First-trimester abortion protocols in hospitals compared to office-based settings in Switzerland – a national survey study in Switzerland

doi:10.21203/rs.3.rs-1760458/v1

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Research Article

First-trimester abortion protocols in hospitals compared to office-based settings in Switzerland – a national survey study in Switzerland

https://doi.org/10.21203/rs.3.rs-1760458/v1

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Purpose

Simplified first-trimester abortion protocols are well established as they facilitate access to services and improve patient satisfaction without compromising safety. However, data on abortion protocols across Switzerland by facility type are lacking. Therefore, the first aim of this study was to analyse hospital-derived abortion protocols, as opposed to office-based protocols, across Switzerland in terms of their acceptance among women. The second aim was to assess abortion protocols and outcomes of specialised general practitioners (GPs) following simplified protocols.

Methods

This study consists of two parts. (i) A nationwide questionnaire was distributed among hospitals and private practices covering details of abortion protocols and numbers between April and July, 2019. The primary endpoint was the proportion of women undergoing an abortion after the first consultation at the chosen facility (adherence), regarding the complexity of abortion protocols in each setting. (ii) A retrospective study was conducted to analyse the outcomes of office-based institutions with simplified abortion procedures over a period of 10 years from January, 2008, to December, 2018. (BASEC-No. Req-2018-01031).

Results

(i) Office-based facilities showed less complex abortion protocols, resulting in a significantly higher probability of undergoing an abortion after the first consultation than hospitals. Their protocols allowed for a higher gestational age by medical means, and they offered mifepristone intake within the first consultation along with fewer staff members involved and a lower number of overall consultations. (ii) From 5,495 women, a total of 5,274 patients were included, of which the incidence of complications requiring surgery was at a low of 2.5%.

Conclusion

This study highlights that simplified abortion protocols are crucial to ease access to abortion services, as represented by higher adherence in office-based facilities. Simplified protocols in abortion services are safe, and repetitive counselling and in-person visits should only be reserved for selected cases.

First trimester abortion

simplified abortion protocols

abortion according to facility type

medical abortion

aspiration curettage

First-trimester abortions can be performed surgically or medically, and has become a safe medical procedure over the past decades [1]. Since 2002, first-trimester abortions have been legally on-demand by women within the first 12 weeks of pregnancy in Switzerland [2]. Public hospitals and specialised general practitioners (GPs), including gynaecologists and family doctors, in office-based settings are approved by cantons to provide abortion care in Switzerland. Since statutory approval in 2002, the number of abortions has remained stable at one of the lowest levels in Europe. Around 11,000 first-trimester abortions are carried out every year, with 6.4 per 1,000 women aged between 15-49 years [3]. In 1999, anti-progestin mifepristone was approved by Swissmedic (the Swiss Agency for Therapeutic Products) for Medical Abortions [4]. The drug combination mifepristone, followed by the synthetic prostaglandin E1 analogue misoprostol, has been approved for pregnancy termination up to a gestational age of 49 days after the last menstrual period (LMP). To date, 74% of all first-trimester abortions were performed by means of medication, whereas 26% were conducted by aspiration curettage [3]. Based on broad evidence, the aforementioned medical regimen has shown efficacy for up to 70 days after LMP [5-8]. However, the Swiss Society of Gynaecology and Obstetrics (SGGG) recommends a gestational age limit of 49 days after LMP for medical abortion, considering off-label use for later gestational ages [9]. Furthermore, women are often obliged to undergo compulsory counselling followed by a time of reflection, whereas the latter is not mandatory according to the law [2]. Neither home use of mifepristone nor misoprostol is routinely offered. Follow-up ultrasound is recommended 14 days later and should be preferred over self-assessment [9]. Women are obliged to attend three to four consultations, leading to longer waiting times, which might impose further barriers and limit access to services. Emerging evidence indicates that a clinical visit with ultrasound might be replaced by self-assessment using low-sensitivity urine pregnancy tests (LSUPC) and standardised telephone calls [10-14]. No differences were observed in complication rates or patient satisfaction [10]. More importantly, simplifying processes is of utmost importance in low-income settings or sparsely populated areas. However, as well in resource-rich countries such as Switzerland, waiting times could be reduced, thereby improving patient experience. Therefore, international guidelines endorse simplification of abortion care [15-17].

