Comparison of medical abortion with surgical vacuum aspiration: women's preferences and acceptability of treatment.

Objectives--To assess women's preferences for, and the acceptability of, medical abortion and vacuum aspiration in the early first trimester.

Design--Patient centred, partially randomised trial. Medical abortion was performed with mifepristone 600 mg followed 48 hours later by gemeprost 1 mg vaginal pessary. Vacuum aspiration was performed under general anaesthesia.

Setting--Teaching hospital in Scotland.

Patients--363 women undergoing legal induced abortion at less than nine weeks' gestation.

Main outcome measures--Women's preferences for method of abortion before abortion; acceptability judged two weeks after abortion by recording the method women would opt to undergo in future and by semantic differential rating technique.

Results--73 (20%) women preferred to undergo medical abortion, and 95 (26%) vacuum aspiration; 195 (54%) were willing to undergo either method, and were allocated at random. Both procedures were highly acceptable to women with preferences. Gestation had a definite effect on acceptability in randomised women; at less than 50 days there were no differences, but between 50 and 63 days vacuum aspiration was significantly more acceptable.

Conclusions--Women who wish to use a particular method should be allowed their choice, regardless of gestation. Women of 50-63 days' gestation without preferences for a particular method are likely to find vacuum aspiration more acceptable. A patient centred, partially randomised trial design may be a useful tool in pragmatic research.

Introduction

In Britain, one third of all legally induced terminations of pregnancy are performed at less than nine weeks' gestation; 99% of these early abortions are achieved surgically by vacuum aspiration, usually under general anaesthesia.[1 2] Medical abortion with mifepristone (RU 486) and a gemeprost vaginal pessary is now available, and reports suggest that it provides a safe and effective alternative to surgery in early pregnancy.[3-6] However, the demand for, and the acceptability of, medical abortion in British women is largely unknown.

There is an increasing awareness among both the general public and the medical profession of the need to incorporate patients' preferences into medical decision making. The acceptability of any method of treatment will influence the degree to which it is used by consumers, with important implications for health care planners.[7 8] Recognising this, Schwartz and Lellouch distinguished between "explanatory" and "pragmatic" objectives in clinical trials.[9] Explanatory trials seek to enhance scientific knowledge by identifying the most efficacious treatment under ideal circumstances, but generalising from a rigidly controlled experiment to actual clinical practice may be difficult.[10 11] Pragmatic trials seek to answer the clinically more relevant question, "Which treatment is most effective in normal clinical practice?", thus contributing to improved decision making.[12] …