Access to abortion services is becoming more and more difficult around the country, and remains problematic worldwide. One potential way to improve access for the majority of women who need abortion services in the first 9 weeks of pregnancy would be to make the medications that induce abortion available over-the-counter at pharmacies nationwide.
Medical abortion (see below for a detailed definition, but for our purposes, an abortion that is completed at home, with just pills rather than a procedure in a clinic) is an extremely safe and effective way to end unintended pregnancies. The most effective regimen, a combination of misoprostol and mifepristone, works up to 98% of the time. In other words, 98% of women who take these two drugs correctly to induce an abortion at up to 9 weeks after their last menstrual period will expel their pregnancy completely, with no medical intervention whatsoever. So why not take the providers out of the equation? It would certainly make abortion far more accessible and affordable for many women.
Additionally, such an approach might present a missed opportunity for providing contraceptive care. If women aren’t seeing a medical provider for their abortion, they may lose out on the opportunity to start a contraceptive method immediately after their abortion. In fact, offering contraceptive counseling and providing a method if desired is a key component of quality abortion care. It’s true that in a perfect world, women would be able to start their chosen contraceptive method immediately after their abortion in all cases (and in fact it would be much easier for many women to do so if more contraceptive methods were available over-the-counter as well!). However, it is never appropriate to make availability of one health service contingent on provision or acceptance of another. (Unfortunately, this is common practice; many medical providers still require patients to come in for their preventive care visits before they will renew prescriptions for contraceptives. Just because it’s common doesn’t make it right).
Finally, some may worry that women who are past the recommended 9 weeks since their last period will use the method even though the instructions say not to. First of all, as I mentioned above, many people do not follow the directions for the use of over-the-counter products. It doesn’t mean those products should not be available. Second, although misuse of over-the-counter products such as acetaminophen (Tylenol) are frequent causes of death and disability in the United States, there are no restrictions on their sale. Third, these medications are still safe to use after 9 weeks of pregnancy; however, their efficacy decreases. In other words, women who use the medications in these doses after 9 weeks of pregnancy are less likely to have a complete abortion, although much of the time the regimen will still work correctly. The worst case scenarios, therefore, are an incomplete abortion or an ongoing pregnancy if women do not use the product as recommended. Such situations would require medical attention, but if a good referral service is available women would be able to access appropriate follow-up care.
What would my dream over-the-counter abortion kit include?
1) Clear, easy-to-understand instructions and a 24-hour phone number to call with questions. Information is key. The instructions should help women determine if a medical abortion is the right choice for them, based on their gestational age and medical history, as well as provide information on where she can go if a medical abortion at home isn’t the best option for her. Additionally, women need to have someone they can call at any time if they have questions before, during, or after the process. The instructions should also point
women to websites and hotlines they can call for information and referrals for contraception after their abortion.
2) Mifepristone and misoprostol. The mifepristone-misoprostol regimen is the most effective for inducing abortion. If the method is going to be used by women on their own, it needs to be a method that is extremely reliable.
3) Several doses of ibuprofen. The most difficult part of a medical abortion for some women is the cramping; pain control is a key component of abortion care.
4) A low-sensitivity urine pregnancy test. Women could take this test themselves at home 2 weeks after their abortion. Although medical abortion is extremely effective, and most women are able to determine from their symptoms alone that their abortion is complete, this test will catch the very rare cases of continuing pregnancy.
Although this may seem to be a radical proposition, the fact is that we have the evidence to support that it would be safe and effective. I would like to see research that it is, additionally, acceptable to women, but it’s hard to believe women wouldn’t be happy about having more choices and more control. What do you think?
Medical abortion: Medical methods of abortion, or medical abortion, is defined by the World Health Organization as follows: The “use of pharmacological drugs to terminate pregnancy. Sometimes the terms “non-surgical abortion” or “medication abortion” are also used.” Medical abortion in the United States is most commonly performed using a combination of mifepristone and misoprostol (this is the recommended protocol as it is the most effective), although sometimes methotrexate is used in combination with misoprostol. In countries where mifepristone and/or methotrexate are not available, misoprostol alone can be used, although it is less effective, that is, less likely to end in a complete abortion.
Low sensitivity urine pregnancy tests: Similar to regular urine pregnancy tests, except they only are positive at higher pregnancy hormone levels. Although it can take several weeks for pregnancy hormone (ß-HCG) levels to become completely undetectable after an abortion, these tests will only turn positive if hormone levels are still high.