This study analysed the abortion protocols of six GPs in office-based settings in Zurich, Switzerland. In 2014, they carried out 4.5 % of all first-trimester abortions in Switzerland, and around 20% of all first-trimester abortions in the canton of Zurich. Their simplified access to abortion services reflects international recommendations. Ninety-five percent of the women completed the entire abortion process at the chosen GP’s office. In contrast, according to abortion protocols of a major Swiss hospital, adherence to the facility suddenly decreased to 50% after the first consultation in 2018. Although the hospital adhered to Swiss national guidelines, a substantial difference in access to service, medical regimes, number of consultations, and surveillance protocols was observed compared with the above-mentioned private practices. In those specific hospitals, those protocols remained unchanged over many years and were in line with the Swiss guidelines and Swissmedic. However, this sudden decline in adherence to only 50% after the first consultation in 2018 couldn’t be explained, as the current protocols impose higher barriers to accessing abortion care.

The aims (i) of this study were to compare nationwide first-trimester abortion protocols of the two facility types (hospitals vs. office-based settings) and to assess the association of the complexity of these protocols with the proportion of abortions carried out (adherence). Essentially, simplified protocols might not always be better in terms of patient safety, which led us to a further objective: (ii) evaluating the safety and approach of first-trimester abortion of those six office-based facilities, well-known for simplified protocols, providing an extensive dataset over the past decade.

Study design

This retrospective study consisted of two parts. The first part (i) was a study on the complexity of first-trimester abortion protocols by medical and surgical means, comparing Switzerland's public hospitals and office-based facilities. The second part (ii) involved a retrospective study evaluating the safety of first-trimester abortion in an office-based setting from six specialised GPs in Zurich, Switzerland.

The study contained anonymised patient data and was approved by the Ethics Committees of Zurich (BASEC-Nr. Req-2018-01031). This study was conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations [18]. In the first part of the study (i), Swiss public hospitals listed by the Swiss Institute for Medical Education (SIWF) [19] and authorised office-based GPs listed by APAC-Suisse (Swiss Study Group for Abortion and Contraception) were identified in March, 2019 [20]. All the data were collected through surveys. A nationwide multiple-choice questionnaire was distributed among 66 hospitals and 21 private practices, comprising a total of 20 questions covering details of abortion protocols by medical and surgical means and abortion numbers between April and July, 2019. The institution's directors were initially contacted by post and asked to complete a questionnaire. If a questionnaire was missing or incomplete, the facility was contacted via email for further enquiry four and six weeks later. The institutions’ abortion protocols, number of consultations, and number of abortions performed, comprising 2014–2018, were retrospectively acquired. In Switzerland, it is mandatory to report these numbers annually to the chief medical officer of the cantons to validate the accuracy of the data. Furthermore, the institutions’ protocols were all reported by medical doctors with regular involvement in pregnancy termination. Information about patient-level characteristics from the institutions was not acquired. However, in this study, all parts of Switzerland were represented.

Although institution-specific abortion numbers are not publicly available, the absolute annual number of Swiss abortion numbers are [3]. Therefore, every patient seeking pregnancy termination needs to sign a consent for publication of the total number of abortions and records about their age. Missing data from the questionnaires are reported in Supplementary Information (SI) Table 1.

For the second part (ii), six specialised independent GPs affiliated with five private practices offering office-based first-trimester abortions were identified in Zurich, Switzerland. Women who had a first trimester abortion between January, 2008, and December, 2018, were retrospectively identified, and data were collected from their encoded medical records from January to April, 2019. Because their medical records were strictly anonymised, informed consent was not obtained. However, ethical approval for the acquisition of encoded medical records was obtained.

(i) Eligibility

All institutions listed in the registers mentioned above (SIWF and APAC-Suisse) were included. The questionnaire had to be completed in terms of specific abortion protocols. Institutions with missing or incomplete abortion protocols were excluded from the study. Nevertheless, institutions with missing annual data regarding the number of abortion consultations or abortions carried out were included for further analysis (Figure 1).

