Medical Abortion Fact Sheet

History of Medical (Medication) Abortion

Throughout the centuries and in all cultures women have ingested substances believed to bring about an abortion. In the Western world some of the most popular have been concoctions made from the following plants: Pennyroyal, Savin-oil of Juniper, Black Cohosh, Blue Cohosh, Queen Anne’s Lace, Parsley and in New Zealand: Supplejack root, Flax root, Toetoe leaves, Poroporo leaves, berries from Te Mahoe.

There is also a large repertoire of chemicals and substances such as ergot and quinine. Many had an effect on the urinary or gastrointestinal tract. The theory was that stimulating other pelvic organs might stimulate the uterus to contract or shed its lining. Many were unsafe. Many were ineffective.

Frequently a combination of supposed abortion inducing agents was packaged as pills or potions e.g. Beecham’s Pills, Dr Bonjean’s Female Pills, George Bettle’s Mixture. Women often used medical methods before resorting to the dangers of do-it-yourself interventions or the perils of illegal backstreet abortionists.

It is only recently that medical scientists have investigated the use of hormones or drugs to interrupt an established pregnancy more effectively e.g. methotrexate, a cancer drug also used for arthritis, has been used for abortions. It is used less often now because it can cause toxic side effects and safer drugs are now available.

The term medical abortion may sometimes be confusing. Sometimes it is used in the sense of safe abortion (medical or surgical) done under medical supervison, as opposed to unsafe illegal abortion. In this fact sheet it is used in the sense of medication abortion as opposed to surgical abortion.

Advances in the Last Two Decades

In the last 20 years the most effective medical abortion method to emerge has been the combination of an antiprogestin, to block progesterone (the hormone essential to maintain the pregnancy), followed by a prostaglandin to stimulate uterine contractions and expel the embryo (the name used up to 8 weeks gestation) or fetus (after 8 weeks).

The antiprogestin which has been used most widely is mifepristone, formerly known as RU486 or the French abortion pill, because it was developed in France and approved for use there in 1988. It has been used in China for as long as this and in the UK since 1991 and in Sweden since 1992. In the UK it is known as Mifegyne. In 2000 it was approved for use in the USA where it is known as Mifeprex. Mifepristone is now available in over 30 countries.

The two most frequently used prostaglandins are misoprostol (Cytotec) an ulcer drug and gemeprost (Cervagem). Cytotec is preferred as it is cheaper and does not need to be refrigerated.

Mifegyne is now available in New Zealand. A group of doctors involved in abortion care formed a not-for-profit company called Istar Ltd to import Mifegyne from the French manufacturers because no established pharmaceutical firm wished to be involved in a controversial product.

Mifegyne was approved for medical abortions by the Ministry of Health in August 2001.

First Trimester Early Medical Abortion in New Zealand

The introduction of an early medical abortion service was delayed because of an ambiguity in the law which states that all abortions must be 'performed' in licensed premises. Did that mean that both sets of medication (the mifepristone followed by the misoprostol) had to be taken in licensed premises and did the woman need to stay in licensed premises between medications or until the abortion was complete? The Abortion Supervisory Committee sought a ruling from the High Court and in April 2003 Mr Justice Durie determined that both drugs must be given in a licensed premise but the woman did not need to stay in a licensed premise between medications or until the abortion was complete.

Level J Unit in Wellington Hospital was the first to use Mifegyne for early medical abortion in April 2002 but until the High Court ruling in April 2003 women had to agree to have a surgical termination if they had not aborted after 6-8 hours. The experience with this group of women was published.

[Reference: Shand C, Rose SB, Simmons A, Sparrow MJ. Introduction of early medical abortion in New Zealand: An audit of the first 67 cases. Aust NZ J Obstet Gynaecol 2005; 45: 316-320.]

After the High Court ruling the Auckland Medical Aid Centre (AMAC) was the next clinic to introduce a medical abortion service.

The experience of 390 medical abortions at AMAC from 1 July 2003 to 30 June 2005 has been published.

[Reference: Goodyear-Smith F, Knowles A, Masters J. First trimester medical termination of pregnancy: An alternative for New Zealand women. Aust NZ J Obstet Gynaecol 2006; 46: 193-198.]

In 2009 early medical abortion is available from six clinics: AMAC, Epsom Day Unit, Wellington Hospital (Previously Level J Unit, since February 2009 renamed Te Mahoe Unit, situated in the new regional hospital), Lyndhurst Hospital Christchurch and Dunedin Hospital.

