Sunday, January 11, 2015

Medication Abortion - A Worldwide Trend



Do you remember the story of a Dutch ship sailing to Ireland in 2001, to provide abortions in international waters?  Rebecca Gomperts, the ship’s doctor, had set up an abortion clinic on board.  Hundreds of Irish women sought appointments when they docked in Dublin, However, conservative politicians in the Netherlands denounced Gomperts for potentially breaking a law that required a special license for any doctor performing abortions after 6 ½ weeks, a license they had failed to give to her.  Gomperts felt she must turn around without performing a single abortion, which she had planned to do with the abortion pills – mifepristone (formerly called RU-486) and misoprostol.  The pills are highly effective, about 98%.

Mifepristone has an anti-progesterone effect, causing the placenta to separate from the uterine lining.  Misoprostol causes uterine contractions which expel the early pregnancy through the cervix.  Misoprostol can also be used during labor, and to prevent or treat post-partum hemorrhage. It is sold in this country as Cytotech, and in this form used to prevent stomach ulcers.  It is sold in many countries, including Mexico, as an inexpensive, over the counter generic.  Women are using misoprostol alone, without mifespristone, frequently without directions as to the dose needed.  This is true in Texas as well as Mexico, as Texas has closed the majority of its abortion clinics.  Used correctly, misoprostol is about 80% effective in producing a complete abortion in early pregnancy. 

Back to Rebecca Gomperts - she did not abandon her plans, traveling with her ship to Poland, Portugal and Spain.  The enormous publicity resulting from her trip to Portugal in 2004 resulted in the legalization of abortion in that country in 2007.

As the word spread that there were pills that could end early pregnancy, women in many countries where abortion was restricted sent emails to the Gomperts website - Women on Waves, now also called Women on Web.  They currently receive about 2000 queries per month from women the world over seeking help with medical abortions.  After a doctor reviews each case to determine whether symptoms might indicate a tubal pregnancy, and whether the dates of last menstrual period mean that the pregnancy is not over 9-10 weeks, a prescription is sent electronically to a drug exporter in India, who sends the package with a tracking number.  Women on Web also sends an emails to the woman telling her how to take the pills and what to expect in terms of bleeding, cramping and pain. The help desk at Women on Web will answer questions during the process, and urge the woman to seek medical help if it sounds like there is a complication, such as excessive bleeding.  Women can claim they are having a spontaneous abortion in places where abortion is illegal.

The Indian company that exports the drugs is run by a man who is said to be dedicated and sympathetic to the women who need his services; he helps them with mail tracking problems, and keeps his prices low.

Women on Web will not provide service in any country with safe abortion services, such as the US, even though it can be hard to obtain abortions here in many areas.  Local laws and the FDA have made it difficult for doctors and clinics to provide what are called ‘medication abortions’ with the pills.   Nevertheless, the Guttmacher Institute says that 23% of non-hospital abortions are done with medication, and 36% of all abortions done before 9 weeks.  The percent of all US abortions done with medications has been increasing yearly, while the total number of abortions has decreased – currently about 1 million a year.  One US woman in 3 has had an abortion by the age of 45.  Abortion is one of the safest procedures done in the US, with fewer than 0.5% of women experiencing a complication. The risk of death associated with abortion is about one-tenth of that associated with childbirth. 

However, there are about 47,000 deaths annually from unsafe illegal abortions worldwide, mostly done with non-sterile instruments by untrained operators. 

Gomperts has left Women on Web, after a quarrel about her management style -  the so-called founder’s syndrome.  She obtained a Masters degree in Public Policy at Princeton, and is pursuing a PhD at the Karolinska Institute in Sweden.  We will probably hear more of this amazing woman in the future.  If you are interested, look at the websites of Women on Waves and Women on Web.  Donations help, as many desperate women in developing countries cannot afford the relatively small cost of the needed services.  The New York Times Magazine on Sunday, August 31st, has a full story on Gomperts and her work. 
Sadja Greenwood, MD , MPH  back issues on this blog

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