For the second part of the study, women of all ages undergoing first-trimester abortion by medical or surgical means with a post-abortion follow-up according to local policies of at least six weeks. The detailed characteristics of the patients were acquired from their encoded medical records.

(ii) Variables and study endpoints

The primary endpoint was the proportion of women undergoing an abortion after the first consultation at the chosen facility (adherence), which was measured annually from 2014 to 2018. The questionnaire entailed 20 questions covering details of abortion protocols by medical and surgical means and abortion numbers between April and July 2019. It has been translated into three main Swiss languages (German, French, and Italian). The English translation of the original questionnaire is outlined in SI Table 2.

(iii) Patients and study endpoints

The primary endpoint was the incidence of complications requiring surgery after a medical or surgical abortion, defined as aspiration curettage due to incomplete abortion, ongoing pregnancy, infection, or anaemia bleeding. Clinical follow-up data, including the aforementioned complications, were recorded for at least six weeks after pregnancy termination. Subsequently, a follow-up visit was scheduled to assess complete abortion by ultrasound or self-assessment using a low-sensitivity urine pregnancy test, and patient symptoms and history.

(iv) Statistical analysis

Statistical analyses were performed in R (R version 4.0.4 (2021-02-15)). Descriptive statistics of the characteristics of facilities and their abortion protocols (i) were tabulated by facility type (hospitals vs. office-based) and (ii) overall characteristics of patients. Frequency and percentage were reported for categorical variables, and mean and standard deviation for continuous variables. To assess the association between abortion protocol characteristics and the proportion of women with an actual abortion among those with a first consultation (adherence), we used binomial generalised estimating equation (GEE) models. The facility was used as a cluster term because of repeated measurements per facility ( 2014–2018). Additionally, explanatory variables are known factors, which complicate access to abortion services. The variables are listed in Table 1. We fitted one GEE for each explanatory variable (single-variable model) and a multivariable GEE with all explanatory variables (full model). Odds ratios with 95% confidence intervals (CI) and corresponding p-values are reported.

The data on abortions performed by six GPs (ii) were descriptively analysed. The frequency and percentage of patient characteristics and complications were reported. The rate of complications requiring surgery was estimated using a 95% confidence interval (Wilson score interval).

(i) Searching the SIWF and APAC Suisse database, a total of 39 institutions (25 hospitals and 14 GPs) were finally included, corresponding to a response rate of 45%. The entire study flowchart is shown in Figure 1. Additionally, the number of abortions in Switzerland compared with the number of abortions performed in the 39 institutions is presented in Table 2.

The characteristics of the abortion protocols according to facility type are shown in Table 3. Overall, office-based facilities applied higher gestational age limits, required fewer abortion-care consultations, and administered a lower dose of mifepristone than hospitals did. While cost coverage for medical abortion was confirmed by the vast majority of hospitals and office-based settings at 80% and 85%, respectively, cost coverage for surgical abortion in hospitals was by far less confirmed (40%) than in office-based settings (78%).

(i) Association between protocol complexity and the proportion of abortions performed.

Factors that decreased the complexity of the abortion protocol were associated with higher odds (higher adherence to the chosen facility). In contrast, factors that increased complexity were associated with lower odds of undergoing an abortion at the selected facility after the initial consultation (lower adherence to the chosen facility). Figure 2 shows the unadjusted ORs from single-variable models, whereas Figure 3 shows the adjusted ORs from the full model. For most factors, the unadjusted ORs were more pronounced than the adjusted ORs were. However, both ORs pointed in the same direction. In contrast, the home use of misoprostol increased the odds of undergoing an abortion in the single variable model, whereas it reduced the odds in the full model when adjusted for all other factors. This change in the OR might be because the home use of misoprostol is offered by a much more significant proportion of private practices than hospitals and is, thus, associated with the facility type and other explanatory variables in the full model.