Useful information is available from the British Pregnancy Advisory Service (BPAS). Click here.

 

ALRANZ BELIEVES THAT THE OPTION OF EARLY MEDICAL ABORTION SHOULD BE MORE WIDELY AVAILABLE

Mid-Trimester Medical Abortion in New Zealand

The technique used for second and third trimester abortions and for induction of labour for fetal death will depend on the experience and expertise of the gynaecologist. In the US the most common method is a surgical dilatation and evacuation. In Europe the most common method is a medication abortion using mifepristone followed by repeated doses of a prostaglandin. In New Zealand both methods are in use.

Prior to the introduction of Mifegyne medical abortions were carried out using repeated doses of prostaglandin. The first use of Mifegyne in New Zealand was in Wellington in October 2001 for a second trimester abortion. Later abortions were not affected by the ambiguity in the law because they are always done under supervision in a hospital setting.

The Mifegyne is given first and after 24-48 hours the patient is admitted for the administration of repeated doses of prostaglandin. Priming with Mifegyne shortens the duration of the procedure.

Most hospitals with an O&G Department provide a mid-trimester service (e.g. for fetal abnormality) and induction of labour for fetal death.

The experience at Wellington Hospital with mid-trimester abortions has been published.

[Reference: Rose SB, Shand C, Simmons A. Mifepristone- and misoprostol-induced mid-trimester termination of pregnancy: A review of 272 cases. Aust NJ Obstet Gynaecol 2006; 46: 479-485.]

A Choice for New Zealand Women

Not all women who are eligible for medical abortion will choose this method; in fact many will choose surgery because this suits their busy lifestyle. Medical abortion takes longer and there is more bleeding and cramping. It is like having a miscarriage. One major advantage is that it can be performed as soon as the pregnancy is confirmed and the earlier, the better. Both methods are safe. Both methods have their advantages and disadvantages. One important difference is between doing something yourself and having something done to you.

Women must still obtain approval from two certifying consultants according to the procedures of the Contraception, Sterilisation and Abortion (CS&A) Act and must have grounds for abortion under the Crimes Act.

Mifegyne followed by Cytotec can be used for early abortions up to 7 or 9 weeks gestation in a clinic and for later abortions after 14 weeks in a hospital. It has also been approved for use in the induction of labour when there has been a fetal death.

Women will need to be referred by their GP or Family Planning doctor, to a clinic that offers medical abortion.

For further information on abortion services from www.abortion.gen.nz click here.

As a matter of sexual and reproductive health rights women should be able to benefit from scientific and medical advances.

Article 7 of Sexual rights: an IPPF declaration is the right to health and to the benefits of scientific progress. For women this means the choice between surgical and medical abortion.

[Reference: IPPF Sexual rights: an IPPF declaration. Click here.]

ALRANZ WOULD LIKE TO SEE ALL CLINICS OFFERING MEDICAL ABORTION AS A CHOICE FOR WOMEN AND IN THE FUTURE IT SHOULD BE AVAILABLE FROM APPROVED PRIMARY CARE FACILITIES. THERE IS NO REASON WHY NURSE PRACTITIONERS SHOULD NOT BE ABLE TO PROVIDE MEDICATION ABORTIONS BUT THIS IS NOT POSSIBLE WITH THE PRESENT LAWS.

In Cairns Australia Dr Darren Russell has established a medical abortion service in the Sexual Health Clinic. He uses methotrexate as mifepristone is not available for this use.

In Britain following pilot programmes there are now a few clinics in general practive surgeries. British Pregnancy Advisory Service (BPAS) runs one in a GP surgery in Wolverhampton under a contract with the NHS and has approval for another in Newcastle upon Tyne.

In the US Planned Parenthood is a major provider of early medical abortion and nurse practitioners are able to provide services including ultrasound examinations in the assessment of patients.

How Many Women Actually Choose Medical Abortion?

A 2005 study of women attending Level J Unit, Wellington Hospital, showed that about 20% of eligible women chose medical abortion.

In the first two years of use at AMAC 12% of all women (eligible and not eligible) chose medical abortion. In 2007 the number of eligible women choosing medical abortion was about 30%.

In Dunedin in 2007 about 20% of all women chose medical abortion.

