Early medical abortion: reflections on current practice

Mifepristone was first licensed for abortion in France and China in 1988. In the last 30 years, medical abortion has globally become an established, safe and straightforward method for pregnancies of less than nine weeks gestation. It is now recommended by the Royal College of Obstetricians and Gynaecologists as the method of choice for women up to nine weeks gestation.¹ ² ³ ⁴ ⁵ ⁶

The reality of providing medical abortion for women, however, is a more complex matter. Abortion services are contextualised by the specific and, at times, changing abortion laws in each country and state. These laws, in turn, are determined and maintained by each jurisdiction’s specific gendered social and political histories, practices and attitudes.⁷

In Australia and New Zealand, this context continues to affect who can provide medical abortions, the models of care adopted, the ongoing struggle to provide affordable and accessible care to all women, and the level to which medical abortion is accepted as a normal and important part of women’s healthcare.

Within the context of these histories and challenges, this article will attempt to guide you through the process of providing a medical abortion as a health practitioner. It also hopes to be a ‘call to arms’ for readers to reflect on what they want to do as an individual practitioner, and as a broader group of women’s health practitioners, to help make medical abortion affordable, accessible and accepted. All health providers must decide about their practice of abortion care with respect to their own personal belief system. However, it is incumbent on us all to understand the services available and guide and support women in their decision-making.

Early medical abortion

Early medical abortion involves the use of two medications, mifepristone (200mg oral) and misoprostol (800µg buccal), in pregnancies of less than 63 days gestation. Misoprostol is given 36–48 hours (Australia) and 24–48 hours (New Zealand) after the mifepristone. Both countries strongly recommend the site of the pregnancy and the gestation is confirmed by ultrasound or, if not available, that every reasonable effort be made to exclude an ectopic pregnancy.

Mifepristone is a synthetic progesterone receptor antagonist, that affects endometrial progesterone receptors, disrupting the attachment of a developing pregnancy. Mifepristone also sensitises the myometrium to contraction-inducing prostaglandin, and softens and dilates the cervix. Misoprostol is a synthetic analogue of prostaglandin E1 and causes uterine contraction and cervical dilatation. Misoprostol can also be given vaginally, which is sometimes worth considering in women as an alternative mode of delivery.

Medical abortion in Australia and New Zealand

Abortion laws are specific to each country and, in the case of Australia, each state or territory.⁸ ⁹ While there has been significant law reform over the past decade, abortion remains in the criminal code in Queensland and New South Wales. Current laws have a specific and unintended impact on the provision of medical abortion. New Zealand, the ACT, South Australia and the Northern Territory require that all abortion services be delivered in a facility licensed to carry out abortions. While individual practitioners and health centres have used creative medical ‘gymnastics’ to make services accessible to women, it has remained a challenge for many women to take misoprostol at home. The laws have also made it difficult to properly service rural and remote communities (particularly remote Indigenous communities), and for GPs to actively take up the provision of medical abortions in these jurisdictions.

The long, drawn-out process of registering mifepristone in Australia has been well-documented and is essential reading to fully understand the political and social forces at play.¹⁰

In Australia and New Zealand, the number of doctors becoming certified prescribers of mifepristone remains comparatively low. Anecdotally, in Australia, we know there are only a small group of registered prescribers performing medical abortions outside of dedicated abortion services. Even in Victoria, after the 2008 law reforms, medical abortions have largely remained the domain of private abortion centres. GPs have been very slow to take up prescribing. The reasons for this are numerous. Many GPs have spoken of their fear of being targeted as the ‘abortion doctor’ in their communities, or of being ostracised if they take up prescribing, or indeed, being overwhelmed by a ‘tsunami’ of women wanting abortions. Others wanting to provide medical abortions, particularly in smaller or regional communities, have struggled to find pharmacists willing to provide the medications. For complex reasons, partly due to the fact that Australia has never had a coordinated, central public health approach to abortion,¹¹ and partly because the private sector needs to run a business (where the majority of abortions are provided), medical abortions have, until recently, remained the same cost as surgical abortions (A$400–500 after a rebate, double this for women who do not have citizenship entitlements).