(ii) Characteristics of patients from the six GPs

Between January, 2008, and December, 2018, 5,495 women sought an office-based first-trimester abortion at six GPs in Zurich, Switzerland. Between January, 2008, and December, 2018, a total of 111,066 first-trimester abortions were carried out in Switzerland. Hence, the size of the study population represents a share of 4.95%. Patient characteristics are shown in Table 4. The proportion of medical and surgical abortions changed over time: in 2009, 65% were medical abortions, and 35% were surgical. In 2018, 75% were medical and 25% surgical abortions.

(ii) Follow-up and complication rates of patients from the six GPs

The complication rates are shown in Table 5. The mean follow-up was three months (from six weeks–six months). Two hundred twenty-one patients from a total of 5,495 were lost to follow-up; this is a percentage of 4.02%. A total of 5,274 participants were included in the calculation of complication incidence.

This study was a nationwide comparison regarding first-trimester abortion protocols in public hospitals as opposed to office-based settings, as the latter were hypothesised to be more straightforward and easier to access. Simultaneously, we aimed to retrospectively analyse a considerable dataset of six specialised GPs in Zurich in terms of complication rates, acknowledged for their simplified protocols to investigate safety, success, and acceptability. Furthermore, we intended to determine the association between the complexity of the facility-specific protocol and the proportion of abortions carried out after the first consultation (adherence). This study indicates that less complex protocols, as preferably seen among office-based facilities, lead to higher adherence to the chosen facility, whereas complicating factors in abortion care, as preferably seen among hospitals, seem to be responsible for lower adherence to the selected facility. Arguably, non-adherence to the institution does not necessarily mean that abortion was indeed performed. However, reliable data from a major Swiss hospital, comprising an extensive dataset over the past decade, demonstrates strong coherence between the number of consultations and the number of abortions carried out (adherence) until 2018. Moreover, the number of abortions has remained relatively stable in Switzerland over the past decade [21]. The institutional settings of both hospitals and private practices are different, and thus, according to the results, the latter implies fewer barriers regarding access to services. Office-based settings were characterised by fewer consultations and staff members involved, no imposed time of reflection, a higher proportion applying a gestational age limit above 63 days, offering home use for medical abortion, and a higher proportion of self-assessment during follow-up. Simplified protocols might not always be better in terms of patient safety, which led us to a further objective. (ii) We evaluated the safety and approach of first-trimester abortion in six office-based facilities, well-known for simplified protocols following international guidelines. They have provided an extensive dataset over the past decade. There were no differences in the complication rates compared to those reported in the literature [8].

To the best of our knowledge, this is the first study in Switzerland to compare two facility types (hospitals vs. office-based settings) in terms of abortion service. This retrospective study on first-trimester abortion protocols represented 45% of Switzerland's registered institutions offering abortion services. It also represents 34 – 41% of the Swiss annual abortion case numbers between 2014 and 2018 [3]. Along with fewer consultations for abortion services in office-based settings, the study revealed that 79% of GPs and only 35% of hospitals initiated medical abortions at the first consultation. Compulsory counselling and the imposed time of reflection could be one reason for this. Hence, more consultations led to lower hospital adherence rates. Repeated assessments and counselling may cause delays in accessing abortion services and are not recommended by several guidelines [15-17, 22]. Furthermore, reduced waiting times decrease distress and improve women’s experiences [16, 17]. However, more consultations and a more comprehensive assessment of the individual woman, especially the more vulnerable women, are not necessarily harmful. Occasionally, more time is needed to elaborate on the woman’s needs in terms of somatic or psychological comorbidities. These factors might have contributed to the higher number of consultations among hospitals, as opposed to office-based settings. Moreover, language barriers are another reason for more consultations, while hospitals have more resources to fund interpreters to overcome them. Another reason why more consultations may be beneficial is ambivalence or more thorough counselling regarding contraceptives. Nevertheless, most women have already decided on abortion before their first contact with the caretaker, and they are aware of the contraceptive methods and how to use them. Perceptive and well-educated healthcare providers can decide on a case-by-case basis whether a woman needs more counselling or whether more consultations impose an undesired barrier to abortion care.

