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Putting abortion pills into women's hands: realizing the full potential of medical abortion

Open AccessPublished:August 03, 2017DOI:https://doi.org/10.1016/j.contraception.2017.05.019

      Abstract

      The promise of medical abortion to both reduce maternal mortality and morbidity from unsafe abortion and to expand the reproductive rights of women can only be realized if information and reliable medicines are available to all women, regardless of their location or the restrictions of their legal system. Activist strategies to actualize the full potential of abortion pills are highlighted.

      Keywords

      The practice of abortion sits at the intersection of public health, human rights, reproductive justice and bodily autonomy. The use of medical abortion pills (misoprostol alone or misoprostol in combination with mifepristone), offers a safe and effective method for ending an unwanted pregnancy. Medical abortion has the potential to both reduce maternal mortality and morbidity from unsafe abortion and to expand the reproductive rights of women. However, the promise of these medicines to improve health and enhance rights can only be realized if information and reliable medicines are available to all women, regardless of their location or the restrictions of their legal system. Even in countries where medical abortion is provided by health systems, legal restrictions and regulations on abortion provision pose obstacles that prevent the technology from realizing its full potential as a public health benefit and a social good. These barriers include lack of available providers, the perceived need for a clinical setting, supply of medicines restricted to clinics and hospitals, use of out-of-date or non-evidence-based regimens, requirements for ultrasound and follow-up visits and criminalization of self-induced abortions outside healthcare systems. In countries such as the United Kingdom, additional barriers such as onerous facility requirements burden access to medical abortion, while in the United States waiting periods, parental consent laws and facility requirements are barriers to access.
      The lack of legal and affordable access to abortion pills is a public health issue. For example, in some parts of the world, specifically Latin America, women have been able to obtain misoprostol from pharmacies and have been self-managing their abortions since the early 1980s. Studies demonstrate a correlation between an increase in self-administered early medical abortions with misoprostol and a reduction in maternal morbidity and mortality in this region [
      • Singh S.
      • Maddow-Zimet I.
      Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries.
      ], a very under-publicized fact.
      Lack of access to safe abortion is also a human rights issue which deeply affects women's reproductive rights and bodily autonomy. The history of women self-managing abortion with pills creates a paradigm shift for realizing the full potential of medical abortion, regardless of the legal restrictions of any country and the availability of a clinician. Projects such as the Socorristas in Argentina and Las Libres of Guanajuato Mexico [
      • International Campaign for Women's Right to Safe Abortion
      Las Libres, Guanajuato: a feminist approach to abortion within and around the law.
      ] demonstrate the potential of community-based, safe, effective and empowering abortion care. This new framework involves informing and empowering activists and women with unwanted pregnancies by enabling them to learn about how abortion pills work and to manage the process themselves. The majority of women who use abortion pills do not need an ultrasound or a clinician. In the rare case of a complication, the woman needs access to a clinician skilled in miscarriage management, which is available in all countries.
      By creating community level access to medicines, medical abortion gives control to women who need abortion, regardless of the legal constraints of their country. Ironically, in legally restrictive settings medical abortion is currently more under women's control than in settings where medical abortion is used within the official healthcare system. In many countries with legal abortion, abortion pills are subject to strict regulations of supply and provision, with penalties for those that transgress those limits. The current use of medical abortion outside of the medical system in legally restricted settings presents an important lesson about the full potential of this technology. Medical abortion is subversive because it challenges traditional assumptions about service delivery requirements, the definition of a provider and the power dynamics related to providing abortion care. The experiences from settings where self-induced abortions are a lifeline for women provoke reflection about the level of regulation that is needed for medical abortion, and what defines quality of care.

