Expanding access to medical abortion

1. Expanding access to medical abortion Marge Berer Editor, Reproductive Health Matters Chair, ICMA Steering Committee *** Lisbon, March 2010

2. 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.

3. Current methods recommended by WHO • Manual vacuum aspiration • Vacuum aspiration • Dilatation & evacuation • Medical abortion (mifepristone + misoprostol)

4. 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.

5. 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.

6. 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.

7. This conference is about expanding accessto medical abortionWhy is access such a problem?

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. Even so… access to medical abortion is getting better… and better!

14. 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.

15. 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.

16. 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)

17. Moreover, women are quietly taking these drugs into their own hands.

18. Meanwhile, back at the hospital.. • Dosage (200mg/600mg mife) and regimens. • Delivery of misprostol(oral, vaginal, buccal, sublingual). • 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?

19. Enhancing access

20. WHO Safe Abortion Guidance2003 • 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.

21. Increase role of non physicians • Use mid level providers who are closest to women geographically and socially: • nurses • midwives • family planning workers and • physicianassistants. (ICMA 2004) • These providers can manage medical abortion provision on their own.Let’sallow them to do so.(Berer 2009)

22. 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.

23. 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.

24. 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.