Medical abortion is the method most preferred in early pregnancy, to date, representing 74% in Switzerland [3]. However, hospitals were more restrictive regarding the gestational age limit, with only 60% offering medical abortion up to 63 days or more compared to 79% of GPs. There is every possibility that, as a consequence, adherence to the initially contacted institution dropped because abortion care beyond 49 days was not offered. Multiple studies have shown the safety and effectiveness of medical abortions up to 70 days of pregnancy with a regimen of 200 mg mifepristone followed by a single dose of misoprostol [1, 6-8, 23-25]. A systematic review conducted by Abbas et al. showed an overall success rate of 92.3% and an overall ongoing pregnancy rate of 3.1% between 64 – 70 days. No statistically significant difference in success rate could be demonstrated compared to a gestational age up to 63 days after LMP (93.9%) [8]. The reason for more conservative approaches by hospitals might be the current Swissmedic approval of mifepristone limited to 49 days after LMP [4] and the guidelines from the Swiss Society of Gynaecologists and Obstetricians (SGGG), where medical abortion beyond 49 days after LMP represents off-label use [9]. Therefore, hospitals are more restrictive in this regard, probably for legal reasons.

Women prefer home use of mifepristone, and misoprostol is preferred by women. It is safe and effective, showing that health professionals are no longer obliged to directly dispense the medication to women [5, 6, 26-28]. Clinicians can prescribe mifepristone, misoprostol, and pain medications for home use, which might increase women’s experience, satisfaction, and privacy. As such, it comes as no surprise that abortion rates were lower in hospitals, which less frequently offered home use of mifepristone and misoprostol, compared to GPs. Privacy is pivotal in abortion care. Therefore, many women prefer home use to surveillance in hospitals. Nevertheless, safety and non-traumatic experiences are crucial, and not all women qualify for self-management. More importantly, those who are eligible and choose home use should be empowered and well informed about painkiller use and instant access to emergency services. Therefore, they should be aware of what is expected during the procedure. Self-determination and independence are paramount for enhancing this challenging experience. Moreover, women suffering from a first-trimester miscarriage are less prepared and possibly without painkillers while experiencing comparable pain somatically and psychologically.

In this study, only 8% of hospitals and 29% of GPs gave women the opportunity for post-abortion follow-up through self-assessment. They were given a low-sensitivity pregnancy test to apply two weeks after the abortion and were contacted by telephone to assess their symptoms instead of a routine clinical visit. These numbers are low because the distances in Switzerland to abortion providers are relatively short, and insurance coverage for ultrasound assessment is granted. However, the number of clinical visits is an essential factor in women’s acceptance of the first trimester abortion protocol, which further reduces waiting times. Guidelines no longer endorse in-person visits with routine clinical follow-up, since remote and self-assessment are viable alternatives to in-person follow-up [5, 16, 17]. Oppegaard et al. demonstrated that self-assessment with a semiquantitative urine human chorionic gonadotropin test and standardised assessment of women’s symptoms were not inferior to standard clinical follow-up in terms of complication rates [10, 29]. Self-assessment and telemedicine are especially valuable in resource-poor settings, sparsely populated regions, and during the COVID-19 pandemic [10, 30]. By experience, many women do not return to in-person follow-up after medical abortions in Switzerland, even though the costs are reimbursed. Hence, self-assessment could be an appropriate alternative, which is currently still underrepresented [10]. These arguments are supported by the fact that ongoing pregnancies are low at around 0.4 – 3% in early medical abortions using a standard regimen with mifepristone and misoprostol [11, 31-34]. More importantly, women undergoing ultrasound assessment frequently receive unnecessary interventions following a medical abortion, such as aspiration curettage for misinterpreted residual abortion material caused by inexperienced providers [10]. The failure rate of surgical abortion is approximately the same as that of medical abortion, and an in-person follow-up visit is not required for the latter procedure [22]. However, follow-up appointments might be valuable for some women in assessing their psychological aspects. Additional contraceptive counselling is another reason why another appointment may be beneficial.

Cost-effectiveness of surgical abortion has only been confirmed by 40% of hospitals compared to 77.8% among GPs, which might be directly related to more complicated protocols (e.g., more staff members involved, more consultations, surveillance during medical abortion). However, amid growing concerns regarding cost coverage, hospitals should be encouraged to adjust their abortion protocols because safety and effectiveness are seemingly uncompromised [34].

