Transcript Access to Medical Abortion

Expanding access to
medical abortion
Marge Berer
Editor, Reproductive Health Matters
Chair, ICMA Steering Committee
***
Lisbon, March 2010
Abortion methods 1960s/70s

Surgical : dilatation and curettage (D&C),
dilatation and evacuation (D&E) and
hysterotomy.

Medical : intra-amniotic, extra-amniotic and
intra-muscular (urea, saline, various older
prostaglandins and ethacridine lactate).
A trained physician was required to carry out
these abortions, and the risk of complications
was much higher than today, especially as
pregnancy progressed.
Current methods
recommended by WHO
Manual vacuum aspiration
 Vacuum aspiration
 Dilatation & evacuation


Medical abortion (mifepristone +
misoprostol)
What is medical abortion?

Medical abortion is the use of pills to
cause a miscarriage; it has high efficacy
(92–99%) and an excellent safety record.

Medical abortion can be used from the
time a woman first misses her period up
through the 2nd trimester of pregnancy.

Yte its potential as a very early abortion
method (almost 100% effective) remains to
be recognised and developed.
Medical abortion has improved

Medical abortion is safer and more
effective now than 10 –15 years ago:



Misoprostol causes fewer complications
than previous prostaglandins.
Optimum regimens, including for
misoprostol alone – based on evidence.
Much more experience with the method.
Why is it so important?

Offers a choice of abortion method for
both women and providers.

Can increase access to safe abortion
where there are few surgical abortion
providers.

Fundamentally alters the way abortion
services should be delivered.

Can put the means of abortion into
women’s hands.
This conference is about
expanding access
to medical abortion
Why is access such a
problem?
Overmedicalised provision

Hospital-based clinics for 1st trimester.

600 mg mifepristone – 3 times too much.

No choice of using misoprostol at home.

Ultrasound to determine gestation /
check abortion complete.

Extra visits.

Physician-only provision.
Restricted/poor access

Legal abortion restricted or unavailable.

Lack of approval/registration of drugs.

Misoprostol available in secret, from
chemists, on the street and on the black
market.

Cost of drugs uncontrolled.

Treatment for complications not assured.

Training for providers haphazard, practice
often not evidence-based.
Problematic aspects for women:
restricted settings

Incorrect use, doses too large or too
small, self-medication beyond 9 weeks.

Uncertainty whether bleeding is normal
or not.

Uncertain whether abortion complete
or not.

And while we want to see women in
control of the method, this does not
mean being left alone with the
responsibility.
Barriers to approval

The registration and approval process has
been made as difficult as possible:


approval commercially driven; drug
companies refuse to apply even in countries
with legal abortion.
national drug regulatory agencies imposing
outdated, overly stringent regulatory
conditions, or not allowing the method into
the public sector at all.
Registration/approval

Mifepristone is currently registered/
approved in only 44 countries since 1988
when registered in France and China.

Misoprostol has been approved or can be
found in most countries, except a few
sub-Saharan African and Asian countries.
But it didn’t arrive as an abortion drug.

Off-label use is common.
Even so…
access to medical abortion
is getting better…
and better!
WHO Essential Medicines list

Mifepristone and misoprostol added to
WHO Essential Medicines list in 2005 –
one aim to reduce unnecessary deaths
from unsafe abortion.
(Hans Hogerzeil, Director of Medicines Policy and
Standards, WHO, and Secretary of its Essential Medicines
Committee in 2005)

“Essential drugs” – drugs that every
country should have available.
Use/availability expanding

More countries approving medical abortion.

More women choosing it and more providers
offering it.

National laws/regulations have begun
incorporating specifics of medical abortion.

Additional indications being approved – e.g.
prevention and treatment of post partum
haemorrhage – making drugs more accessible.

Medical and surgical methods are being
combined in various (creative) ways.
Global use of medical abortion
Millions of women have used medical
abortion globally, but no global data
collected.
China – up to 200 million abortions since 1988
(50% of all abortions)
 USA – 1.5 million abortions
 India – 6 million mifepristone pills sold in 2009
alone
 Viet Nam – 1 million abortions

(Personal communication, Beverly Winikoff, Feb 2010)
Moreover,
women are quietly taking
these drugs
into their own hands.
Meanwhile, back at the hospital..

Dosage (200mg/600mg mife) and regimens.

Delivery of misprostol (oral, vaginal, buccal,

Where woman takes pills, where abortion
happens.

Pain relief or not.

Ultrasound or not.

More or fewer visits.

When to do follow-up / what kind.

Surgical or medical at 9-13 weeks and in 2nd
trimester?
sublingual).
Enhancing access
WHO Safe Abortion Guidance
2003

Abortion services should be provided at
the lowest appropriate level of the health
care system.

Vacuum aspiration can be provided at
primary care level up to 12 completed
weeks of pregnancy and medical abortion
up to 9 completed weeks of pregnancy.
This guidance is more than 8 years old
and is still often not being implemented.
Increase role of non physicians

Use mid level providers who are closest to
women geographically and socially:
nurses
 midwives

family planning workers and
 physician assistants.


(ICMA 2004)
These providers can manage medical
abortion provision on their own. Let’s
allow them to do so. (Berer 2009)
Women-centred perspectives

Don’t be overly protective of women
needing abortions. Simplify services.

Give good information that all women
can understand, including how to take
the drugs safely.

Allow home use of both drugs (<9 wks).

Support bona fide web provision and
self medication, esp. where services are
lacking/illegal.
More global stakeholders

When ICMA began in 2002, few people
knew about medical abortion.

Today, many international, regional,
national and local stakeholders
involved in advocacy, providing
information, and providing medical
abortion pills through many outlets.

Many more drug companies, many new
brands, and now the two drugs are
being packaged together.
Increased opportunity

Opportunity to share goals, develop
simple, women centred service delivery
norms, support each others’ work and
engage in joint activities.

Let’s try to get consensus on some of the
contentious issues on the agenda of this
conference.

To expand access for women, let’s work
together to promote medical abortion in
the context of safe abortion.