Ideology or evidence?  The battle over abortion pills

The debate about the use of abortion pills at home is one of a number of controversial issues where I believe that we are increasingly seeing the triumph of ideology over evidence.

I’ve explained elsewhere what the current practice is but, briefly, medical abortions (as opposed to surgical) are most commonly used up to nine weeks (note this number of weeks as I’ll come back to it), but medical abortion can also be used after 13 weeks of pregnancy.  To carry out a medical abortion, first an oral dose of Mifegyne (mifepristone, also known as RU486) is given at a clinic/hospital which will (usually) kill the fetus. Women leave the hospital or clinic then have to return up to 48 hours later to be administered misoprostol, either orally or vaginally. This expels the dead fetus.

However, a recent decision by Ministers in Scotland now permits women to take the second abortion pill ‘in the comfort of their own homes’ if they choose, rather than in an abortion clinic or hospital under medical supervision, as long as they have an adult with them. There is pressure to extend this change in policy to the rest of the UK.

Why not, when it is claimed that that this is ‘safe and sensible’ and that ‘it is unacceptable for any woman to be made to risk miscarrying on her way home from a clinic’?  It is also ‘potentially time-consuming and cumbersome in that each visit [to obtain the abortion pills] may involve rearranging work and childcare commitments.’ These claims remain unchallenged in the media.

Why not just let a doctor or nurse hand women the pills, to then take in the comfort and privacy of their own home, at her own convenience? Why does she need to have someone supervising her taking it?

The reason why I believe this is primarily an ideological battle, that ignores evidence, is because evidence shows that complications from medical abortions are common, not rare, according to official CIOMS criteria (see my blog here too) and, importantly for this new policy change, medical supervision is in the best interests  for women taking the pills, assuming, that is, that we want to protect their health.

The reason women should continue to take misoprostol under medical supervision is because the precise timing and the exact manner of misoprostol administration both directly influence the failure and complication rate of the abortion ie. when and how it is taken is crucial to whether it works and whether complications arise.

1. The precise time interval between taking mifepristone and taking misoprostol is critically important in the effectiveness of the regimen and directly affects how likely the woman is to experience a failed drug-induced abortion and require surgery. Misoprostol is recommended to be taken 24 to 48 hours after taking mifepristone, otherwise its effectiveness is significantly lowered. Yet there is nothing to stop a woman taking this outside the recommended hours if she is outside of medical supervision,

Research has shown that women have a strong preference for a short time interval between the mifepristone and misoprostol, consequently may well be inclined to take it quicker. But the use of misoprostol sooner than 24 hours after mifepristone leads to a significantly increased failure rate with one study finding that nearly one out of every three to four women who took buccal misoprostol (one of the methods of taking it) shortly after the mifepristone failed to abort. For women who are over seven weeks gestation (note my earlier comment on when medical abortions are most commonly used) the failure rate was up to 31%. Yet in Scotland women can now take misoprostol at home up to 10 weeks gestation.

This means that removing control over the timing of misoprostol administration, allowing women take it at a time ‘convenient for them’, will increase failure rates, complications and need for subsequent surgery.

A meta-analysis of 20 studies in 2015 comments on the lack of research and understanding of the effect of taking misoprostol at varying times after mifepristone. It warns of the ‘paucity of data on the actual time interval at which women actually administer misoprostol when instructed’. It adds that: ‘Our ability to fully understand if buccal misoprostol is more effective with a dosing interval closer to 48 hours is limited by the relatively small number of women in protocols.’

2. The precise manner in which it is taken also affects failure rates. Vaginal and buccal administration is generally recommended over oral, but if a woman gets frustrated and uncomfortable with keeping the misoprostol pill between her cheek and gum for the full 30 minutes and instead chews it up and swallows it early, she has just converted a ‘buccal’ administration into an ‘oral’ administration. The recommended 200mg dose of mifepristone is low, thus necessitating larger doses of misoprostol. But oral administration of misoprostol combined with this low dose of mifepristone is not as effective in emptying the uterus after the fetus has died and results in a higher failure rate.

72% (83/115) of women in a study stated that they disliked buccal administration: 43% found the taste objectionable, 30% found buccal retention uncomfortable or inconvenient and 10% reported oral irritation, sensitivity, numbness or oral ulcers.

So, the second visit builds in an important safety feature by allowing for direct observation and monitoring of the administration of misoprostol at a precise time and method after mifepristone administration.

Note that although medical treatment for miscarriage, as opposed to abortion, may be self-administered it only requires a dose of misoprostol, not mifepristone, so timing and manner of administration are not as significant. This is because in miscarriage the fetus is already dead.

3. If all that is still insufficiently persuasive, then consider the practicalities of self-administering. Once a woman leaves the clinic there is absolutely nothing to stop the abortion pill being taken at other locations such as schools, colleges etc (even, ‘back streets’? The irony of this seems to have missed most people). There is nothing to stop it getting into the wrong hands or taken at the wrong gestation. There is nothing to stop it being taken by the woman alone, even though the Scottish guidance underlines the absolute necessity of the woman having another adult there.

I do not see how it can be ensured that misoprostol is actually self-administered at home, at the right time, in the right way and with an adult present. So how is this change in the best interests of women’s health and safety, let alone in keeping with the law?

The experimental use of misoprostol is dangerous to women (indeed, it is the misoprostol component of the drug-induced abortion regimen that has been implicated in fatal infections seen after some medical abortions).   And, interestingly, misoprostol will be withdrawn from the French market in March 2018, according to the Lancet, following reports of serious side-effects from medical abortions.

It has been argued that some women may have transportation problems getting to the clinic for both pills. But medical abortion is contraindicated for such women!  Women should not be given medical abortion if they are not easily available for follow-up contact or medical evaluation. Surgical abortion is an option for women with genuine transportation difficulties.

As readers of my blogs will know, I oppose abortion in total, however this issue raises new, and real, concerns about the safety of women being subjected to this procedure.

Medical supervision of exactly when, how and where women actually take misoprostol is a key element in minimising the complication and failure rate of the abortion and in protecting women’s health. Which leaves me asking the following question:

What is more important, is it evidence or is it ideology?  Is it protecting the health, safety and best interests of women or is this actually just another part of an ideological drive to remove as much medical supervision and legal regulation from abortion as possible?