The second part of our study evaluated the safety of first-trimester abortion in an office-based setting in a cohort of six specialised GPs in Zurich. We had access to an extensive dataset from specialised GPs regarding office-based abortion services by medical and surgical means. Their policies, in order to ease access to abortion, services were adopted more than ten years ago.

From 2008 to 2018, 5,495 first-trimester abortions were performed. Of these (total of 5,495), 75% and 25% were performed by medical or surgical means, respectively. Abortion protocols for medical or surgical abortion were focused on facilitating access to abortion services, namely, limiting the number of consultations, reducing waiting time, offering medical abortion up to 70 days after LMP, home use of mifepristone and misoprostol, and the possibility of self-assessment instead of routine clinical follow-up. Despite simplified protocols, the overall complication rate requiring surgical aspiration was at a low of 2.4%. This rate is comparable to those of other studies that offer the same setting [8, 10, 11, 14, 34, 35]. Anaemic bleeding, ongoing pregnancies, and the patient’s preference to refuse another dose of misoprostol was included in this 2.4% aspiration rate. Acceptance among women was high and the number lost to follow-up was low at 4%. The known simplified abortion protocols of the six GPs with effectiveness, safety, limited waiting times, and a low number of consultations might be the reason for the higher adherence. In a retrospective cohort study of more than 50,000 abortions conducted by Robertson et al., abortion-related morbidities and adverse events were compared by facility type (hospitals vs. office-based settings). The overall abortion-related morbidity or adverse event was 3.3%, not indicating a significant difference between the two facility types [36].

This study has several limitations. (i) First, its retrospective nature leads to potential bias. Second, the variables were self-reported based on questionnaires. Third, despite the nationwide survey, the French speaking part was underrepresented in this study. Fourth, the abortion rate was defined as the number of abortions performed out of the number of consultations seeking an abortion at a specific institution in a particular year. However, we do not know whether women not undergoing abortion at the institution where they had their first consultation did not undergo an abortion or underwent an abortion at another institution. Consequently, the rates of abortions performed are probably underestimated as such and need to be interpreted as institution specific. However, since the focus of our study was on associations with rates of abortion based on odds ratios, rather than communicating rates of abortion themselves, this should not compromise our results. (ii) First, despite a nearly complete dataset of six specialised GPs over a decade, the retrospective nature of the study leads to some potential bias. Second, the complication rates that required surgery were not clearly defined. Reasons such as retained tissue, abortion-related infection, haemorrhage, ongoing pregnancies, and missed ectopic pregnancies have not been further specified. Therefore, the minor and major adverse events could not be differentiated.

Our nationwide study highlights that simplified abortion protocols are crucial to ease access to abortion services, represented by higher adherence in office-based facilities as opposed to hospitals. Additionally, we found that office-based settings, compared with hospitals, allow for fewer consultations, more flexible gestational age limits, and self-assessments as a follow-up. At the same time, cost coverage of the procedures supports office-based settings. Abortion is a form of health care and, as such, safety is crucial. Nevertheless, unnecessary barriers, including repetitive counselling and undesired in-person visits, should be avoided because they are no longer recommended for every woman seeking abortion care. Simplified protocols in abortion services are safe, and repetitive counselling and in-person visits should only be reserved for selected cases.

Footnotes

Reporting guidelines: The authors have completed the STROBE reporting checklist.

Ethical statement: The authors are accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The second part of the study contained anonymised patient data and was conducted in accordance with a clarification of responsibility, approved by the Ethics Committees of Zurich (BASEC-Nr. Req-2018-01031).

