , Wellings Kaye , Ivory Alice , Wong Geoffrey ,   The SACHA study team
Published: July 2022

Objectives

To synthesise evidence on user experience of medical abortion at home

To develop a realist programme theory to explain what interventions improve user experience for whom and in what context.

To use this programme theory to develop recommendations for service providers and those having medical abortions at home

Background

Changes in the therapeutic, technological and regulatory landscape are increasing access to medical abortion at home. This intervention is safe, effective and acceptable to most. Clinical pathways and user experience are nevertheless variable and a minority would not choose this method again. We synthesised evidence to inform service development and responsiveness for different people and contexts.

Methods

We used a realist approach to literature review that starts from an initial programme theory and generates causal explanations in the form of context-mechanism-outcome configurations to test and develop that theory. We searched the literature 01/01/2000 - 09/12/2022 using broad search terms and then selected papers for their relevance to theory development in contexts relevant to service development in the UJ. Data were analysed using a realist approach to analysis to develop causal explanations.

Results

Our searches identified 12,517 potentially relevant abstracts with 835 selected for the full text assessment and 49 papers included in the final review. Our synthesis suggests that having a choice of abortion location remains essential as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (number, timing and wait for appointments), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and wish to be aware of/involved in the process. We found that the option for self-referral through a telemedicine consultation, realistic information on range of experiences, opportunities to personalise the process, improved pain relief and choice of when and how to discuss contraception could improve experience.

Discussion

Acknowledging the work done by patients when moving an intervention from clinic to home is important. This includes preparing a space, managing privacy, managing work/caring obligations, deciding when/how to take medications, understanding what is normal, assessing experience and deciding when and how to ask for help. Strategies that reduce surprise or anxiety and enable preparation and a sense of control support the transition of this complex intervention outside healthcare environments.

Strenghts and limitations

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Strengths: systematic and transparent approach to the realist review, which was conducted in accordance with the RAMSES standards (27); Authorship team represents a variety of clinical and academic backgrounds

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Limitations: analysis on publicly accessible literature, located through recognised research databases and Google; there were gaps in the evidence that we found and we have highlighted these in our conclusions.