How does this compare with the use overseas? In Scotland where much of the pioneering research has taken place in the UK, the use of medical abortion has gradually increased from 16.4% when the method was first introduced in 1992 to 59.1% in 2006.

FIGURE 1. Percentage of women eligible for early medical abortion who were prescribed mifepristone, four European countries, 1990-2000

http://www.guttmacher.org/graphics/340302/3415402f1.gif

[Reference: Jones & Henshaw. Mifepristone for eary medical abortion: Experience in France, Great Britain and Sweden. Perspectives on Sexual and Reproductive Health.2002; 34 (3): 154-161.]

Why has the uptake been relatively low in New Zealand?

1. A reluctance to change when staff already provide a well-estalished surgical service with a high success rate and a low complication rate.

2. Administrative barriers.

3. Legal barriers. The requirement to give both medications on licensed premises means an extra visit.

4. Lack of information on availability, both public and professional.

[Reference: Sparrow M, Shand C. Abortion in New Zealand. O&G magazine 2007; 9 (4): 29-30.]

 

ALRANZ WOULD LIKE TO SEE IMPROVED ACCESS TO MEDICAL ABORTION. MANY NEW ZEALAND WOMEN DO NOT HAVE A CHOICE.

CRITICS SAY IT WILL MAKE HAVING AN ABORTION TOO EASY AND THE NUMBER OF ABORTIONS WILL INCREASE. IS THIS SO?

 

In countries where medication abortion has been introduced there has not been a significant increase in the total numbers of abortion. In Sweden, France and Great Britain, availability of medication abortion when abortion was already legal did not increase the number of abortions.

Since the introduction of medical abortion the numbers of abortions have not increased but have acutally decreased. (Source ASC & Statistics NZ)

2003 18,511 (Total number of abortions)

2004 18,211

2005 17,531

2006 17,934

2007 18,382

Having an Early Medical Abortion

The woman should have a pregnancy test as soon as she thinks that her period is late. After full consideration of her options her referring doctor will arrange for an ultrasound scan to check the stage of her pregnancy and make sure that she does not have an ectopic (tubal) pregnancy.

The method is suitable for most healthy women. She should however be sure of her decision as once the drugs have been taken there is a risk of them causing fetal abnormality, if the pregnancy were to continue. The method is not suitable for women who live more than one hour from emergency medical services or for women who do not have a telephone or transport or home support.

After full assessment at the clinic, she will be given an oral tablet of Mifegyne and she will wait there for about an hour. She will then return home. Nothing much will happen to begin with but about half the women will begin to bleed in the first 48 hrs. A few (about 3%) will abort with Mifegyne alone.

In 24-36-48 hrs time (depending on the clinic protocol) she will return to the clinic where she will be given four vaginal tablets of Cytotec and this will result in more bleeding and cramps to expel the tiny embryo or fetus. Some women may need pain relief. Tissue that is passed will be checked to confirm that the abortion is successful. She will return to her referring doctor for a check in 14 days.

Is Medication Abortion Safe?

Medication abortion represents decades of medical research to develop and make available a safe alternative to surgical abortion.

[Reference: For the WHO 2006 publication on Frequently Asked Questions About Medical Abortion click here.]

[Reference: von Hertzen H, Baird D; Bellagio Study and Conference Center. Frequently asked questions about medical abortion. Contraception. 2006 Jul;74(1):3-10.]

[Reference: Fiala & Gemzell-Danielsson. Review of medical abortion using mifepristone in combination with a prostaglandin analogue. Contraception 2006; 74: 66-86.]

Misoprostol has also been shown to be valuable for other obstetric uses. The inclusion on the essential medicines list of mifepristone and misoprostol is an important milestone. Since 1977, the World Health Organization (WHO) has been publishing a Model List of Essential Medicines which meets the priority health care needs of the population of developing countries. Medicines on this list are selected with regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. Since mid-2005 WHO’s Model List of Essential Medicines has included mifepristone and misoprostol.

[Reference: www.who.int/emlib/ for web-based information now into 15th edition click here.]

National essential medicines lists are meant to serve as the main basis for public sector drug procurement and distribution in countries with those lists. Inclusion of mifepristone and misoprostol for medication abortion and misoprostol for other obstetric and gynaecological uses in national essential medicines lists paves the way for their wider availability in public health services.

