It was very pleasing to see a paper reporting a pilot study of Primary care endometrial sampling1as this was something I have been involved with over the last 25 years, although I was a little disappointed that there was no reference to some of the previous work on this subject in primary care2. I published two papers on the subject in 1998, The first considered the end of the operation Dilatation and Curettage (D & C) which until the 1990s had been the investigation of choice for abnormal uterine bleeding and the emergence of new techniques such as Pipelle sampling3. The second paper I published was entitled Endometrial sampling in general practice and was a case series of 38 women investigated for unexpected vaginal bleeding4. I had introduced the procedure to the Honiton Practice in 1993; having held the qualification for intrauterine techniques for many years and having acquired further training from the local gynaecology department and taken advice from the relevant defence unions. It was not part of General Medical Services then and under new general practice arrangements it was recognized as ‘provision of secondary care within primary care’ and remunerated. It is also important to realize that the current 2 week wait referral procedure did not exist and sometimes women with abnormal bleeding could w...
It was very pleasing to see a paper reporting a pilot study of Primary care endometrial sampling1as this was something I have been involved with over the last 25 years, although I was a little disappointed that there was no reference to some of the previous work on this subject in primary care2. I published two papers on the subject in 1998, The first considered the end of the operation Dilatation and Curettage (D & C) which until the 1990s had been the investigation of choice for abnormal uterine bleeding and the emergence of new techniques such as Pipelle sampling3. The second paper I published was entitled Endometrial sampling in general practice and was a case series of 38 women investigated for unexpected vaginal bleeding4. I had introduced the procedure to the Honiton Practice in 1993; having held the qualification for intrauterine techniques for many years and having acquired further training from the local gynaecology department and taken advice from the relevant defence unions. It was not part of General Medical Services then and under new general practice arrangements it was recognized as ‘provision of secondary care within primary care’ and remunerated. It is also important to realize that the current 2 week wait referral procedure did not exist and sometimes women with abnormal bleeding could wait quite a while for further investigation. One woman in this study was actually diagnosed with endometrial cancer from the primary care sample. The published study was awarded a local audit prize and I also received a research award from the BMA for it.
I tried to help other practices introduce the procedure with limited success. As further reorganizations of the NHS and primary care happened this important service was rarely recognized and eventually funding ceased although within the practice we continued to provide the service. I hope that this paper1 would encourage a renewed interest in undertaking this procedure in primary care.
1.Dickson JM, Delaney B, Connor ME. Primary care endometrial sampling for abnormal uterine bleeding: a pilot study. J Fam Pann Reprod Health Care 2017;43:296-301
2.Shapley M, Redman CWE. Endometrial sampling and general practice. Br J Gen Pract 1997;47:387-392
3.Seamark CJ. The demise of the D&C. J Roy Soc Med 1998;91:76-79
4.Seamark CJ. Endometrial sampling in general practice. Br J Gen Pract 1998;48:1597-1598
The move to single visit medical abortion[1] will be a great improvement in convenience to clients. The requirement of two doctors to sign the HSA form results in many attending and sometimes waiting for hours purely to obtain a signed form. This inconvenience could easily be removed by distant signing of such forms. In a service such as ours with an electronic patient record, readily accessed at a remove, the requirement for such attendance seems especially egregious.
Reference
1 Lord J, Regan L, Kasliwal A, et al. Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England. BMJ Sex Reprod Health 2018;44:155–8.
In their article about Natural Cycles, Hough et al quote a Cochrane Review that dismisses fertility awareness based contraception (natural family planning).
A Cochrane Review is an understandable choice but not an appropriate one. It would be more helpful to quote NHS Choices, the Family Planning Association or Faculty Guidance, which all have a more nuanced approach to the evidence, and say that fertility awareness is up to 99% effective.
Typical use rates are lower but many women achieve high effectiveness thanks to either their own research or appropriate support. Books like “Taking Charge of Your Fertility” by Toni Weschler, websites like Fertility UK and apps such as Kindara, Cycle Beads and Ovuview have helped women to avoid (and plan) pregnancy for years. There is also NHS-funded fertility awareness support in some areas.
