Expanding access Expanding access to to medical abortionmedical abortion

Marge BererMarge Berer

Editor, Reproductive Health Editor, Reproductive Health MattersMatters

Chair, ICMA Steering Chair, ICMA Steering CommitteeCommittee

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Lisbon, March 2010Lisbon, March 2010

Abortion methods Abortion methods 1960s/70s1960s/70s

SurgicalSurgical : dilatation and curettage (D&C), : dilatation and curettage (D&C), dilatation and evacuation (D&E) and dilatation and evacuation (D&E) and hysterotomy.hysterotomy.

MedicalMedical : intra-amniotic, extra-amniotic and : intra-amniotic, extra-amniotic and intra-muscular (urea, saline, various older intra-muscular (urea, saline, various older prostaglandins and ethacridine lactate). prostaglandins and ethacridine lactate).

A trained physician was required to carry A trained physician was required to carry out these abortions, and the risk of out these abortions, and the risk of complications was much higher than today, complications was much higher than today, especially as pregnancy progressed.especially as pregnancy progressed.

Current methods Current methods recommended by WHOrecommended by WHO

Manual vacuum aspirationManual vacuum aspiration Vacuum aspirationVacuum aspiration Dilatation & evacuationDilatation & evacuation

Medical abortion (mifepristone + Medical abortion (mifepristone + misoprostol)misoprostol)

What is medical What is medical abortion?abortion?

Medical abortion is the use of pills to Medical abortion is the use of pills to cause a miscarriage; it has high efficacy cause a miscarriage; it has high efficacy (92–99%) and an excellent safety record.(92–99%) and an excellent safety record.

Medical abortion can be used from the Medical abortion can be used from the time a woman first misses her period up time a woman first misses her period up through the 2nd trimester of pregnancy. through the 2nd trimester of pregnancy.

Yte its potential as a very early abortion Yte its potential as a very early abortion method (method (almost 100% effectivealmost 100% effective) remains to ) remains to be recognised and developed.be recognised and developed.

Medical abortion has Medical abortion has improvedimproved

Medical abortion is safer and more Medical abortion is safer and more effective now than 10 –15 years ago:effective now than 10 –15 years ago:

Misoprostol causes fewer Misoprostol causes fewer complications than previous complications than previous prostaglandins.prostaglandins.

Optimum regimens, including for Optimum regimens, including for misoprostol alone – based on misoprostol alone – based on evidence.evidence.

Much more experience with the Much more experience with the method.method.

Why is it so important?Why is it so important?

Offers a choice of abortion method for Offers a choice of abortion method for both women and providers.both women and providers.

Can increase access to safe abortion Can increase access to safe abortion where there are few surgical abortion where there are few surgical abortion providers.providers.

Fundamentally alters the way Fundamentally alters the way abortion services should be delivered.abortion services should be delivered.

Can put the means of abortion into Can put the means of abortion into women’s hands.women’s hands.

This conference is This conference is about expanding about expanding

accessaccessto medical abortionto medical abortion

Why is access such a Why is access such a problem?problem?

Overmedicalised Overmedicalised provisionprovision

Hospital-based clinics for 1st trimester.Hospital-based clinics for 1st trimester.

600 mg mifepristone – 3 times too much.600 mg mifepristone – 3 times too much.

No choice of using misoprostol at home.No choice of using misoprostol at home.

Ultrasound to determine gestation / Ultrasound to determine gestation / check abortion complete.check abortion complete.

Extra visits.Extra visits.

Physician-only provision. Physician-only provision.

Restricted/poor accessRestricted/poor access

Legal abortion restricted or unavailable.Legal abortion restricted or unavailable.

Lack of approval/registration of drugs.Lack of approval/registration of drugs.

Misoprostol available in secret, from Misoprostol available in secret, from chemists, on the street and on the black chemists, on the street and on the black market.market.

Cost of drugs uncontrolled.Cost of drugs uncontrolled.

Treatment for complications not assured.Treatment for complications not assured.

Training for providers haphazard, Training for providers haphazard, practice often not evidence-based.practice often not evidence-based.

Problematic aspects for Problematic aspects for women: women: restricted settingsrestricted settings

Incorrect use, doses too large or Incorrect use, doses too large or too small, self-medication beyond too small, self-medication beyond 9 weeks.9 weeks.

Uncertainty whether bleeding is Uncertainty whether bleeding is normal or not.normal or not.

Uncertain whether abortion Uncertain whether abortion complete or not.complete or not.

And while we want to see women And while we want to see women in control of the method, this does in control of the method, this does not mean being left alone with the not mean being left alone with the responsibility.responsibility.

Barriers to approvalBarriers to approval

The registration and approval The registration and approval process has been made as difficult as process has been made as difficult as possible:possible: approval commercially driven; drug approval commercially driven; drug

companies refuse to apply even in companies refuse to apply even in countries with legal abortion.countries with legal abortion.

national drug regulatory agencies national drug regulatory agencies imposing outdated, overly stringent imposing outdated, overly stringent regulatory conditions, or not allowing regulatory conditions, or not allowing the method into the public sector at all.the method into the public sector at all.

Registration/approvalRegistration/approval

Mifepristone is currently registered/ Mifepristone is currently registered/ approved in only 44 countries since approved in only 44 countries since 1988 when registered in France and 1988 when registered in France and China.China.

Misoprostol has been approved or can Misoprostol has been approved or can be found in most countries, except a be found in most countries, except a few sub-Saharan African and Asian few sub-Saharan African and Asian countries. But it didn’t arrive as an countries. But it didn’t arrive as an abortion drug.abortion drug.

