Over-the-counter abortion? Why not?

21 Sep

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?

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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.

5 Responses to “Over-the-counter abortion? Why not?”

  1. Cand86 September 21, 2012 at 4:33 pm #

    I’d love to see it happen, but I don’t see it any time soon; already EC had to fight massive battles with the whole “what if a rapist buys it to give to his victim!” argument. I can imagine anti-choicers having a field day with the fact that there wouldn’t be any pre-abortion counseling, and of course they’d see OTC medication abortion as a huge circumvention for minors who’d otherwise have to obtain parental consent or seek judicial bypass. Then there’s the whole fear that men would secretly administer abortions in partners they didn’t want to be pregnant . . .

    Just feels like a pie-in-the-sky dream to have that level of access when they already throw up roadblocks to very basic access through a doctor.

  2. Chris September 21, 2012 at 5:51 pm #

    Should certainly be available on demand from your usual doctor (without the usual restrictions in the UK that you need two doctors, and have to take the drugs within a licensed clinic rather than at home)

    • LongtimeAbortionProvider September 24, 2012 at 8:49 am #

      While I applaud the author’s commitment to expanded access to abortion care, this idea is very problematic on many levels. I’ve been working in the field of abortion provision, advocacy, and research for going on thirteen years, and from the time medication abortion was approved for clinical trials in the U.S., there have been serious concerns about lack of adequate follow-up, as well as the importance of ACCURATE ultrasound dating of a pregnancy before the regimen is begun. In the clinics where I’ve worked, we often see women who haven’t had an ultrasound and whose pregnancies are much further along than they would think based on menstrual dates, in addition to the women who’ve gotten amateur ultrasounds at CPCs and been told either that they are much earlier than they actually are, or much later (both as ways to make it more difficult for women to actually get an abortion). Either of these factors could result in women taking medication abortion drugs when they are not within a safe timeline for doing so, and then assuming everything is fine when it isn’t, allowing a pregnancy to continue. There is also a discernible trend in women who come to clinics for medication abortions being less likely than surgical patients to come back for follow-up — some of the same reasons why having a ‘miscarriage’ at home might be appealing (secrecy, domestic violence, lack of transportation, etc.) are also reasons why it is hard for some of these same women to get follow-up care when they need it.

      Having been present for second-trimester surgical procedures performed for women who initially did a medication abortion that failed (which happens about 5% of the time) and did not come back for follow-up right away, I am comfortable saying that the ‘easy’ medication abortion they sought in the first place becomes a lot more complicated (and expensive) when it becomes essentially an incomplete miscarriage necessitating a subsequent surgical procedure.

      Moreover, the widespread American attitude that ‘you take a pill, the problem goes away’ is being seen more and more in teens who request a medication abortion because they believe that they will simply take a pill, and “Poof!” they will no longer be pregnant. Many women who ask to do a medication abortion do not realize that they will be experiencing anywhere from 2 days to 3 weeks of intense cramping and bleeding, and that they will pass the pregnancy tissue, and need to examine it to be sure it is complete. When we explain the whole process to women, they often decide (as I would, personally) that being at the clinic, once, for 4 hours with IV pain meds. and professional counseling support, and then leaving *no longer pregnant* is not only cheaper, but actually easier and more preferable than having a miscarriage, at home, alone, often without support, and without somewhere there to tell you if the amount of bleeding and cramping is normal, or excessive.

      And some people just are not good candidates for a medication abortion, medically speaking — people who request the medication procedure specifically to avoid a vaginal exam or blood-draw are presumably also less likely to come back for the vaginal ultrasound or blood-test confirmation that is FDA-required to be sure the procedure is complete.

      Finally, a medication abortion is more expensive than a surgical procedure — usually $600+, as opposed to first-trimester surgical procedures, which can cost more like $500. And in some states where Medicaid covers abortion, it only covers surgical, not medication.

      I’m all for helping any and all women access safe abortion care on demand and as easily as possible — but the way to do that is to increase women’s access to existing providers by donating to funding hotlines and transportation assistance, working to improve Medicaid coverage of abortion and reduce legal restrictions, and by training more providers. Handing out medication abortion drugs OTC could put many women at risk for self-diagnosis and self-treatment, with all the associated expensive, inconvenient, and dangerous implications.

      • NYCprochoiceMD September 25, 2012 at 2:08 pm #

        Thank you LongTimeAbortionProvider for this thoughtful response. Although most US providers routinely perform ultrasound prior to all abortions, including medical abortions, there is good evidence that this is not necessary on a routine basis, and the WHO evidence-based safe abortion guidelines do not recommend routine ultrasound, because women are in general quite good at estimating their dates. Similarly, because the regimen is so effective, routine follow-up is also not a “requirement” in the WHO safe abortion guidelines.

        I do agree that in a US setting anything less than 100% efficacy means that follow-up is important. However, I see no need for women to see a doctor to follow up, unless something goes wrong, which they themselves would know based either on their symptoms or a positive low-sensitivity urine pregnancy test 2 weeks later. Just because the FDA thinks we should do a follow-up test doesn’t mean it’s the right thing to do; the FDA also put a black box warning on DMPA with no evidence, and only recommends medical abortion with mifepristone up to 7 weeks even though it is routinely used until 9 weeks in the US and well beyond 9 weeks abroad.

        It’s true that some women will be better served with a surgical abortion; however, many women do prefer medical abortion to surgical. We also know that alternative follow-up (ie, not a clinic visit but a home pregnancy test and questionnaire by phone) is highly acceptable to women and preferred by many to in-person follow-up. Why not make this option available for those who prefer it? Truly trusting women means putting all decision-making in their hands when the evidence supports it.

        The cost issue varies from setting to setting. In many clinics both kinds of abortions have the same price; as I don’t know your setting, I don’t know why medical abortions are more expensive than surgical abortions where you are. The most expensive parts of the medical abortion procedure are the mifepristone (about $100/dose) and the (often unnecessary) ultrasound. I imagine OTC medical abortion could cost significantly less than $600.

        I agree with all the suggestions you make in your final paragraph to improve access to safe abortion. I also agree that OTC medical abortion would lead to self-diagnosis and self-treatment by women. I disagree that the implications are necessarily expensive (I think that, in general, women would save a significant amount of money by using an OTC kit, though there would be some women who do not self-diagnose their pregnancy correctly or do not use the medications correctly, for whom there would be an added expense) or dangerous (as I stated, the worst case scenarios are ongoing pregnancy or incomplete abortion– both of which could be easily identified by the woman and treated). I do agree that the implications are inconvenient — but primarily they are inconvenient for us as medical providers. If we had less control over what treatments women have access to, some of them would certainly use the medications inappropriately, and we would have to learn to take care of them in these circumstances and truly push our own boundaries as to what it means to let women decide for themselves what to do.

        @cand86: Yes, pie in the sky, but why not?

        @chris: I agree that having “kits” available from primary care doctors would be ideal. Unfortunately that leaves women at the mercy of their particular primary care provider; if a woman has the misfortune to choose someone who is anti-abortion or even just uncomfortable with abortion, she’s out of luck. Having medical abortion available at pharmacies (and perhaps an online listing of which pharmacies have pharmacists who will dispense it) would circumvent that problem.

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