Using mobile phones to strengthen medical abortion provision: opportunities and dangers identified from the South African experience.
Deborah Constant1, Katherine de Tolly2, Marijke Alblas3,4 1University of Cape Town, Cape Town, South Africa, 2Cell-Life, Cape Town, South Africa, 3Association des sages femmes, Douala, Cameroon, 4CSU/CNRS, Paris, France - email@example.com
Objective: To report the South African experience using text systems on mobile phones to provide support and a self-assessment of completion of their procedure to women undergoing medical abortion. Methods: A randomized controlled trial during 2011-2012 recruited 469 women seeking medical abortion at clinics in South Africa. All women received standard abortion care with mifepristone and home administration of misoprostol and were asked to return to the clinic to assess completion 14 - 21 days later. Consenting women were randomized to standard-of-care or intervention groups. The intervention group received timed SMSs over the period between their clinic visits, with reminders on what to expect, alerts to complications and encouragement to complete the self-assessment. They were also prompted to access a contraception mobisite. Interviews were conducted at both clinic visits and one month later by telephone. Results: Most found the SMSs helped them manage the abortion symptoms and would recommend them to a friend; however 20% of recipients had concerns around phone privacy. The intervention group were significantly better prepared (p<0.05) for the pain, bleeding and side effects of the abortion. Of the 5471 messages sent, there was only a 5% failure rate. Seventy-eight percent completed the self-assessment and of these, 93% found it easy to do, however the questions did not predict all cases requiring further surgical management or additional misoprostol. More in the intervention group chose long-acting reversible contraception at their follow-up clinic visit. Conclusions: Support SMSs were effective in assisting women manage their abortion symptoms between clinic visits. Most could conduct a self-assessment of abortion completion on their mobile phones and promotion of contraception can succeed using mobile text systems. The self-assessment showed promise but was not sufficiently accurate; problems with privacy can be of concern for some women and a mechanism for stopping the SMSs is required.
Strengthening autonomy: Mobile technology and self-assessment for medical abortion
Deborah Constant1, Jane Harries1, Caitlin Gertz2
1University of Cape Town, Cape Town, South Africa, 2Ibis Reproductive Health, San Francisco, USA
Shortages of providers of surgical abortion methods are a significant barrier to safe abortion care across diverse settings where abortion is legal. Early medical abortion using mifepristone and misoprostol requires less provider involvement, is highly effective and can largely be managed by women themselves. Medical methods are highly acceptable to women and can increase women’s autonomy.
Self-determination of gestational age eligibility, self-administration of misoprostol and management of abortion symptoms, self-assessment of abortion outcome and selection of postabortion contraception can be strengthened using mobile phone technology (mhealth). Reliable networks, adequate connectivity, phone ownership and phone privacy are necessary for mhealth to effectively facilitate safe abortion care. These conditions exist in developed but also in many developing countries.
In South Africa studies have shown most women with gestations within 70 days can recall their last menstrual period with sufficient accuracy and use an online gestational age calculator to determine eligibility for medical abortion. Supportive text messages including reminders and information on complications over 14 days following mifepristone significantly improved preparedness and provided effective emotional support during the abortion. Self-assessment using a text questionnaire was feasible, but not accurate, and a low sensitivity pregnancy test was necessary to better detect ongoing pregnancies. Twenty-three percent of women correctly recalled information from the messages on contraceptive methods 4-6 weeks after they had received them. In Colombia a low sensitivity pregnancy test together with text questions for self-assessment was a safe and feasible alternative to in-facility care.
Mhealth, using text messages, shows promise for strengthening women's roles and control with respect to medical abortion. Other approaches include telemedicine consultations, automated text checklists on incomplete abortion symptoms, digital images to verify pregnancy test results and online resources with contraceptive advice. The increasing familiarity with digital technology provides a powerful opportunity to strengthen women’s reproductive autonomy.