Natural Cycles is the new app that is revolutionising fertility awareness thanks to huge amounts of funding for marketing and research and a clean design that removes all judgement from the user (in a similar way to CycleBeads) and simply pronounces a day “red” or “green”.
The accessibility, if not the advertising, of Natural Cycles is welcome. Women need options. But it is not ideal.
Advertising is one issue. As Hough et al describe, because Natural Cycles is not a prescribed product, and because they have substantial financial resources, they are able to bypass health professionals and advertise direct to potential c...
In their article about Natural Cycles, Hough et al quote a Cochrane Review that dismisses fertility awareness based contraception (natural family planning).
A Cochrane Review is an understandable choice but not an appropriate one. It would be more helpful to quote NHS Choices, the Family Planning Association or Faculty Guidance, which all have a more nuanced approach to the evidence, and say that fertility awareness is up to 99% effective.
Typical use rates are lower but many women achieve high effectiveness thanks to either their own research or appropriate support. Books like “Taking Charge of Your Fertility” by Toni Weschler, websites like Fertility UK and apps such as Kindara, Cycle Beads and Ovuview have helped women to avoid (and plan) pregnancy for years. There is also NHS-funded fertility awareness support in some areas.
Natural Cycles is the new app that is revolutionising fertility awareness thanks to huge amounts of funding for marketing and research and a clean design that removes all judgement from the user (in a similar way to CycleBeads) and simply pronounces a day “red” or “green”.
The accessibility, if not the advertising, of Natural Cycles is welcome. Women need options. But it is not ideal.
Advertising is one issue. As Hough et al describe, because Natural Cycles is not a prescribed product, and because they have substantial financial resources, they are able to bypass health professionals and advertise direct to potential clients. They run targeted Facebook and Instagram adverts and get support from trusted social media influencers, favourable press articles and others.
Still, it is worth remembering that prescribed medication is also not free of commercial influence. As Ben Goldacre describes in Bad Pharma, not being able to advertise direct to consumers simply means Big Pharma concentrates on selling direct to trusted health professionals, researchers and influencers through educational events, smooth sales reps, research grants, lobbying and other methods.
Another issue is the lack of transparency about the Natural Cycles algorithm. There has been decades of research about fertility awareness. It is a shame that they are not adding to this in a more meaningful way – or even acknowledging it, simply saying that they have “invented” an algorithm, as if it has come out of thin air and not decades of research about different algorithms.
It is also worrying that their algorithm seems to have a “one-size-fits-all” approach. Fertility is not an on/off switch. There are days on which pregnancy is very likely, days on which it is likely and days on which it is very unlikely or impossible.
Some women use fertility awareness in a very cautious “life or death” way – not having unprotected sex till after ovulation has been and gone.
Others are more willing to push the boundaries – depending on our cycles and on how we feel about unplanned pregnancy – and our age. A woman of 48 might choose to be less cautious than she was aged 38, or even 44.
We also use different fertility indicators. Some of us use temperature and ovulation sticks (in the style of Natural Cycles). Many women find temperature and fluid more convenient, or simply fluid and/or calendar calculations.
A better fertility app would have a transparent algorithm that allows women to choose the approach that suits them. It would also open up the data (in anonymised form) to researchers. This is not only an important contraceptive option, it is important knowledge. We should have an NHS app for this - not a private one.
Jonathan Lord, Lesley Regan and colleagues make a strong case for allowing home use of misoprostol in early medical abortion. Indeed it has been obvious for some years ever since the WHO reviewed research trials in various countries. Isn't this really the time to make both abortifacients, mifepristone and misoprostol, available off prescription?
They are safe, reliable and easy to use. Complications requiring further medical attention after self-administration are only marginally more common than when supervised by medical staff. Dire results are rare. Is this the time to recognise that the present, medically supervised, regulated system has been outflanked by pharmaceutical technology?
In fact abortion has become so easy that many women obviously prefer it to contraception. In 2017 approximately 74 000 abortions in England & Wales (39% of the total) were for women who had had at least one before. Whether or not repeated abortion by medical means in early pregnancy is undesirable or even harmful does not seem to have been established.