      1. Information and access

      The classic framework of abortion rights advocacy, where safe equals legal and illegal means unsafe, is turned on its head by self-managed medical abortion. Abortion pills create a universal opportunity for safe abortion regardless of laws. Medical abortion can be used in the privacy of one's home in at least the first 10 weeks of pregnancy and the risk of complication is low [
      • Platais I.
      • Tsereteli T.
      • Grebennikova G.
      • Lotarevich T.
      • Winikoff B.
      Prospective study of home use of mifepristone and misoprostol for medical abortion up to 10 weeks of pregnancy in Kazakhstan.
      ]. As long as the woman is well-advised about what to say if she needs medical care and is in the first trimester where the products of pregnancy can easily be disposed of, the use of pills is undetectable. The loss of pregnancy with medical abortion pills is clinically nearly indistinguishable from a spontaneous miscarriage [
      • Frye L.
      • Winikoff B.
      • Meckstroth K.
      Claims of misoprostol use based on blood sampling should be viewed with skepticism.
      ], which occurs in 15–20% of all pregnancies [
      • Ahman E.
      • Shah I.
      Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated morbidity in 2000.
      ].
      Access to abortion pills has been sharply limited by the politics surrounding abortion. For example, there has been only one large government-supported campaign to raise awareness about the use of misoprostol for safe abortion (in Uruguay), and that was under the harm reduction framework, rather than as part of a human rights initiative. Anti-abortion activism continues to constrain the availability of this life-saving medicine. Deliberate misinformation by media and anti-abortion groups in countries such as Ireland, the USA and Poland discourage the use of these pills. In countries like Brazil, Egypt and Thailand, misoprostol was removed from pharmacies and is available only to physicians in hospitals, specifically to prevent its use for abortion. Where governments have failed to provide essential safe abortion care or have created barriers through very restrictive laws, non-governmental groups, especially in the Global South, have mobilized to fill the gaps. In the last decade, safe abortion information helplines run predominantly by feminist collectives have evolved as a successful strategy for disseminating information about using abortion pills (misoprostol alone or mifepristone and misoprostol) for safe abortion and as a vehicle for social change. The concept of helplines has spread quickly, and 20 telephone hotlines have been established in Africa, Europe, Asia, and Latin America [
      • International Campaign for Women's Right to Safe Abortion
      ,
      • Women Help Women
      Hotlines and regional resources.
      ]. These hotlines are run by grassroots feminist activists, filling the void left by their governments' collective failure to provide for women's health. There are currently also internet-based telemedicine services (Women Help Women, safe2choose, TelAbortion, Tabbot Foundation in Australia, Women on Web) that provide information and access to abortion pills locally or globally.
      The mission of the helplines is to provide accurate information about abortion pills including the most effective regimens, how to manage the experience and clear guidelines for aftercare. Recommendations about sources for reliable supply of medicines are tailored to the local context. Most of the helplines also provide information about contraceptives, healthy pregnancies, post-partum hemorrhage prevention and treatment, post-abortion care, adoption services, and other sexual and reproductive health matters.
      The helplines stress the importance of the connection between a caller and the helpline staff. Through these relationships, each caller or writer is given informed support in her own language, ensuring that her cultural and social context is understood and that the best possible local information about post-abortion care and reliable medicines is available to her.
      Several scientific studies have already demonstrated the positive impact of abortion hotlines [
      • Gerdts C.
      • Hudaya I.
      • Belusa E.
      Mobile health innovations for improved access to safe abortion in Indonesia.
      ,
      • Dzuba I.G.
      • Winikoff B.
      • Pena M.
      Medical abortion, a path to safe, high-quality abortion Care in Latin America and the Caribbean.
      ,
      • Drovetta R.I.
      Safe abortion information hotlines: an effective strategy for increasing women's access to safe abortions in Latin America.
      ]. One study concluded “they [the hotlines] have the potential to reduce the risk to women's health and lives of unsafe abortion, and should be promoted as part of public health policy, not only in Latin America but also other countries” [
      • Drovetta R.I.
      Safe abortion information hotlines: an effective strategy for increasing women's access to safe abortions in Latin America.
      ]. Those studies highlight the important role of community level activists in filling the need for accurate and culturally appropriate information about abortion pills.
      However, information alone will not expand access to safe abortion. Women must also be able to obtain the medicines easily and reliably. Current impediments to access include a lack of knowledge about how to identify reliable sources, government-imposed restrictions on pharmacy distribution of misoprostol, stigma around and prosecution of self-managed abortions, the unavailability of mifepristone in a majority of countries [
      • Gynuity Health Project
      ], and customs regulations restricting the importation of medicines. As a result, unofficial markets offer unreliable medicines or medicines at very high cost profit from desperate needs.
      To overcome these barriers, de-centralized networks of activists have emerged in many countries to help women find reliable medicines and to support women through the process. This “conscientious commitment” to help individuals in need of abortion stands in ethical opposition to the “conscientious objection” claimed by some clinicians and medical staff. While most of these community networks stay silent due to fears of prosecution, in some countries members of these networks are publically committing acts of civil disobedience to bring attention to the importance of putting abortion pills into women's hands. For example, when a woman in Northern Ireland was arrested for illegally obtaining abortion pills, three Northern Ireland activists turned themselves in to the police self-identifying as having helped women get abortion pills, and dozens of others signed a letter stating that they too have been helping women access abortion pills [].
      Another strategy to overcome barriers to access is the use of telemedicine. Online abortion services combine information provision via email with service delivery. Women who cannot access the pills locally can receive a discrete package with mifepristone and misoprostol by post to their home address. However, in many countries the local postal services are unreliable or packages are stopped by customs officials. Local groups, supported by global initiatives such as Women Help Women (WHW), can provide a crucial link to reliable medicine and accurate local information and referral sources. By creating a network of activists across national boundaries, WHW supports local activists learning from each other and creating innovative strategies like community distribution of medicines to expand access in each country.