The specific history of the provision of medical abortion reminds us of an important lesson: that all positive change takes the combined and sustained efforts of many individuals and groups. Why can’t medical abortions be affordable and readily available for any woman seeking one, no matter where she lives?

Become a provider

To become a certified prescriber in Australia, complete an online course via the Marie Stopes website (https://www.ms2step.com.au). There is no cost and it takes 4–6 hours. Individuals with FRANZCOG or DRANZCOG Advanced certificates will get immediate certification on registering and are not required to do the training.

The Marie Stopes MS-2 Step website is excellent and the training is recommended for all healthcare providers wanting to offer medical abortions as part of their practice. The website provides good resources for practitioners providing medical abortions and women seeking one. You can also access a list of registered pharmacies by postcode. If there are no pharmacists in your area, consider visiting some in person to encourage them to register. Visiting your local ultrasound service can be very important, to check they will communicate ultrasound findings in an appropriate manner and to accurately appreciate costs involved. There is now a closed Facebook page for medical abortion providers to discuss challenging cases, seek advice and get support.

In New Zealand, the majority of abortions are performed in the public system. Doctors interested in prescribing should contact the Abortion Providers Group Aotearoa New Zealand (www.apganz.org.nz). Another important website for women and providers is www.abortion.org.nz. This site lists all providers and their services.

Important steps in providing best practice medical abortion care

The following three tables outline recommended best practice abortion care, combined with the author’s own reflections, having provided medical abortions for many years in different work environments (a private abortion provider, a publicly funded young person’s health centre, and currently, at the Austin Hospital’s Family Planning Clinic).

The few medical contraindications to having a medical abortion are summarised in Table 1.

Table 1. A summary of contraindications and other factors to consider.

Medical abortion: Medical contraindications	Medical abortion: Precautions and warnings
No confirmation of pregnancy/uncertain of gestational age	Severe cardiovascular disease
Ectopic pregnancy	Renal or liver failure
Known bleeding disorder/current anticoagulant medication	Malnutrition
Chronic adrenal failure	Multiple uterine scars or history of uterine rupture
Porphyria	Epilepsy
Anaemia (Hb<100g/L)	Heavy smokers
IUCD in-situ	Long-term steroid medication (mifepristone may make steroid less effective and mean that increased doses may be needed)
Known allergy/hypersensitivity to mifepristone or misoprostol	Breastfeeding
Pregnancy in non-communicating horn of uterus

Notes
It is important to acknowledge the early role of Istar, the New Zealand not-for-profit pharmaceutical company, formed in 1999 by five doctors for the sole purpose of importing mifepristone from France. At that time, no established pharmaceutical firm was willing to import mifepristone. Istar helped Australia access the drug in those early years and remains the sole supplier of mifepristone in New Zealand.

Women who have had multiple caesarean sections have had no problem with having a medical abortion.

Breastfeeding is listed in the product information, but there are, as yet, limited data, suggesting that the levels of mifepristone in a 200mg dose are very low. In practice, we advise women to continue breastfeeding with mifepristone. We advise women to avoid breastfeeding or express and dispose of the milk for up to 6 hours after misoprostol intake. Misoprostol may cause diarrhoea in the infant.

Uterine didelphys is not a contraindication to medical abortion.

Table 2. Best practice pre-medical abortion care.