Pills over the counter would be a popular innovation because it would enable a pregnant woman to achieve a termination more quickly and with greater privacy than now. She would, for example, not need to run the gauntlet of abortion protesters outside clinics.
Of course there are snags and difficulties. It could not be done without a change in the laws which currently forbid self-induction of abortion and r...
Jonathan Lord, Lesley Regan and colleagues make a strong case for allowing home use of misoprostol in early medical abortion. Indeed it has been obvious for some years ever since the WHO reviewed research trials in various countries. Isn't this really the time to make both abortifacients, mifepristone and misoprostol, available off prescription?
They are safe, reliable and easy to use. Complications requiring further medical attention after self-administration are only marginally more common than when supervised by medical staff. Dire results are rare. Is this the time to recognise that the present, medically supervised, regulated system has been outflanked by pharmaceutical technology?
In fact abortion has become so easy that many women obviously prefer it to contraception. In 2017 approximately 74 000 abortions in England & Wales (39% of the total) were for women who had had at least one before. Whether or not repeated abortion by medical means in early pregnancy is undesirable or even harmful does not seem to have been established.
Pills over the counter would be a popular innovation because it would enable a pregnant woman to achieve a termination more quickly and with greater privacy than now. She would, for example, not need to run the gauntlet of abortion protesters outside clinics.
Of course there are snags and difficulties. It could not be done without a change in the laws which currently forbid self-induction of abortion and require each to be approved by two doctors. The control and supervision of this procedure by medical staff would be greatly reduced. Identifying other medical conditions would also be less frequent. A few women might use the drugs in late pregnancy, when the foetus was already viable, but they can do this already. Statisticians, without a medical certificate for every abortion, would have to make estimates.
Making such a radical change in the present parliament would not be easy but it might help British society catch up with the reality that these pills are available fairly cheaply, world-wide, right now. If most women could manage the whole process themselves it would be a further step towards equality with men.
Reference
1 Lord J, Regan L, Kasliwal A, et al. Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England. BMJ Sex Reprod Health 2018;44:155–158.
Regarding the Scottish decision on home abortion of 26th October 2017, Lord J, Regan L, Kasliwal A, et al. claim that "Home use of misoprostol in Scotland is relatively new. The larger abortion services in Scotland report widescale uptake of home use of misoprostol among women and that it is highly appreciated with no negative impact on services." The Scottish “abortion services” consulted are not named and the reference for the bold claim that home use of misoprostol is “highly appreciated” is “S Cameron [co-author], personal communication 2018”. Such statements do not inspire confidence.
In response to some other claims made in the article: women having better control over timing in practice will mean less precision in timing, since medical supervision is supposed to guarantee ‘correct’ time between drugs and a ‘correct’ route of administration, whether sublingual, buccal or vaginal. If these are departed from, the effectiveness goes down, and the complications go up. This is well-known.
As regards travel and onset of bleeding, the Creinin paper [1] referred to by the authors had a bleeding onset median time of 2 hours for the standard (misoprostol taken 24 hours after mifepristone), and 3.7 hours when mifepristone and misoprostol were taken together. Others state that the onset of bleeding with the standard regimen was after 2 hours and meant light to moderate spotting at 4 hours after misoprostol [2]. Depending on the travel time, there m...
Regarding the Scottish decision on home abortion of 26th October 2017, Lord J, Regan L, Kasliwal A, et al. claim that "Home use of misoprostol in Scotland is relatively new. The larger abortion services in Scotland report widescale uptake of home use of misoprostol among women and that it is highly appreciated with no negative impact on services." The Scottish “abortion services” consulted are not named and the reference for the bold claim that home use of misoprostol is “highly appreciated” is “S Cameron [co-author], personal communication 2018”. Such statements do not inspire confidence.
In response to some other claims made in the article: women having better control over timing in practice will mean less precision in timing, since medical supervision is supposed to guarantee ‘correct’ time between drugs and a ‘correct’ route of administration, whether sublingual, buccal or vaginal. If these are departed from, the effectiveness goes down, and the complications go up. This is well-known.
