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• Second doctor signature on HSA forms
  Humphrey Birley
  Published on: 27 August 2018
• Comment on ‘Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England’
  Keith Hindell
  Published on: 27 August 2018
• Home use of misoprostol: is it really safe and appreciated?
  Dr Anthony McCarthy
  Published on: 27 August 2018

• Published on: 27 August 2018

  Second doctor signature on HSA forms

  • Humphrey Birley, GUM Consultant The Cordell Centre, Aneurin Bevan Health Board, Royal Gwent Hospital, Newport

  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.

  Conflict of Interest:
  None declared.

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• Published on: 27 August 2018

  Comment on ‘Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England’

  • Keith Hindell, Former Vice-Chairman of Pregnancy Advisory Service None

  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...

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  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.

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  Conflict of Interest:
  None declared.

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• Published on: 27 August 2018

  Home use of misoprostol: is it really safe and appreciated?

  • Dr Anthony McCarthy, Bioethicist Society for the Protection of Unborn Children

  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...

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  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.

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  Conflict of Interest:
  None declared.

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