Author contributions

Herewith, we confirm authorship credit as follows:

Conception and design: Samuel Martin Eckstein, Stefanie von Felten, Denise Vorburger
Administrative support: all authors
Provision of study materials: all authors
Collection and assembly of data: Samuel Martin Eckstein, Denise Vorburger
Data analysis and interpretation: Samuel Martin Eckstein, Stefanie von Felten (data analysis), all authors (interpretation)
Manuscript writing: all authors
Final approval of manuscript: all authors

Acknowledgements

The authors would like to thank André Seidenberg, MD, Bruno Maggi, MD, Daniel Oertle, MD, Heinrich Diggelmann, MD, Benjamin Stutz, MD, and Choon-Kang Walther, MD, for their valuable contributions in providing anonymised complete datasets about first-trimester abortion in their office-based settings. Furthermore, the authors thank all participants from hospitals and office-based services for their valuable replies to the questionnaires, which made this study possible. We would also like to thank Editage (www.editage.com) for Enlish language editing.

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Kahn, J.G., et al (2000) The efficacy of medical abortion: a meta-analysis. Contraception. 61(1): p. 29-40.
Schummers, L., et al (2022) Abortion Safety and Use with Normally Prescribed Mifepristone in Canada. N Engl J Med. 386(1): p. 57-67.
Perriera, L.K., et al (2010) Feasibility of telephone follow-up after medical abortion. Contraception. 81(2): p. 143-149.
Roberts, S.C.M., et al (2018) Association of Facility Type With Procedural-Related Morbidities and Adverse Events Among Patients Undergoing Induced Abortions. JAMA. 319(24): p. 2497-2506.

Tab 1 Complicating parameters in abortion care – definitions

	Possible answers	Specified as complicating
Gestational age limit - d	Up to 49/63/70/77/84 days after LMP	Lower gestational age limit in days
No. of consultations	1 - 6	Higher no. of consultations
Compulsory counselling and imposed time of reflection	Yes / No	Yes
Possibility for oneStopMTOP*	Yes / No	No
Possibility of misoprostol home-use	Yes / No	No
No. of staff members involved	1 – 4	More staff-members involved

* one Stop (consultation) for Medical Termination of Pregnancy

Tab 2 Total number of abortions in Switzerland compared to those performed in the 39 institutions analysed from 2014 to 2018

	2014	2015	2016	2017	2018
	n (%)
No. of abortions in Switzerland (FOPH*)	10275	10289	10273	10037	10457
No. of abortions in the 39 institutions analysed	3852 (38%)	4112 (40%)	4021 (39%)	4166 (41%)	3567 (34%)

*Federal Office of Public Health [21]

Tab 3 Characteristics of abortion protocols by facility type (Hospital vs office-based)

			Hospital n=25	Office-based n=14	Missing data
			n (%)	n (%)	%
Gestational age limit for medical abortion (days after LMP*) - days		49	10 (40.0)	3 (21.4)	0
		63	10 (40.0)	8 (57.1)
		70	2 (8.0)	3 (21.4)
		77	1 (4.0)	0 (0.0)
		84	2 (8.0)	0 (0.0)
Total no. of consultations for medication abortion - no		1	0 (0.0)	1 (7.1)	0
		2	4 (16.0)	6 (42.9)
		3	11 (44.0)	6 (42.9)
		4	10 (40.0)	1 (7.1)
Imposed time of reflection			17 (73.9)	2 (14.3)	5.1
Possibility of medical abortion induction at the first consultation			8 (34.8)	11 (78.6)	5.1
Home-use after misoprostol intake			6 (25.0)	8 (57.1)
Possibility of oneStopMToP†			2 (8.3)	4 (28.6)	2.6
Total number of consultations for surgical abortion - no		2	2 (8.0)	0 (0.0)	10.3
		3	12 (48.0)	10 (100.0)
		4	11 (44.0)	0 (0.0)
Procedural setting	Operating theatre with ward-use		8 (32.0)	1 (10.0)	10.3
	Operating theatre without ward-use		9 (36.0)	0 (0.0)
	Day-care unit		8 (32.0)	1 (10.0)
	Office-based (short stay)		0 (0.0)	8 (80.0)
Cervical maturation with misoprostol			23 (92.0)	8 (80.0)	10.3
General anaesthesia			25 (100.0)	3 (30.0)	10.3
Neuraxial anaesthesia			12 (48.0)	1 (10.0)	10.3
Local anaesthesia			0 (0.0)	6 (60.0)	10.3
Local anaesthesia with sedation			0 (0.0)	7 (70.0)	10.3
No. of staff members involved - no		1	8 (32.0)	11 (78.6)	0
		2	14 (56.0)	3 (21.4)
		3	3 (12.0)	0 (0.0)
Cost coverage to first-trimester medical abortion by TARMED‡ - Yes			12 (80.0)	11 (84.6)	28.2
Cost coverage to first-trimester surgical abortion by TARMED‡- Yes			6 (40.0)	7 (77.8)	38.5
Do you think that simplified abortion protocols (e.g. oneStopMTop, home use of misoprostol and no compulsory counselling and time of reflection) decrease safety? - Yes			8 (33.3)	6 (46.2)	5.1
Do you think simplified abortion protocols increase women’s comfort? - Yes			18 (75.0)	4 (33.3)	7.7
Language		G	23 (92.0)	13 (92.9)	0
		F	1 (4.0)	1 (7.1)
		I	1 (4.0)	0 (0.0)

