Medical abortion offered in pharmacy versus clinic-based settings: A systematic review

Objective: Expanding access to medical abortion through pharmacies is a potential strategy to promote safe abortion care. To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion. Study design: We searched multiple databases and the gray literature through November 2020. No language restrictions were applied. We included randomized and nonrandomized comparative studies. We applied standard risk of bias tools to each included study and used GRADE methodology to assess certainty of evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion. Results: Our search yielded 2030 studies. One prospective cohort study from Nepal met inclusion criteria. This study collected data on 605 women obtaining medical abortion rom either a clinic or pharmacy, and was judged to have low risk of bias for our primary outcome. For women who received medical abortion in a pharmacy compared to a clinic there was probably little or no difference in complete abortion rates (adjusted risk difference 1.5%; 95% confidence interval [CI] −0.8 to 3.8, 1 study, 600 participants; low certainty of evidence). No cases of blood transfusion were reported in the study and a composite outcome comprised mainly of infection complications showed little or no difference between settings (adjusted risk difference 0.8; 95% CI −1.0 to 2.8, 1 study, 600 participants; very low certainty of evidence). Conclusion: Evidence from just one nonrandomized study provides low certainty evidence that the effectiveness of medical abortion is probably not different between the pharmacy or clinic setting. Implications: Provision of medical abortions through pharmacy-based models of care may improve access to safe abortion. Comparative studies examining each model of care and outcomes on safety, effectiveness, and patient experience are needed.