What is a “medical” abortion and why should anyone really care? Unintended pregnancies continue to occur, despite best efforts at prevention. Even with the best efforts to make every pregnancy a planned and wanted one, there is still a need for abortion services as part of comprehensive reproductive care as noted in Prime Minister Trudeau’s recent funding announcement supporting reproductive rights. Currently, about 31% of Canadian women will choose to terminate a pregnancy at some point in their lives. The introduction of a new drug in Canada, Mifegymiso, means that hopefully more Canadian women will now have a choice between a surgical termination and a non-surgical one that can be done very early in the pregnancy and in the privacy of any doctor’s office and their very own home. My concern is that unless the health care system and local providers sit down to plan for this, it simply won’t be an option for many women who would choose this for themselves.
Mifegymiso is actually a combination of two drugs: misoprostol and mifepristone. It’s the second ingredient which is new, approved by Health Canada in July 2015 although it has been in use in France and China since 1988. More than 60 countries have approved this drug, also dubbed the “abortion pill”. When mifepristone is ingested in early pregnancy, it blocks the progesterone receptors that keep the pregnancy viable. It also helps to soften and dilate the cervix. The other ingredient, misoprostol, triggers uterine contractions necessary to expel the pregnancy. Used together, the onset is rapid and the event is completed in a number of hours. This treatment is not effective in ectopic pregnancies, which are those that occur outside of the uterus, often in a fallopian tube. Ectopic pregnancies can be life threatening and need to be identified early. Fortunately, there is a non-surgical option as well, using the injectable drug methotrexate, along with specialized follow-up.
Women who experience an unintended pregnancy need to be counselled and supported in making the decision that is best for them. This can be a time of great vulnerability and indecision. It is important to remember that intimate partner violence increases the risk of abortion, unintended pregnancy and sexually transmitted infections. A non-judgemental, nondirective approach to counselling in a confidential setting is essential.
If the woman’s decision is to terminate the pregnancy, information about both medical and surgical options should be provided. How are these different? In studies where women were given a choice between medical and surgical abortions, 35% to 84% chose a medical termination. Reasons for this include the avoidance of surgery and anesthesia, the ability to accommodate other commitments such as home and work tasks, privacy, and perceived safety. It does entail more office visits, but can be done immediately rather than waiting for a surgical appointment, and can be delivered closer to home. Medical abortions must be done early in a pregnancy, usually within a few weeks of a missed period. If done before 49 days since the last menstruation, they are almost 99% effective. Most women who have had a medical abortion would opt for the same, if facing a similar choice. Published studies show high satisfaction rates ranging from 63% to 96%.
Surgical terminations also have high satisfaction rates. However, for the patient, it means waiting for a booking, securing a ride to and from the hospital, and the possibility of having to endure the presence of protestors on her approach. That said, there may be other reasons why a woman chooses a surgical option, including the reality that this may be the one and only option if a pregnancy is late in being diagnosed.
Up until the advent of mifegymiso, less than 5% of abortions being done in Canada have been nonsurgical. This may now change, but won’t unless there is proactive engagement of our medical community to plan for greater access, regardless of geography. March is the month when we celebrate International Women’s Day. This year, we can drive it home with a commitment to ensure that women in all Ontario communities have access to a more comprehensive range of confidential and effective reproductive choices.
Op Ed from Dr. Rosana Salvaterra, Medical Officer of Health, Peterborough Public Health