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Cervical priming before D & E in South Africa

Daniel Grossman, Ibis Reproductive Health, 2009

Project abstract

In South Africa, abortion is legal for several indications up to 20 weeks gestation, and approximately 25% of all abortions take place in the second trimester. Most public sector second trimester procedures are performed by medical induction with misoprostol alone, although in the Western Cape Province, a team of roving doctors provides D&E. Cervical priming is achieved using sublingual misoprostol, and laminaria tents are not used.

Recent research documented that D&E is being performed safely in this setting, and no major complications were observed in a series of 203 procedures. However, 43% of all women undergoing D&E expelled the fetus prior to the procedure, and this was often an unexpected and traumatic experience for women.

The goal of the proposed project is to improve cervical preparation prior to D&E by performing a randomized controlled trial comparing a modified protocol using sublingual misoprostol to one using laminaria. Women seeking abortion between 13 and 20 weeks gestation will be randomized to one of two cervical preparation treatments: 1) misoprostol 400 mcg sublingual administered approximately six hours prior to D&E and repeated three hours later, or 2) laminaria tents placed intracervically 18 to 24 hours prior to D&E.

Approximately 100 women will be recruited into each treatment arm. Clinical information will be recorded, and women will be interviewed about their experience. The primary outcome will be fetal expulsion prior to D&E, and the secondary outcomes will be need for manual cervical dilation and client acceptability. Feasibility of scaling up the use of laminaria for cervical priming will be assessed by performing in-depth interviews with 15 physicians, nurses, administrators and Department of Health coordinators.

The results of the study will be used to improve the quality of second trimester abortion care in South Africa and inform programs and policies in other similar low-resource settings.

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