• abortion
• abortion pill

Regarding the Scottish decision on home abortion of 26 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 et al paper1 referred to by the authors had a bleeding onset Adelaide 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 common4 and associated with regret.5 Indeed, some women having medical abortions refuse to take misoprostol after mifepristone, whereupon the fetus 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 some women will get no support at all and the ‘support’ they will get may be pressure to abort (bearing in mind the strong link between abortion and intimate partner violence7).

A Scottish trial in 2010 surveyed women’s responses and experience of returning home immediately after the administration of misoprostol to abort. One hundred out of 145 women answered the survey (making one wonder why 45 did not respond). Twelve of the 100 responded that they were extremely upset by the experience. Eight 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 9, which highlights the increased risk of complications when women take mifepristone and misoprostol simultaneously. Lord et al 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 British Pregnancy Advisory Service (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%), diarrhoea (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.