Medical abortion is fundamental to women's health care.

Abstract

Medical abortion is fundamental to women's health care. It provides a safe and effective alternative to early surgical abortion and can occur in the privacy of a woman's home. Compared to European countries and the United States (US), access to medical abortion in Australia has been a recent development, as prior to 2013 use of mifepristone was severely restricted and only available under the Authorised Prescriber provisions of the Therapeutic Goods Act 1989 to the few clinicians who applied for it.1 In 2015 a composite pack of mifepristone and misoprostol, sponsored by MS Health, a subsidiary of Marie Stopes International (MSI), became available for use up to 63 days gestation. The study by Goldstone et al.2 in this issue of ANZJOG, documents the recent clinical experience of 15 008 Australian women who sought abortion up to a gestation of 63 days and received the regimen of 200 mg of oral mifepristone followed 24–48 h later by 800 μg misoprostol self-administered buccally at home. This followed a previous study by the same lead author which detailed the outcomes of 13 345 early medical abortions between 2009 and 2011.3 The combined regimen of mifepristone, followed 36–48 h later by the prostaglandin E1 analogue misoprostol, is now well established as both safe and effective for gestations up to 63 days and the Goldstone paper adds to the extensive international evidence. Studies on the use of mifepristone in over 400 000 women have reported that the rates of serious adverse events, including hospital admission, blood transfusion, or significant infection, range from 0.01 to 0.7%, and that these events are almost always treatable without long-term sequelae.4, 5 Common side effects such as bleeding, cramping, fever and chills are generally minor and transitory.5 There have been a small number of deaths worldwide attributable to the use of mifepristone related to post-abortion sepsis with a rare organism, Clostridium sordellii.6 While not diminishing the significance of these deaths, the mortality risk for both medical and surgical abortion is substantially lower than continuing a pregnancy to term.7 The Goldstone study is one of the largest published cohorts and confirms previous findings with high method success (95.16%), low rates of infection (0.11%) or haemorrhage requiring transfusion (0.13%). No link could be confirmed between the one death that occurred as a result of Streptococcal pyogenes-related necrotising pneumonia and mifepristone administration. In countries where mifepristone has been available for some time, around half of all women choose medical over surgical abortion and the few randomised trials that have been undertaken show comparable acceptability of both methods.8 Irrespective of whether misoprostol (following mifespristone administration) is administered in a public hospital/clinic or in a private setting,9 most international studies report that around 90% of women who undergo medical abortion would, if required, choose the method again or would recommend it to a friend.10 Overall acceptability varies with parity (lower in nulliparous than in parous women), gestational age (reduces as gestational age increases) and according to the amount of pain and bleeding experienced.11, 12 Despite the fact that abortion is one of the most commonly performed gynaecological procedures in Australia and that approximately one in four women will have an abortion in their lifetime,13 the availability of medical abortion in Australia, however positive a development, has not reduced some of the barriers to access faced by many women. As a result of law reform in six of eight Australian jurisdictions, abortion can be performed lawfully subject to various conditions in these jurisdictions but it has been fully decriminalised only in the Australian Capital Territory. Abortion remains a crime in New South Wales (NSW) and Queensland and can only be performed lawfully at all as a result of case law permitting abortion where it is necessary to prevent serious risk to the life or health of the woman. Australian research has consistently indicated that 70–80% of the public support a woman's right to access abortion and believe it should be lawful.14, 15 Practitioners report that the current complex and varied legal status of abortion across Australia has a significant impact on service provision and compromises patient care.16, 17 Regardless of legal status and public opinion, access in most states and territories is complicated by the costs of largely private provision and lack of access for women in rural regions where few private services operate. Women are often required to pay for the costs of an abortion ‘upfront’ and if they live at a distance which necessitates extensive travel and an overnight stay near the abortion clinic, costs can be prohibitive.18 Of the 80 000 estimated abortions in Australia each year, most occur in the private sector.18-20 In several states, including the most populous state of NSW, public access to abortion is extremely limited. Public hospitals have abrogated responsibility for abortion service provision, leaving the private sector, including independent abortion clinics and a small number of motivated general practitioners (GPs), to fill the need. Although private services provide high-quality medical care, they can be costly and out of financial reach for some women. While costs vary, particularly with the introduction of newer services, a recent study of women attending a service provider reported the median out of pocket cost for a medical abortion as $560 and more than two-thirds (68.1%) of women had to rely on financial assistance from two or more sources.18 Compared to women from urban areas, women who had to travel for four or more hours to a city-based clinic were significantly more likely to present later than nine weeks gestation which made them more often ineligible to choose medical