Pregnancy tests can now identify a pregnancy even before a woman misses her period. Where medication abortion is accessible, this means the pregnancy can be terminated very early, effectively and safely. This is preferable for women, providers and the health system. In general terms the earlier an abortion is carried out the safer.

The goal is to have as many abortions as possible done before eight weeks gestation. In New Zealand the number being carried out at this early stage is 7% compared to 70% in the Netherlands.

The risk of developing a complication following any safe abortion procedure, including medication abortion, is very low. Less than 1% of women have been shown to develop infection after medication abortion in the first nine weeks of pregnancy, and no more than one in 1,000 women experiences heavy bleeding requiring a blood transfusion.

[Reference: Shannon et al. Infection after medical abortion: a review of the literature. Contraception 2004; 70: 183-190.]

Whatever method is used, there is a small risk of complications, including infection and bleeding. With a medical abortion the bleeding can be quite heavy and in 1 in 300 cases a transfusion or surgery may be needed to stop it. In a few cases the method is not successful and the woman will need to have a surgical abortion.

What About Deaths?

The risk of serious infection has received publicity because of a small number of deaths following medical abortion in North America due to toxic shock syndrome. After the first four deaths were reported in 2005 the FDA issued an advisory warning.

[Reference: US Food and Drug Administration. FDA Public Health Advisory: sepsis and medical abortion. Click here.]

Since 2005 there have been further case reports. To date there has been one death in Canada and eight deaths in the USA following early medical abortion, since mifepristone was approved in September 2000. Seven of the eight in the US followed early medical abortion using mifepristone and misoprostol. One of the eight had not taken mifepristone but had used laminaria followed by misoprotol. In the same time frame there were nine reported deaths from the same cause following live births and three reported cases following mid-trimester spontaneous abortions or miscarriages. The common denominator to these tragic cases is pregnancy, not specifically abortion.

No deaths have been reported following early medical abortion in Europe, the UK or Australasia.

The infections were caused by Clostridium sordellii and in one case Clostridium perfringens.

[Reference: Cohen AL et al. Toxic Shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneious abortion. Obstet & Gynecol 2007; 110:1027-33.]

Another non-fatal case has been reported where the organism was a Group A Streptococcus.

[Daif JL et al. Group A Streptococcus causing necrotizing fasciitis and toxic shock syndrome after medical termination of pregnancy. Obstet & Gynecol 2009; 113: 504-506.]

It is important to remember that the risk of death following medical abortion is rare. More than 800,000 women in the US have used mifepristone since it was approved in September 2000 and the death rate is estimated as 0.8 per 100,000. The case fatality rate for spontaneous abortion (miscarriage) is estimated at 0.7 per 100,000 and the difference is not significant.

Having an early safe medical abortion is approximately ten times safer than giving birth.

And remember no medication is completely safe. There are deaths from aspirin which is available over the counter.

Five men die from Viagra-related drug reactions out of every 100,000 prescriptions.

Legal Issues

Section 18 of the CS&A Act states that all abortions must be ‘performed’ in licensed premises. Because of differing legal opinion as to the meaning of the word ‘performed’ a case was taken to the High Court by the Abortion Supervisory Committee to clarify the meaning in respect of medical abortions. In April 2003 Mr Justice Durie ruled that women must take both sets of pills on licensed premises but they do not need to remain there between taking the pills or until the embryo or fetus is expelled.

Until this ruling clinics were reluctant to provide an early medical abortion service because of the cost of providing overnight accommodation or surgical services for those who had not aborted in 6-8 hrs. The legal problem does not affect later abortions because women are always kept in a hospital until the procedure is complete.

In the US women usually take the prostaglandin medication at home, making it a more acceptable procedure. In the UK abortions must be carried out in licensed institutions but exemptions have been made to provide a more economical and efficient service.

 

ALRANZ BELIEVES THAT OUR LAWS SHOULD BE CHANGED TO MAKE MEDICAL ABORTIONS A MORE ACCEPTABLE, MORE EFFICIENT AND MORE COST-EFFECTIVE CHOICE FOR NEW ZEALAND WOMEN.

APART FROM THE LAW THERE IS NO NEED FOR MEDICATIONS TO BE TAKEN IN LICENSED PREMISES PROVIDING WOMEN ARE WELL INFORMED AND ARE ABLE TO SEEK HELP WHEN REQUIRED.

 

Fact Sheet on Medical Abortion Edited March 2009