As regards travel and onset of bleeding, the Creinin paper [1] referred to by the authors had a bleeding onset median time of 2 hours for the standard (misoprostol taken 24 hours after mifepristone), and 3.7 hours when mifepristone and misoprostol were taken together. Others state that the onset of bleeding with the standard regimen was after 2 hours and meant light to moderate spotting at 4 hours after misoprostol [2]. Depending on the travel time, there may be some women who would begin bleeding on the way home from a clinic. However, 30-40% of women will begin bleeding after mifepristone and before misoprostol in any case, and the chance that the abortion would occur on the way home would normally be slim.
If travel time is greater than a couple of hours, it is surely in any case risky to offer a woman misoprostol to take at home because by the same token she would presumably have difficulty accessing emergency care. Rural women without easy access to emergency care are not candidates for medical abortion. This is so whatever our views about whether abortion more generally is in fact ‘care’ or ‘treatment’ for the woman [3], given that her pregnancy is not a disease. We should also bear in mind that ambivalence in women about the abortion decision is common [4] and associated with regret [5]. Indeed, some women having medical abortions refuse to take misoprostol after mifepristone, whereupon the foetus may be found to be still alive, and born without adverse effects [6].
Nor is it clear as to why there should be better emotional support for a woman who takes misoprostol at home rather than at a clinic. Either way, the abortion will happen at home, and if, for example, a partner or family are going to provide emotional support at all to the woman as she loses the baby, there are multiple ways that they can do so. If misoprostol is taken at home, we must face the fact that not only will some women get no support at all but the ‘support’ they will get may be pressure to abort (bearing in mind the strong link between abortion and intimate partner violence ) [7].
A Scottish trial in 2010 surveyed women’s responses and experience of returning home immediately after the administration of misoprostol to abort. 100 out of 145 women answered the survey (making one wonder why 45 did not respond). 12 of the 100 responded that they were extremely upset by the experience. 8 out of 100 were home alone at the time of the abortion [8].
Removing a second visit to take misoprostol, with an increase in complications and side effects, could have a significant impact on resources because of the severity of some of the complications.
It is somewhat ironic that the authors refer to the paper by Lohr et al , which highlights the increased risk of complications when women take mifepristone and misoprostol simultaneously. Lord et al. [9]claim that because 85% of women choose to take misoprostol and mifepristone at the same time at the clinic, this demonstrates “how much of a barrier access is for many women.” Instead, we think it shows two different things. First, that BPAS is prepared to offer a less effective and more risky regimen that they know significantly increases harm to women (perhaps as a wedge to use in campaigning for home abortions?) And second, rather than choosing simultaneous drug taking because of access barriers, we think it just as likely that women choose simultaneous use because all they want is for the horrible process to be over sooner.
The experience is clearly unpleasant with high percentages of women experiencing a lot of pain, excess bleeding, cramps, chills, vomiting, diarrhoea, nausea, dizziness, weakness, fever, and headache. Some figures for these from the three key US trials are as follows: listed as very common (>10%) by the manufacturer of Mifegymiso (mifepristone plus misoprostol) include nausea (30.7 - 69.2%), vomiting (22.3 - 34.1%), diarrhea (31.8 - 58.6%), pain (91.6%), fever (21.3 – 44.3%), chills (36.5 – 44.3%), headache (12.3 – 42%), dizziness 13.1 – 45.5%), and weakness (19.2 – 56.6%). We wonder how many women undergoing this ordeal, many of whom would have been emotionally conflicted about the abortion, were offered help at any stage to have their baby.
I am grateful to Dr Greg Pike for the use of his research materials.
[1] Creinin M et al. (2007) Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion. A randomized controlled trial. Obstet. Gynecol. 109(4):885-894.
[2] Sitruk-Ware R (2006) Mifepristone and misoprostol sequential regimen side effects, complications and safety. Contraception 74:48-55.
[3] McCarthy A (2018). Abortion Matters. Philos Educational Publications.
[4] Kero A, Högberg U, Jacobsson L & Lalos A (2001) Legal abortion: a painful necessity. Social Science and Medicine 53:1481-1490.
[5] Kero A, Högberg U & Lalos A (2004); Wellbeing and mental growth – long-term effects of legal abortion. Social Science and Medicine 58:2559- 2569.