abortion. This group of women were also more likely to identify as Aboriginal and/or Torres Strait Islander, report less knowledge of medical abortion and have greater difficulty paying for the procedure. These results indicate that the potential for medical abortion to improve equitable access to abortion services will remain limited unless geographical, knowledge and financial impediments to obtaining early care are reduced.18 Many of these barriers that leave some women without the means to terminate an unwanted pregnancy could be addressed through medicare funded access to both medical and surgical abortion through the public hospital system. Nevertheless, other service delivery models within the Australian setting need consideration. Private provision through dedicated clinics can remain an option, but primary care services delivered through general practice, family planning clinics and sexual health services ought to be enhanced. It was hoped that with subsidy of mifepristone and misoprostol through the Pharmaceutical Benefits Scheme in 2013, coupled with the provision of accredited online training for GPs in the delivery of medical abortion, that improvements in access, especially for women in rural areas, would occur through GP provision. However, uptake in general practice appears to be low with a recent NSW-based qualitative study suggesting reasons for this ranging from from the belief that medical abortion is beyond the scope of general practice, to fears of community stigma and the perception that provision is complicated.21 While medical abortion will not be within the scope of all GP practices, support by local gynaecologists and hospital services for those who do want to provide this service is imperative in the event that specialist back-up is required. Other innovations include the availability in most states and territories of telemedicine medical abortion services. One of the first, The Tabbot Foundation, underwent a recent independent review. The results presented at the 15th World Congress on Public Health in Melbourne found it to be a safe and effective service.22 Since its establishment in 2015, mifepristone and misoprostol have been sent through the post to over 1800 women following a referral for an ultrasound and blood tests and a telephone assessment consultation. Follow-up to confirm abortion completion involves a blood test but, as mentioned in the paper by Goldstone et al., the use of a home-based semi-quantitative urine pregnancy test shows promise in reducing the need for women to return to the clinic to confirm successful treatment. This, together with the use of remote access communication technologies, is ideally suited to the Australian context where repeat clinic visits can be challenging but follow-up is required. While implementation of evidence-based clinical and service delivery innovations are imperative, promoting a workforce that is competent and willing to provide abortion is even more fundamental.23 Early exposure to each component necessary to support women in controlling their fertility should begin in medical school and continue through to specialist gynaecology training, as well as general practice and other relevant disciplines. All gynaecologists and GPs, regardless of whether they personally choose to provide abortion services, should have skills in supporting informed decision-making about pregnancy options, knowledge about medical and surgical abortion and skills or rapid referral pathways for the provision of effective contraception, including post-abortion long acting reversible contraception (LARC) to prevent repeat unwanted conceptions. Only then will abortion service provision become normalised as an essential component of women's health care in Australia.24 Globally, many would be aware that the Trump administration in the United States has issued an executive order that restricts funding to international organisations that provide women in low and middle income countries with information about their reproductive health rights and options. The policy requires non-governmental organisations receiving federal funding to agree to ‘neither perform nor actively promote abortion as a method of family planning in other nations’. This will potentially see many organisations forfeiting federal funding from the US, the largest contributor to global health funds, for crucial reproductive health care as well as non-abortion-related health initiatives.25 Within the US, the Trump government is also planning to defund Planned Parenthood which provides contraceptive advice and abortion to millions of women across the country. In Australia threats to severely restrict access to abortion are unlikely in the current climate, but as a nation we continue to fail to address the issue of equity of access to one of the most common procedures women will require in their lifetime. The public health system in a number of states has neglected management of unintended pregnancy and provision of abortion procedures. In countries where women can elect either medical or surgical abortion, around 50% choose the former, whereas currently only a third of Australian women take up this option. This may be due to several reasons, including the relative recency of its introduction, a lack of community or even medical practitioner awareness and knowledge about medical abortion and current clinical guidelines for follow-up care requiring a repeat clinic visit. Studies such as the one by Goldstone et al. have been essential in documenting the uptake, safety and efficacy of medical abortion in Australia and are crucial in helping women make informed choices when faced with an unintended pregnancy, and in equipping healthcare providers to support women in their choice. But more needs to be done to ensure that our health system does not fail to provide the basic services which every woman has a right to access, regardless of her financial circumstances or where she lives.