Off-label use is common.Off-label use is common.

Even so… Even so…

access to medical access to medical abortion abortion

is getting better… is getting better…

and better!and better!

WHO Essential Medicines listWHO Essential Medicines list

Mifepristone and misoprostol added Mifepristone and misoprostol added to to WHO Essential Medicines list in 2005 WHO Essential Medicines list in 2005 – one aim to reduce unnecessary – one aim to reduce unnecessary deaths from unsafe abortion. deaths from unsafe abortion. (Hans Hogerzeil, Director of Medicines Policy and (Hans Hogerzeil, Director of Medicines Policy and Standards, WHO, and Secretary of its Essential Medicines Standards, WHO, and Secretary of its Essential Medicines Committee in 2005)Committee in 2005)

““Essential drugs” – drugs that every Essential drugs” – drugs that every country should have available.country should have available.

Use/availability expandingUse/availability expanding

More countries approving medical abortion.More countries approving medical abortion.

More women choosing it and more More women choosing it and more providers offering itproviders offering it..

National laws/regulations have begun National laws/regulations have begun incorporating specifics of medical abortion.incorporating specifics of medical abortion.

Additional indications being approved – Additional indications being approved – e.g. prevention and treatment of post e.g. prevention and treatment of post partum haemorrhage – making drugs more partum haemorrhage – making drugs more accessible.accessible.

Medical and surgical methods are being Medical and surgical methods are being combined in various (creative) ways.combined in various (creative) ways.

Global use of medical Global use of medical abortionabortion

Millions of women have used medical Millions of women have used medical abortion globally, but no global data abortion globally, but no global data collected.collected.

China – up to 200 million abortions since China – up to 200 million abortions since 1988 1988 (50% of all abortions)(50% of all abortions)

USA – 1.5 million abortionsUSA – 1.5 million abortions India – 6 million mifepristone pills sold in India – 6 million mifepristone pills sold in

2009 2009 alonealone Viet Nam – 1 million abortionsViet Nam – 1 million abortions

(Personal communication, Beverly Winikoff, Feb 2010)(Personal communication, Beverly Winikoff, Feb 2010)

Moreover, Moreover, women are quietly taking women are quietly taking

these drugs these drugs into their own hands.into their own hands.

Meanwhile, back at the Meanwhile, back at the hospital..hospital.. Dosage (Dosage (200mg/600mg mife200mg/600mg mife) and regimens.) and regimens.

Delivery of misprostolDelivery of misprostol (oral, vaginal, buccal, (oral, vaginal, buccal, sublingual).sublingual).

Where woman takes pills, where abortion Where woman takes pills, where abortion happens.happens.

Pain relief or not.Pain relief or not.

Ultrasound or not.Ultrasound or not.

More or fewer visits.More or fewer visits.

When to do follow-up / what kind.When to do follow-up / what kind. Surgical or medical at 9-13 weeks and in Surgical or medical at 9-13 weeks and in

2nd trimester?2nd trimester?

Enhancing accessEnhancing access

WHO Safe Abortion GuidanceWHO Safe Abortion Guidance 20032003

Abortion services should be provided at Abortion services should be provided at the lowest appropriate level of the the lowest appropriate level of the health care system.health care system.

Vacuum aspiration can be provided at Vacuum aspiration can be provided at primary care level up to 12 completed primary care level up to 12 completed weeks of pregnancy and medical weeks of pregnancy and medical abortion up to 9 completed weeks of abortion up to 9 completed weeks of pregnancy.pregnancy.

This guidance is more than 8 years old This guidance is more than 8 years old and is still often not being implemented.and is still often not being implemented.

Increase role of non Increase role of non physiciansphysicians

Use mid level providers who are closest Use mid level providers who are closest to women geographically and socially:to women geographically and socially: nursesnurses midwivesmidwives family planning workers andfamily planning workers and physicianphysician assistants. assistants. (ICMA 2004)(ICMA 2004)

These providers can manage medical These providers can manage medical abortion provision on their ownabortion provision on their own. Let’s allow them to do so. (Berer 2009)

Women-centred Women-centred perspectivesperspectives

Don’t be overly protective of women Don’t be overly protective of women needing abortions. Simplify services.needing abortions. Simplify services.

Give good information that all Give good information that all women can understand, including women can understand, including how to take the drugs safely. how to take the drugs safely.

Allow home use of Allow home use of bothboth drugs drugs ((<<9 9 wks).wks).

Support bona fide web provision and Support bona fide web provision and self medication, esp. where services self medication, esp. where services are lacking/illegal.are lacking/illegal.

More global More global stakeholdersstakeholders

When ICMA began in 2002, few When ICMA began in 2002, few people knew about medical abortion.people knew about medical abortion.

Today, many international, regional, Today, many international, regional, national and local stakeholders national and local stakeholders involved in advocacy, providing involved in advocacy, providing information, and providing medical information, and providing medical abortion pills through many outlets.abortion pills through many outlets.

Many more drug companies, many Many more drug companies, many new brands, and now the two drugs new brands, and now the two drugs are being packaged together.are being packaged together.

Increased opportunityIncreased opportunity

Opportunity to share goals, develop Opportunity to share goals, develop simple, women centred service simple, women centred service delivery norms, support each others’ delivery norms, support each others’ work and engage in joint activities.work and engage in joint activities.

Let’s try to get consensus on some Let’s try to get consensus on some of the contentious issues on the of the contentious issues on the agenda of this conference.agenda of this conference.

To expand access for women, let’s To expand access for women, let’s work together to promote medical work together to promote medical abortion in the context of safe abortion in the context of safe abortion.abortion.