* Last menstrual period

† one Stop (one consultation) for Medical Termination of Pregnancy

‡ Swiss Fee-for-Service-System

G = German, F = French, I = Italian; Group 1 = Hospitals, Group 2 = General Practitioners

Tab 4 Characteristics of the Patients treated by six General Practitioners (GPs) from Zurich.

Characteristics		N = 5495	Missing data
		n (%)	n (%)
Age (yr) - Mean (SD)		29.95 (6.81)	0 (0.0)
Age group – yr	18 – 20	433 (7.9)
	20 – 25	1086 (19.8)
	25 – 30	1349 (24.5)
	30 – 35	1301 (23.7)
	35 – 40	929 (16.9)
	40 – 45	371 (6.8)
	>45	26 (0.5)
Residency	Zurich	3809 (72.8)	258 (4.7)
	All cantons in CH except Zurich	1146 (21.9)
	Foreign countries	279 (5.3)
Country of origin	CH citizen	2604 (49.8)	264 (4.8)
Country of origin	Foreign countries	2629 (50.2)
No. of current pregnancy	1st	2476 (45.1)	0 (0.0)
	2nd	1252 (22.8)
	3rd	878 (16.0)
	4th	518 (9.4)
	5th and more	371 (6.7)
No. of previous pregnancies	0	3297 (60.0)	0 (0.0)
	1	967 (17.6)
	2	870 (15.8)
	3	278 (5.1)
	4 and more	82 (1.5)
No. of previous first-trimester abortion	0	4214 (76.7)	0 (0.0)
	1	1027 (18.7)
	2 and more	254 (4.6)
Type of abortion	By surgical means	1729 (31.5)	0 (0.0)
Type of abortion	By medical means	3766 (68.5)	0 (0.0)
Gestational age (days) – Mean (SD)		49.71 (15.84)	0 (0.0)
Gestational age – d	0 – 56	4320 (78.6)
	57 – 70	601 (10.9)
	71 – 84	243 (4.4)
	85 – 112	316 (5.8)
	113 – 154	15 (0.3)

Tab 5 Complications in patients who had an abortion at six General Practitioners (GPs) from Zurich.

Complications		N = 5274	95% CI	Missing data
		n (%)	%	%
Indication of curettage (Total)		133 (2.5)	2.12 – 2.99	0
Indication of curettage after medical abortion		119 (3.3)	2.76 – 3.96	0.8
Indication of second curettage after surgical abortion		14 (0.8)	0.475 – 1.433	0
Reason for curettage by medical mean	Anaemic bleeding	24 (20.2)	13.6 – 28.7	0
Reason for curettage by medical mean	The patient refused repetitive misoprostol due to incomplete abortion in the absence of anaemic bleeding	95 (79.8)	89.2 – 98.8	0
Reason for curettage by surgical mean	Anaemic bleeding	4 (28.6)	9.58 – 58.00	0
Reason for curettage by surgical mean	Incomplete abortion needing surgery in the absence of anaemic bleeding	10 (71.4)	42.0 – 90.4	0

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First-trimester abortion protocols in hospitals compared to office-based settings in Switzerland – a national survey study in Switzerland

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