Best practice pre-medical abortion care	Recommended practice and lessons learnt
Consultation approach	Know the specific laws in your jurisdiction. If you practise in a state that no longer requires you to determine a ‘reason’, make sure your consultation approach reflects this. It is important to acknowledge difficulties and the particular significance of decision-making for each woman. It is important to ask, specifically, if the woman is clear in her decision-making and to confirm that the decision has been her decision, with no coercion. Avoid prescriptive ideas that a woman must always have a certain type of support at home. Listen to her specific circumstances and work out a plan that is safe and as supportive as possible.
Confirm pregnancy: intrauterine and gestational age	BhCG. One BhCG is not unreasonable (approx. 100 at 4 weeks, 1000 at 5 weeks, 10,000 at 6 weeks). Remember that you may not see a gestational sac on a vaginal scan <1,500 IU/L). Ultrasound scan. If you are referring a woman to another service, you do not need to organise a scan. The service will do a scan as part of the visit. If you are providing the service, you will need to organise the scan yourself.
Contraindications/ precautions or warnings	See Table 1.
Is medical abortion the best option?	Discuss surgical options. Ensure that a medical approach is appropriate in each context.
Determine/confirm rhesus status	Give Rh(D) immunoglobulin to Rh negative (non-sensitised) women in accordance with local protocols. There is a point-of-care test available to health practitioners. It has a low false negative rate and is considered reliable. Be sure to include rhesus status and antibodies, if known, if you are a GP referring a woman for a medical abortion.
Consider STI screening	STI screening and treatment in accordance with surgical abortion; published local guidelines and knowledge of local prevalence.
How to take medications and expected experience	Bleeding and cramping 1–4 hours after misoprostol ranging from mild to severe. Bleeding may be very heavy with clots, but will decrease after the gestational sac has passed. Average bleeding 10–16 days, but can be bleeding on and off until the next period, which will come 4–6 weeks later (with 28-day cycle). Mild short-term nausea, vomiting, diarrhoea, fever/chills with misoprostol, though relatively uncommon now with buccal or vaginal administration. Don’t underestimate the expected bleeding or pain. This is often documented in feedback as the primary failing on the part of providers of medical abortions. Consider if the woman won’t be able to cope with cramping and heavy bleeding. Nothing in the vagina for 14 days (tampons/sex/baths/spas/swimming). General experience is that 90% of women will pass the pregnancy sac 1–4 hours after taking misoprostol. Make a plan about what to do if there is no bleeding 24 hours after misoprostol. Occasionally there is some bleeding after mifepristone.
Treatment failure medical abortion	Ongoing pregnancy rates <0.8%3,4 (lower with smaller gestational age 0.4%).
Possible complications	Discuss possibility of requiring further follow up, including surgical evacuation of products. Curette rate 2–5%.¹² ¹³ With quoted rates nearer 5%, it is possible that a surgical procedure is decided upon, due to over-reporting of retained products, or woman/provider unwilling to wait or try second dose misoprostol. Haemorrhage requiring a transfusion (0.1%).¹⁴ Infection (0.1%).¹⁵
Access to emergency medical care and adequate support	Make a plan for emergency care. Is there a hospital less than 1 hours’ travel from home? Lack of telephone access or difficulties communicating easily by phone may mean that a medical abortion is not an option. Australia: 24-hour MS health nurse (1300 515 883). There is an option online to register a woman, so she will receive timely text follow up and reminder of appointment. It helps to explain that any level of heavy bleeding in the first hour is normal. However, in the second hour, if still bleeding heavily (2 maxipads/hr) / unmanageable pain / worried in any way, call the 24-hour service or attend closest hospital as appropriate.
Follow-up	Most services arrange follow-up consultation at 1–2 weeks. Discuss this and make a plan if the woman cannot make an appointment. Phone consultation with local BhCG (blood/urine) follow up is another valid approach where face-to-face follow-up is difficult.
Written information and consent	It is useful to provide written information about process AND a plan for adequate analgesia. Give one dose of non-steroidal medicine prior to any cramping, repeat this when cramping starts and then use paracetamol/codeine with further non-steroidal medication, in accordance with usual prescribing practices.
Contraception	Discuss contraception and make a plan (ovulation can occur <2 weeks after medical abortion). You can start: COCP: as soon as heavy bleeding has settled. implants and injectables: once bleeding has begun (many providers are inserting implants on day of first consult with no ill effect). IUCDs: once complete medical abortion is confirmed.

Table 3. Best practice post-medical abortion care.