[6] Delgado G et al. (2018) A case series detailing the successful reversal of the effects of mifepristone using progesterone. Issues in Law & Medicine.33(1): 1-12.
[7] Pallitto CC, García-Moreno C, Jansen HAFM, Heise L, Ellsberg M & Watts C (2013) Intimate partner violence, abortion, and unintended pregnancy: results from the WHO Multi-country Study on Women’s Health and Domestic Violence. Int J Gynecology Obstetrics 120:3-9.
[8] Cameron S et al. (2010) Women’s experiences of the final stage of early medical abortion at home: results of a pilot survey. J Fam Plann Reprod Health Care 36(4): 213–216.
[9] Lohr PA, Wade J, Riley, et al. Women’s opinions on the home management of early medical abortion in the UK. J Fam Plann Reprod Health Care 2010; 36:21-5.
The article of Frances Doran and Susan Nancarrow [1] suggests that
there is a need for more research about the barriers to access to abortion
services in developed countries. I totally agree with this finding,
especially for qualitative research, and would like to provide a point of
view from France.
As part of my doctoral research on the social determinants of
reproductive health, I attended the trial of Domin...
The article of Frances Doran and Susan Nancarrow [1] suggests that
there is a need for more research about the barriers to access to abortion
services in developed countries. I totally agree with this finding,
especially for qualitative research, and would like to provide a point of
view from France.
As part of my doctoral research on the social determinants of
reproductive health, I attended the trial of Dominique Cottrez, a woman
who killed eight of her newborns and was jailed for 9 years on July 3rd in
Douai (North of France). This kind of child homicide has to be referred to
as neonaticide, which is characterized by an unwanted and concealed
pregnancy, solitary delivery and without prior mental illness [2].
Recognizing the specificities of neonaticide allows us to situate
these acts in connection with the issue of fertility control. From a
sociological perspective, neonaticide constitutes an illuminating case to
analyze reproductive behaviours by the margins. Dominique Cottrez has
herself explained that her crimes were a means of birth control. She
discussed her phobia of doctors, due to both her obesity and the traumatic
experience during the birth of her first child at the hospital, because
the caregivers were chiding and hurtful to her. A phobia that prevented
her from consulting for contraception or abortion.
In other cases of neonaticide, the women I interviewed also explained
that they had encountered barriers to access abortion: difficulties to
organize or afford a travel to the health facilities, fear to confront the
medical staff, lack of information on the existence of family planning
services and also lack of availability to organize a consultation within
the legal deadlines. The burden of daily housework for women, especially
single mothers in rural areas, with limited health literacy, appears to be
a barrier to abortion.
These obstacles are well known and documented in many developing
countries [3]. However, in developed countries, or at least in France, the
idea prevails that universal access to contraception and abortion allows
any women to make their own reproductive choices [4]. Further research
therefore appears necessary to specifically study the upstream constraints
on women's autonomy in decision-making for reproductive matters, well
before the entry into the health system.
References :
1. Doran F, Nancarrow S. Barriers and facilitators of access to first
-trimester abortion services for women in the developed world: a
systematic review. J Fam Plann Reprod Health Care 2015; 41:170-180.
2. Friedman S. H, McCue Horwitz S, Resnick P. J. Child murder by
mothers: A critical analysis of the current state of knowledge and a
research agenda. Am J Psychiatry 2005; 162:1578-1587.
3. WHO, Social determinants of sexual and reproductive health:
Informing future research and programme implementation, Geneva, 2010.
4. Bajos N, Ferrand M. De l'interdiction au controle: les enjeux
contemporains de la legalisation de l'avortement. Revue francaise des
affaires sociales 2011; 1:42-60.
Counseling is voluntary by definition. A person being 'counseled' can
leave at any time and without any consequences. If 'counseling' is
mandatory it becomes in fact a state ordered instruction. Like for example
in the case of obligatory military service.
We as society should at least have the courage to name things with their
correct terminology. And not pretend to 'counsel' women if in fact we
force them to listen to an...
