Effectiveness, Safety, and Acceptability of Medical Abortion at Home vs. In the Clinic: A Systematic Review and Meta-Analysis in Response to COVID-19

Abstract

Background: Increased access to home-based medical abortion may offer women a convenient, safe, and effective abortion method, reduce burdens on healthcare systems, and support social distancing during the COVID-19 pandemic. We compared the evidence on the effectiveness, safety, and acceptability of home-based to clinic-based medical abortion among women seeking abortion in any setting.Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized studies (NRSs) was conducted. We searched Cochrane Central Register of Controlled Trials, POPLINE, and WHO ICTRP from inception to 10 July 2019. We searched MEDLINE, Embase, CINAHL, LILACS, clinicaltrials.gov, Google Scholar, and PubMed from inception to 14 June 2020. Successful abortion was the main outcome of interest. Eligible studies were RCTs and NRSs studies with a concurrent comparison group comparing home vs. clinic-based medical abortion. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Estimates were pooled using a random-effects model. We used the GRADE approach to assess risk of bias by outcome and to evaluate the overall quality of the evidence. We registered the study with PROSPERO, number CRD42020183171.Findings: We identified 6277 potentially eligible records. Nineteen studies (three RCTs and 16 NRSs) were included with 11,576 women seeking abortion up to nine weeks gestation. Neither the RCTs nor the NRS found any difference between home-based and clinic-based administration of medical abortion in having a successful abortion (RR 0.99, 95% CI: 0.98-1.01, I2 =0%; RR 0.99, 95% CI: 0.97-1.01, I2 =52%, respectively). The certainty of the evidence for the 16 NRS was downgraded from low to very low due to high risk of bias and publication bias. The certainty of the evidence for the three RCTs was downgraded from high to moderate by one level for high risk of bias.Interpretation: Home-based medical abortion is effective, safe, and acceptable to women. This evidence should be used to expand women’s abortion options and ensure access to abortion for women during COVID-19 and beyond.Funding: This review is supported by the William & Flora Hewlett Foundation.Declaration of Interests: The authors declare no competing interests.