Induced abortion: rights, technology and delivery of care
By Jennie Bristow
June 03, 2009
This stimulating event was organised by Dr Sam Rowlands, Honorary Associate Professor at Warwick Medical School, for the Sexuality and Sexual Health Section of the Royal Society of Medicine. Speakers addressed a range of important current issues in international abortion care, leading to a lively discussion among delegates about the gaps between policy and practice.
Introducing the conference, Dr Rowlands drew attention to the conclusions reached by the House of Commons Science and Technology Committee in its 2007 report Scientific Developments Relating to the Abortion Act 1967. These included recommendations for the removal of the need for two doctors' signatures before an abortion can be carried out; that suitably trained nurses and midwives be permitted to carry out all stages of early medical and surgical abortions; and that women undergoing Early Medical Abortion be permitted to take their misoprostol at home. Despite these recommendations, noted Rowlands, Parliamentarians showed themselves unable to translate science into law, when the opportunity to discuss amendments to the British abortion law was blocked last year.
Marge Berer, editor of the journal Reproductive Health Matters, provided a global perspective on the abortion debate, by examining the extent to which 'abortion is on the agenda across the world - sometimes for good and sometimes for ill'. The best of the 'good', argued Berer, are the recent decisions by the USA and Australia to repeal their 'global gag rules', which prohibited federal funding for foreign family planning agencies that promote or give information about abortion. The decriminalisation of abortion in the Australian state of Victoria in 2008 is an exciting and progressive development.
On the other hand, changes to abortion laws that are taking place in Latin America, Germany, Poland and Spain give some cause for concern. Spain is a particularly interesting case: while the proposed changes are promoted as a clarification and a liberalisation of the Spanish abortion law, one effect of these changes, argued Berer, may be to restrict further the possibility of women being able to obtain abortions in the second trimester. The fact that the law is currently loosely defined and open to interpretation has meant that Spain has been the one place where European women can potentially go for an abortion after 24 weeks - the law reform may close this down.
In a general sense, argued Berer, there is cause to be concerned about the provision of second trimester abortion. Even now, only the most dedicated providers are prepared to carry these out, and these abortions are 'the subject of attacks by anti-abortionists, which seek to separate them as "more wrong"'.
In countries where abortion is still largely illegal, developments in Early Medical Abortion have made a huge difference: where mifepristone is not licensed, 'women are self-medicating with misoprostol all over the world'. When used alone, misoprostol is less effective than when used in combination with mifepristone, which means that some women who self-medicate are ending up in hospitals with incomplete abortions and receiving D&Cs; however, 'what is disappearing are the horrific complications from [illegal, unsafe] invasive methods in the first trimester'.
Self-medication with misoprostol was also the subject of a presentation by Dr Rebecca Gomperts, director of the Dutch organisation Women on Waves. This non-profit organisation, founded in 1999, provides a reproductive health clinic on board a ship, which can provide Early Medical Abortion 'safely and legally outside the territorial waters of countries where termination of pregnancy is illegal'. The related service, Women on Web, helps women living in countries where abortion is highly restricted to gain access to the drugs for EMA, and provides women with the information they need to carry out their abortion using these drugs.
In discussing her work, Dr Gomperts noted that 'abortion is the most performed medical intervention in the world', and that making it illegal 'does not reduce the number of abortions'. What illegal abortion does do is increase the risk to women's mortality caused by undergoing an unsafe procedure. Unlike mifepristone, which is approved only in countries where abortion is legal, 'misoprostol is approved almost everywhere - and women have worked out how to use it', which is already causing a decline in mortality due to unsafe abortion.
In Britain, where abortion is legal up to 24 weeks' gestation, the availability of Early Medical Abortion has helped to account for the fact that an increasing proportion of first-trimester abortions take place at under 10 weeks' gestation. The relative simplicity and cost-effectiveness of this method led the Department of Health to commission an evaluation of a pilot study examining whether EMA could be provided to women in a way that is effective, safe and acceptable in a wider range of venues than is currently the case. The evaluation considered this issue by assessing the safety, efficacy and acceptability of the provision of EMA in two pilot sites and in three additional sites.
The evaluation, led by Professor Roger Ingham of the University of Southampton, was published in May 2008. Presenting on the findings, Professor Ingham confirmed that the use of EMA in community settings carries extremely low levels of risk, and there was no difference in effectiveness. He also addressed the importance of particular elements of care, for example sympathetic staff, the separation of women who are having abortions from those undergoing other gynaecological or obstetric procedures, and the need for adequate facilities - specifically enough toilets, in cases where women are required to stay on site following the administration of misoprostol, rather than going home immediately after taking this medication.
Professor Ingham also raised his concerns about the lack of speed with which the Department of Health appears to be building upon these findings. Having commissioned the evaluation at short notice and, upon publication of the findings, announcing a consultation among medical professionals, remarkably little energy at a policy level seems to be going into widening provision of EMA along these lines.
Presentations by Dr Patricia Lohr, Medical Director of bpas, and Professor James Trussell of Princeton University and the Hull York Medical School, addressed issues of EMA provision in terms of clinical practice. Dr Lohr focused on the body of research on shortening the interval between mifepristone and misoprostol. This indicates that, when misoprostol is administered vaginally, the interval between the two drugs can range from simultaneous dosing to an interval of up to three days. This research is examined in detail by Professor Mitchell Creinin, in a paper shortly to be published in a special edition of Abortion Review.
Professor Trussell's presentation examined the issue of reducing serious infection following medical abortion, by examining changes made in the practice of EMA provided through clinics of the Planned Parenthood Federation of America (PPFA). Professor Trussell noted that in the UK, antibiotics have routinely been administered during EMA, despite the lack of a clear evidence base for this.
PPFA clinics in the USA did not administer antibiotics during medical abortion until it emerged that the rate of serious infection was far higher than previously estimated and five women in North America who had medically induced abortions had died from toxic shock caused by a Clostridium sordellii infection. This led to a change in practice, whereby PPFA clinics began to administer misoprostol through the buccal, rather than vaginal, route, and prescribed antibiotics - either routinely, or as treatment following screening for Chlamydia or gonorrhoea. Later a further change was made to provide doxycycline routinely to all women. The result of these changes in practice has been a significant (93%) reduction in the rate of serious infection following EMA.
A presentation by the barrister Barbara Hewson discussed the question of abortion and human rights, reflecting on some of the cases that she has discussed in detail on Abortion Review: D v Ireland (2006), and the case of 'Miss D' in 2007, a teenager who was pregnant with a fetus with anencephaly, and was forced into a legal battle over travelling for an abortion.
Other speakers at this conference included Dr Kate Guthrie, consultant community gynaecologist for Hull and East Yorkshire, who discussed the importance of integrated care pathways in relation to a patient's journey through the abortion process; and Gill Aston, research associate in the Florence Nightingale School of Nursing and Midwifery at King's College, London, who addressed the issue of domestic violence. Dr Sam Rowlands reviewed research on women's decision-making about abortion, and discussed the issues raised by mandatory counselling, 'cooling-off periods', and parental authorisation in some laws worldwide. The event concluded with a panel discussion of the day's proceedings, chaired by John Spencer, Senior Clinical Consultant at Marie Stopes International.