Counseling is voluntary by definition. A person being 'counseled' can
leave at any time and without any consequences. If 'counseling' is
mandatory it becomes in fact a state ordered instruction. Like for example
in the case of obligatory military service.
We as society should at least have the courage to name things with their
correct terminology. And not pretend to 'counsel' women if in fact we
force them to listen to an instruction, simply because they do not act
according to the social expectation.
It was interesting to read Sharon Moses' thoughtful commentary
questioning the role of an 'express' contraceptive service in a community
sexual health clinic and advocating improving contraceptive provision in
primary care, the primary provider of contraception in the UK.[1] My
colleagues in Newcastle, however, support this service innovation as they
feel that women in their late teens and early twenties have been
overl...
It was interesting to read Sharon Moses' thoughtful commentary
questioning the role of an 'express' contraceptive service in a community
sexual health clinic and advocating improving contraceptive provision in
primary care, the primary provider of contraception in the UK.[1] My
colleagues in Newcastle, however, support this service innovation as they
feel that women in their late teens and early twenties have been
overlooked in the process of sexual health service integration and are at
risk of unplanned pregnancy. A number of women attending our sexual health
walk-in clinics had had to wait several hours to receive further pills or
their injection. Given an 'express' service for asymptomatic sexually
transmitted infection (STI) screening, is it not reasonable to offer a
similar service for those needing further contraceptive supplies?
The separation of sexual health commissioning in England has led to
women aged 20+ years finding it difficult to access 'same-day'
contraceptive help. Due to the increase in primary care workload, many
women report being unable to see their general practitioner (GP) or
practice nurse for several days and then are provided with unsuitable
appointment times. A growing number of GP practices are no longer
providing comprehensive contraceptive care due to pressure of work and
withdrawal of long-acting reversible contraception (LARC) contracts.
Integration of sexual health services may work for the young, those
at risk of STIs and some vulnerable groups but not those who work, have
young children, are from a number of the black and minority ethnic
communities, or at low risk of STIs and are requesting further
contraceptive supplies. In Newcastle we have a protected number of
'contraceptive' appointments otherwise we would be overrun with those
requesting help with 'STI issues' that frequently are not STI-related but
fall into the category of 'primary care' urology, dermatology and
gynaecology problems. Patients are quick to learn that sexual health
services provide walk-in clinics where patients can be seen that day and
treatment is dispensed free of charge for 'STI' problems.
The setting up of an 'express' contraceptive clinic[2] is not
'dumbing down' of a service or failing to provide high-level 'sexual
health provision' as these services will identify those who would benefit
from STI testing and meet the needs of those who are being failed by the
current pressures placed on our National Health Service.
References
1. Moses S. Mini-Commentary on 'Would an exclusive contraceptive
clinic help meet the needs of patients attending an integrated sexual
health clinic?' J Fam Plann Reprod Health Care 2015;41:312-313.
2. Percy LA. Would an exclusively contraceptive clinic help meet the
needs of patients attending an integrated sexual health service? J Fam
Plann Reprod Health Care 2015;41:309-311.
Conflict of Interest:
Dr Mansour has received financial support to attend pharmaceutical advisory board meetings, undertake research studies, speak at educational meetings and conferences, and travel grants from Astellas, Bayer, Consilient Healthcare, HRA Pharma, Merck, Pfizer and Vifor Pharma.
The move to single visit medical abortion[1] will be a great improvement in convenience to clients. The requirement of two doctors to sign the HSA form results in many attending and sometimes waiting for hours purely to obtain a signed form. This inconvenience could easily be removed by distant signing of such forms. In a service such as ours with an electronic patient record, readily accessed at a remove, the requirement for such attendance seems especially egregious.
Reference
1 Lord J, Regan L, Kasliwal A, et al. Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England. BMJ Sex Reprod Health 2018;44:155–8.
In their article about Natural Cycles, Hough et al quote a Cochrane Review that dismisses fertility awareness based contraception (natural family planning).
Show MoreA Cochrane Review is an understandable choice but not an appropriate one. It would be more helpful to quote NHS Choices, the Family Planning Association or Faculty Guidance, which all have a more nuanced approach to the evidence, and say that fertility awareness is up to 99% effective.