      2. Reconceptualizing “the provider”

      Telephone and some email helplines build on three innovations in health care: medical abortion, m-health/telemedicine, and task-shifting to new types of providers. The paradigm of surgical abortion required trained clinicians as providers of abortion care and centralized the services in facilities. Conversely, medical abortion invites decentralization, as no facilities are necessary for early medical abortions.
      Medical abortion allows the reconceptualization of “provider” and the redefinition of “performing” an abortion, as it is the woman herself who can be in control of the process, with support from those who share accurate information, help her to access medicines, and, if needed, support her throughout the abortion process. When a woman herself is empowered with information on how to access the medicines, she is the “provider”, while those who assist her can be seen as her support team.
      Task-shifting and task-sharing have been recognized in the 2015 World Health Organization's report that highlighted the pivotal role that lay community health workers play when appropriate tasks are shifted and become their responsibility [
      • World Health Organization
      Health worker roles in providing safe abortion care and post-abortion contraception.
      ]. By empowering community activists to become key providers of safe abortion information, the helplines provide an example of the benefits of such shifting. For example the email helpline of Women Help Women in 2016 received and answered 60,000 emails in multiple languages and is staffed by 24 lay activists who reside in 16 countries on four continents, supported by two gynecologists and research advisors.

      3. Activism around self-managed abortion

      While self-management of medical abortion presents enormous potential for the empowerment of women, the experience of individual women often remains stigmatized. With independent use of abortion medicines, especially in settings with oppressive laws and attitudes, the effects of abortion stigma are multiplied. The helplines support the breaking of this stigma. While individuals who self-manage their own abortion may not always view their actions in a political context, the helplines frame this practice as hands, rejecting systems of law, local medical practice, societal norms, religious norms and sometimes deeply held personal beliefs. In this context, women may recognize that they are committing a political act by refusing to submit to various oppressive systems. This leads to activism around decriminalization, or changing laws and policies.
      In recent years the notion of provision of information about abortion medicines as a harm reduction strategy has been adopted by some larger non-profit organizations working in reproductive health. While the concept of harm reduction may prove useful for building larger national coalitions, the harm reduction framework stigmatizes self-managed abortion and those that need this type of service. The helplines demonstrate that using abortion pills outside a medical context is not in the same category as “coat hanger abortions” and other unsafe, backstreet methods. Nor is it merely a “less unsafe” last resort when clinic abortions are illegal or unavailable. Self-managed abortion can be a safe and viable option.
      Putting abortion pills and information into women's hands promotes women's autonomy. Learning the science behind the medicines and being able to support other women is inherently empowering. The helplines translate this self-empowerment into local activism that contributes to the normalization of the abortion experience. They break the taboos around women's sexuality and sexual expression and advocate for de-criminalization of abortion. Additionally, those that become involved in ensuring a supply of reliable medicines to women with unwanted pregnancies, take a powerful position of resistance and political commitment to the right to abortion and self-determination. Local ownership is key to sparking local activism, which links with national and regional advocates. This local ownership creates the potential for systemic change and increases sustainability.
      Innovative local projects such as hotlines and community programs on dissemination of information medical abortion, working in collaboration and with support from global online helpline like Women Help Women serve as clear examples of the benefits of making abortion pills accessible to women in order to improve women's health and transform the politics of abortion. Putting abortion pills directly into women's hands can enhance the health and rights of women around the world.

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