Use of Medicines Changing the Face of Abortion

Abstract

Medication abortion (also commonly referred to as medical abortion) is arguably the most important advance in reproductive health technology since the discovery of oral contraceptives. This simple process, involving the use of pins rather than invasive surgical instruments, has been shown to be safe and up to 98% effective for early pregnancy termination. (1-3) In settings where abortion is legal, medication abortion has expanded the array of effective options available, thus improving the abortion experience for those who wish to avoid surgery. In settings where abortion is illegal or highly restricted, it has provided many women for the first time with a safe and discreet means for early termination of unwanted pregnancy. Further, in all settings where it is available, medication abortion has reduced women's dependence on medical systems, providing them with greater autonomy and control over their most important reproductive decisions. Administration of mifepristone, followed by a prostaglandin, is the gold standard for medication abortion. Mifepristone was initially approved in the late 1980s in China and France and has since been safely and effectively used by many millions of women worldwide. (4-7) Mifepristone diminishes the biological availability of progesterone, the hormone needed to sustain pregnancy. It is typically used in combination with misoprostol, which helps empty the uterus by inducing uterine contractions. (1) However, mifepristone is not available in many settings because of legal restrictions on the provision of abortion services. It is also unavailable in numerous settings where the population of reproductive-age women is small, since the high cost of drug registration makes entering the market unappealing to commercial entities. As a result, mifepristone is registered for pregnancy termination in only about 50 of the world's countries, the majority of which are in the developed regions of Europe. (8) Of the 20 developing countries where mifepristone is registered, two-thirds are in Asia. At present, mifepristone is registered in just five African countries (Mozambique, Zambia, Tunisia, South Africa and Ghana) and two Latin American countries (Mexico and Guyana). In many settings where mifepristone is unavailable, misoprostol is commonly used alone for early pregnancy termination. Misoprostol was originally developed in the mid-1980s for gastrointestinal indications and is licensed for such purposes in about 90 countries worldwide. (9), (10) The drug is inexpensive and stable at room temperature, making it ideal for inducing abortion in low-resource settings. The first reported widespread use of misoprostol for pregnancy termination was in Brazil in the late 1980s. (11),(12) Since then, knowledge and use of misoprostol by itself as a means of early pregnancy termination have grown throughout Latin America, as well as in other regions where abortion is legally restricted and mifepristone is unavailable. (13), (14) Although use of misoprostol alone is less effective than its use with mifepristone, misoprostol-only abortions are nevertheless a safe, acceptable and effective means of early pregnancy termination. (6), (15), (16) In still other settings, women lack access to both misoprostol and mifepristone. These include much of northern and western Africa; some parts of middle, eastern and southern Africa; and a number of countries in Asia and South America. (10) Perhaps not surprisingly, some of the world's most restrictive abortion laws and highest rates of abortion-related mortality are found in these same places. (17), (18) The acceptability of medication abortion among women seeking an abortion is high in developing countries, regardless of the setting or regimen used. (5), (6), (19) Furthermore, demand for the procedure appears to be increasing rapidly in many places. It is difficult to document specific trends in the use of medication abortion, because mifepristone is frequently unavailable and use of misoprostol is largely off-label or clandestine. …