Best practice pre-medical abortion care	Recommended practice and lessons learnt
Ensure medical abortion is complete	Depending on resources available and skill set, you may (in addition to a good history) do a follow-up serum BhCG (for example, the day before consultation) or an abdominal/vaginal ultrasound. Expected BhCG drop: 96.3% day 7–9 and 97.5% day 10–14 (CI 95%).¹⁶ Urinary BhCG is less helpful as may be positive for up to 4 weeks. Semi-quantitative BhCG point-of-care tests are available in other countries, but not currently in Australia and NZ. (This would be a very helpful tool to have, making follow up simpler and potentially cheaper).
Has medical abortion failed?	Surgical evacuation of products of conception or repeat medical abortion if still within gestational criteria. (Experience at the Austin Hospital has been that most women proceed to a surgical procedure after a failed medical abortion).
Managing retained products of conception (RPOC)	If the woman is well and has no significant ongoing bleeding, most retained products of conception are not an issue and will pass with the next period. If ongoing bleeding, consider surgical management, or further misoprostol. A surgical evacuation of remaining products will need to be considered if bleeding is heavy, or if anaemic.
Contraception	Ensure the woman has contraception (see above). Ensure the woman is not pregnant again if follow-up appointment has been delayed. (At the Austin, we have occasionally seen women present pregnant after a medical abortion 3 weeks prior.)
Review STI screening results	If positive, it is likely that treatment has already been started. Check notification and treatment of sexual partners. Check adequate treatment.

Providing quality care

With respect to abortion delivery in Australia, Baird, in 2015, wrote, ‘Countries like ours, have ended up delivering an approach to medical abortion that is overly cautious, highly regulated and medicalised’.¹⁷ Other countries have taken up different models of care and are researching the efficacy of non-medical providers offering medical abortion. It is essential to explore these different models, to reflect on what is worth protecting and developing with each, and to determine the care each woman requires and can readily access.

In Victoria, services are starting to change. Private abortion clinics, such as Marie Stopes, have commenced offering medical abortion via telemedicine (from A$290 with a healthcare card). Family Planning Victoria is now seeing women for medical abortions (A$120 out-of-pocket plus medications; healthcare card holders are bulk-billed). Some public hospitals, (such as the Royal Women’s and the Austin in Melbourne), are providing medical abortions to small numbers of women each week and offering training and support to GPs who would like to provide medical abortions (and IUD insertion) in their practice. In addition, a new central referral service called 1800 My Options has recently been launched by Women’s Health Victoria.

New models are also emerging in response to a call from GPs for more collegiality and support in setting up and embedding medical abortion services in their practices. Three services, (the Royal Women’s Hospital, Family Planning Victoria and the Centre for Excellence in Rural Sexual Health [CERSH], University of Melbourne), have joined forces to provide a new and innovative approach to medical abortion in rural Victoria. To date, this has involved taking education, resources and support to GPs and nurses in rural areas. An inspiring expansion of affordable access to medical abortions has begun.¹⁸ In a few rural areas, women can now obtain a medical abortion, where the only cost is the medication (A$15–45). Nurse-led and nurse-GP partnerships are becoming the most successful abortion care models.¹⁹ ²⁰

Telemedicine approaches have been available for over a decade and are becoming more well known (the Tabbot Foundation, launched in 2005, costs $250). Home self-administration is also available, through women accessing medical abortions online. Practitioners may have heard about Women on Waves and Women on Web. It is worth knowing more about these groups, so that you can let women know about their services. Increasingly, practitioners may see women who have accessed a medical abortion this way and then present with a complication.

Conclusion

When medical abortions became available in Australia and New Zealand, many of us could see potential to solve the problems of access, affordability and stigma associated with abortion.

Until recently, this had happened only to a small extent. The ground is still ‘eggshells’ around abortion care services. Yet, the situation will become more solid as practitioners engage in thinking about what role they would like to have. Many GPs, gynaecologists and nurses are doing this and there are now some innovative and exciting models for duplication. Doctors are increasingly no longer the gatekeepers. Women are choosing and accessing medical abortion for themselves.

Acknowledgement

I would like to acknowledge the support and editorial guidance of Dr Paddy Moore, Head of Unit, Early Pregnancy Services, Royal Women’s Hospital, in writing this article.

References

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