Medical abortion – popularly known as the abortion pill – has been in the news almost non-stop for several months now in both Britain and Ireland, though for very different reasons. That’s good news because more women are getting to hear about it. Although the method has been around since the late 1980s, most women didn’t start hearing about it until the last ten years or so. But as it’s become more known, so has controversy begun to brew around it. Why? Because the abortion pill potentially puts the control over abortion into women’s hands, and a lot of conservative men and women aren’t sure they like that.

Medical abortion, when used from the time a woman first misses her period until up to 9 weeks of pregnancy (dated from the first day of the last menstrual period), is more than 95% effective, and the earlier it is used, the closer to 100% effective it is. The method consists of two kinds of medication.

First, mifepristone (one 200mg pill) is taken by mouth, swallowed with some water. Then, misoprostol (four pills of 200mcg each) is used 24–48 hours later. These 4 pills can be inserted high up in the vagina, which a woman can do herself, or a nurse or doctor can do for her. Or, they can be taken buccally, that is, placed inside her mouth, two on the inside of each cheek, where they will slowly start to melt and should remain for up to 30 minutes, and then whatever is left should be swallowed with water. Within 4-5 hours later, the woman will (in almost all cases) have a miscarriage.

Spontaneous miscarriages almost always happen at home; women cope with them. There will be menstruation-like bleeding and fluids, but far heavier than a period, more with every week of pregnancy, often with clots. When the embryo is passed with the bleeding, the bleeding will slowly become lighter. It is likely to continue for several days, or somewhat longer, and then gradually stop. The woman will experience cramps and commonly nausea, and she should take ibuprofen for the pain when the cramping starts and more when needed.

For most women, at this early stage, this will terminate the pregnancy. This method is both safe and, yes, easy. Easy for women, and easy for the health service provider, who in almost all cases only has to give the woman information, give her a choice between this method and an early aspiration abortion, and then give her the pills (and insert them vaginally for her if the woman prefers that). With training, this person can be a family planning nurse, a regular nurse, a midwife, a GP, or if no one else is allowed, a gynaecologist. [1]

Three things may go wrong. First, nothing may happen and the woman will need to take a repeat dose of four more 200mcg misoprostol tablets, or opt for an aspiration abortion. Second, bleeding will start and the embryo will be expelled, but the abortion will be incomplete and treatment will be needed to complete it, again a repeat dose of four more 200mcg misoprostol tablets or aspiration. Third, very very rarely, bleeding will become very heavy and the woman will need immediate medical treatment to stop it.

Because these three things may happen, even though they will not happen for the great majority of women, access to medical treatment is very important. Moreover, access to assurance that everything is going OK is also important for women using this method for the first time. Waiting is involved and women can become nervous, and may want someone to talk to, so an abortion phone line can be an important part of providing this method in a way that meets women’s needs.

However, for the vast majority of women, early medical abortion consists of taking the tablets as prescribed, having a miscarriage, and it’s over.

So what’s going on?

In both the North and South of Ireland, where almost all abortion is illegal, women have been crossing the border and coming to Britain or other European cities for a safe, legal abortion. But that costs a lot of money and many women in Ireland can ill afford it. It may take them precious weeks or even a month or two to raise the cash and arrange the trip and the abortion. And meanwhile their pregnancy is advancing. And since the financial crisis started, more women are reporting difficulties in coming up with the money necessary to access abortion services, according to the Irish Family Planning Association (IFPA).

Women in Ireland have discovered medical abortion, because the women’s grapevine and the internet are more powerful these days than the 19th and 20th century Irish laws prohibiting abortion. Pills can be transported all sorts of ways, including through the post. And clearly that is now happening. The newspapers in Ireland picked up the story recently of a Chinese woman who brought medical abortion pills into Ireland and was selling them over the counter in her supermarket. Shock, horror! How could this be allowed to happen, and she has had to pay a €5,000 fine and €5,500 costs. I hope the pro-choice movement in Ireland is brave enough to come out publicly and support her.

But the fact is that in almost every country in the world across Latin America, Asia and many parts of Africa where abortion is still mostly illegal, medical abortion pills are available in pharmacies, drug shops, and street markets. This is far from an ideal situation, and no one who supports women’s right to a safe, legal abortion thinks it is fine as it is.

For a start, only misoprostol tends to be available on its own, and it is not nearly as effective (even with the optimum dose) as it is when taken in combination with mifepristone. Secondly, women and drug sellers may not know what the correct dosage and procedure to follow are. Thirdly, when things go wrong, women may or may not have access to medical back-up. However, medical abortion is reducing the number of deaths from unsafe abortion in many of these countries, because the method does not kill women in the same way as unsafe, invasive methods, such as putting a twig or a rubber hose up the vagina into the uterus, did.

The use of medical abortion pills in Ireland is also not ideal, though women in Ireland who know enough to have accessed the pills are also very likely to know where to ask for help if needed, and they will get that help. Everyone who is pro-choice would far prefer this situation to be regularised. However, that requires abortion to be made legal and medical abortion pills made available through national drug registration and health service provision. How likely is that, do you think, in the near future?

Well, it is possible after the recent European Court of Human Rights judgement (16 December 2010)– that Ireland’s strict law violated the right to life of a pregnant woman suffering from cancer – that Ireland will liberalise its abortion law, at least to allow abortion when the health and life of the woman are at risk. But the North? A more reactionary, anti-women set of male politicians in charge of the law would be hard to find.