Typical use rates are lower but many women achieve high effectiveness thanks to either their own research or appropriate support. Books like “Taking Charge of Your Fertility” by Toni Weschler, websites like Fertility UK and apps such as Kindara, Cycle Beads and Ovuview have helped women to avoid (and plan) pregnancy for years. There is also NHS-funded fertility awareness support in some areas.
Natural Cycles is the new app that is revolutionising fertility awareness thanks to huge amounts of funding for marketing and research and a clean design that removes all judgement from the user (in a similar way to CycleBeads) and simply pronounces a day “red” or “green”.
The accessibility, if not the advertising, of Natural Cycles is welcome. Women need options. But it is not ideal.
Advertising is one issue. As Hough et al describe, because Natural Cycles is not a prescribed product, and because they have substantial financial resources, they are able to bypass health professionals and advertise direct to potential c...
Jonathan Lord, Lesley Regan and colleagues make a strong case for allowing home use of misoprostol in early medical abortion. Indeed it has been obvious for some years ever since the WHO reviewed research trials in various countries. Isn't this really the time to make both abortifacients, mifepristone and misoprostol, available off prescription?
They are safe, reliable and easy to use. Complications requiring further medical attention after self-administration are only marginally more common than when supervised by medical staff. Dire results are rare. Is this the time to recognise that the present, medically supervised, regulated system has been outflanked by pharmaceutical technology?
In fact abortion has become so easy that many women obviously prefer it to contraception. In 2017 approximately 74 000 abortions in England & Wales (39% of the total) were for women who had had at least one before. Whether or not repeated abortion by medical means in early pregnancy is undesirable or even harmful does not seem to have been established.
Pills over the counter would be a popular innovation because it would enable a pregnant woman to achieve a termination more quickly and with greater privacy than now. She would, for example, not need to run the gauntlet of abortion protesters outside clinics.
Of course there are snags and difficulties. It could not be done without a change in the laws which currently forbid self-induction of abortion and r...
Show MoreRegarding the Scottish decision on home abortion of 26th October 2017, Lord J, Regan L, Kasliwal A, et al. claim that "Home use of misoprostol in Scotland is relatively new. The larger abortion services in Scotland report widescale uptake of home use of misoprostol among women and that it is highly appreciated with no negative impact on services." The Scottish “abortion services” consulted are not named and the reference for the bold claim that home use of misoprostol is “highly appreciated” is “S Cameron [co-author], personal communication 2018”. Such statements do not inspire confidence.
In response to some other claims made in the article: women having better control over timing in practice will mean less precision in timing, since medical supervision is supposed to guarantee ‘correct’ time between drugs and a ‘correct’ route of administration, whether sublingual, buccal or vaginal. If these are departed from, the effectiveness goes down, and the complications go up. This is well-known.
As regards travel and onset of bleeding, the Creinin paper [1] referred to by the authors had a bleeding onset median time of 2 hours for the standard (misoprostol taken 24 hours after mifepristone), and 3.7 hours when mifepristone and misoprostol were taken together. Others state that the onset of bleeding with the standard regimen was after 2 hours and meant light to moderate spotting at 4 hours after misoprostol [2]. Depending on the travel time, there m...
Show MoreThe article of Frances Doran and Susan Nancarrow [1] suggests that there is a need for more research about the barriers to access to abortion services in developed countries. I totally agree with this finding, especially for qualitative research, and would like to provide a point of view from France.
As part of my doctoral research on the social determinants of reproductive health, I attended the trial of Domin...
Counseling is voluntary by definition. A person being 'counseled' can leave at any time and without any consequences. If 'counseling' is mandatory it becomes in fact a state ordered instruction. Like for example in the case of obligatory military service. We as society should at least have the courage to name things with their correct terminology. And not pretend to 'counsel' women if in fact we force them to listen to an...
It was interesting to read Sharon Moses' thoughtful commentary questioning the role of an 'express' contraceptive service in a community sexual health clinic and advocating improving contraceptive provision in primary care, the primary provider of contraception in the UK.[1] My colleagues in Newcastle, however, support this service innovation as they feel that women in their late teens and early twenties have been overl...