It is ironic that women can cross the border and leave Ireland for an abortion in Britain, paying anything up to £2000 for the privilege, and do so legally (which it must be added Irish women fought for in the courts up to European level in the late 1980s/early 90s), yet medical abortion pills cannot cross the border into Ireland without the customs seizing them – do they not have anything better to do, like seizing seriously harmful drugs such as heroin? – and the anti-abortion movement making their usual hysterical remarks about the pills being “deadly” and so on and so forth, blah blah blah.

When will these guys get over it? As Agata Chelstowska from Poland says in an article I’m about to publish in RHM: “Is it possible that the purpose of the law is not to reduce the number of abortions, but to serve a purely political role, as a symbolic achievement of the Church and right-wing parties?” Yes, it is!! And the name of that achievement is control over women for its own sake. Unfortunately, women don’t accept that anymore, guys, and medical abortion pills are helping us to bypass all that medieval misogynistic control freakery.

Meanwhile, back in Britain…

Yesterday, in 21st century Britain, where abortion has been legal and available since 1967, you would have thought the “guys” involved had got over this issue and accepted that women need abortions, and always will, and that it is the job of the health service to make them available as early and as safely as possible, based on the best evidence-based practice.

We hear a lot about evidence-based practice today. It’s meant to be what everyone follows because it shows you what is best to do to achieve the ends you want and what can go wrong, so you can avoid it – in lawmaking, in economic policy, in health care. Ha ha. Are you watching the coalition government? Never heard of it. Or rather, mouth the words and then ignore the evidence and do something else.

Yesterday, a High Court judge ruled in a case brought by Bpas[2] that the regulations related to the 1967 Abortion Act, which say that the treatment for abortion must be carried out in hospital premises, would have to be amended to allow women to use the second half of the medical abortion regimen (the misoprostol pills) at home.

At the moment, the procedure is that the woman must take the mifepristone pill in front of the doctor or nurse who hands it to her. Then she can go home and wait and come back 24 or 48 hours later to get the misoprostol pills, which must be inserted in her vagina at the clinic or taken buccally (described above) and then she can either wait 4-5 hours for the abortion to happen in the clinic (if they have the facilties for this) or go straight home again. In some cases, if she goes straight home again, the abortion may happen while she is on her way. This is not best practice, and something that any clinician with a brain would prefer not to see happen.

The judge recommended (and many thanks to him for that, it was the best he could do), based on the substantial evidence provided by Bpas, that the government could amend the regulations, which were written at a time when all abortions were surgical procedures and carrying them out in hospital premises was intended to remove them from the backstreets to make them safe. We have long ago moved on from that, and the regulations need to move on too.

Bpas said:

“Bpas is very pleased that the Hon Mr Supperstone J has ruled that Section 1(3A) of the Abortion Act as amended in 1990 enables the Secretary of State to react to “changes in medical science” as it gives him “the power to approve a wider range of place, including potentially the home,  and the conditions on which such approval may be given relating to the particular medicine and the manner of its administration or use.” …

Since we brought our case to court, the Royal College of Obstetricians and Gynaecologists has produced new guidelines noting the weight of evidence in support of home-use of misoprostol for abortions up to nine weeks and the importance of giving women choice of method. This new, evidence-based guidance was supported by the Department of Health. Given Health Secretary Andrew Lansley’s commitment to evidence-based medicine, patient choice and the liberation of clinicians, we assume he will wish to employ the powers the ruling highlights rapidly so that doctors may provide women legally accessing early abortion with the best possible care.”

What will Andrew Lansley, the Tory Secretary of State for Health, who is planning to destroy the NHS, do? Hard to tell. He’s behind a radical blueprint to privatise and break up the NHS in England, which those who understand how the health service functions, from the medical professional associations to the editors of the BMJ and Lancet, are sure will cause chaos and destruction and cost £3 billion to implement. Does he also have the courage to amend this out-of-date regulation, to bring it in line with current practice in the USA, Sweden, Norway, France, Switzerland, and elsewhere? Probably not, because the anti-abortion fringe in his own party are likely to want to make mincemeat of him if he tries.

Ironically (and this is looking like the century of irony), in this same week the Roman Catholic Diocese of Phoenix, Arizona in the USA, castigated a Catholic hospital for allowing an abortion that saved a woman’s life.

Welcome to the 21st century.

[1] Why should we believe pain and suffering are good for women? Only misogynists and anti-abortionists think that.

[2] Bpas provide abortions for the NHS and for women not eligible for NHS abortions.

References

Chelstowska A. Stigmatisation of abortion and commercialisation of abortion services in Poland: turning sin into gold (working title). Reproductive Health Matters 2011;19(37). (In press)

Donnellan E. More find it harder to afford abortion services. The Irish Times. 29 June 2010.

Bpas disappointed its interpretation of Abortion Act is not deemed viable, but ruling shows Lansley now has power to ensure women receive best possible care. Bpas press release, 14 February 2011.

Hamilton S. Deadly abortion pills on sale in Ireland. Sunday Mirror (Ireland). 2 February 2011. [no link available]

Jacobson J. European Court finds Ireland’s abortion law violates rights of pregnant woman with cancer. RH RealityCheck. 16 December 2010.  

Jordan A. Woman charged with selling illegal abortion tablets in supermarket. Medical Independent. 27 January 2011.