Women's Global Network for Reproductive Rights, Newsletter 73, July 2001

Abortion

Medical abortion - Where we are in Europe
By Christian Fiala

Eleven years after becoming commercially available in France, mifepristone (RU486/Mifegyner) is still being withheld from most potential users in Europe (see Table 1). It is interesting to note that in 1988 the French government gave the pharmaceutical company Russel-Uclaff the choice to either market mifepristone or it would take away the rights and ask another company to produce and sell the drug. The government argued it would be unlawful for a private company to withhold a drug with therapeutical benefits from the population for commercial reasons (fear or boycott).

And resistance to its use continues even 11 years after the first commercialisation although it has been proved to be safe and effective. By comparison, Viagra was available before its official authorisation and received a licence quickly. It can also be used without medical supervision and outside a hospital, despite a high number of deaths that have been reported in connection with its use (130 US citizens died during the first six months of commercialisation in the US alone; see http://www.fda.gov/). The comparison between Mifegyne and Viagra is just another example of the double standard that continues to exist between men and women, and particularly women facing an unwanted pregnancy.

What is medical abortion?
Mifepristone is a hormone that resembles the Luteal hormone progesterone and is taken by the woman as tablets. It binds to the receptors in the uterus but exerts no effect. (This is similar to a wrong key blocking a padlock). The progesterone is vital for the mucous membrane in the uterus for the continuation of the pregnancy. Lack of progesterone or blockage of its receptors by mifepristone results in menstrual bleeding and loss of the pregnancy. A second drug, a prostaglandin tablet is taken by the women in two days later to make sure that expulsion takes place.

The course of medical abortion
In the General Public Hospital of Korneuburg, just outside Vienna, we have been carrying out terminations with Mifegyne(R)(Sanne, tekentje kan ik in WP niet maken) since January 1999. We treat approximately 50 women per month, the demand being very high. Most of the women come from Vienna and its surrounding area. An (after) curettage was needed for three per cent of all women treated. After completion of the treatment, we asked the women, inter alia through a questionnaire, which method they would choose in any future termination. Of those responding, over 90 per cent would choose this method again.

1. First telephone contact
The first telephone contact begins with a detailed discussion of information on abortion itself, though also on the details of the various methods. The discussion then proceeds rapidly -according to the situation- to a counselling session. This discussion is often of great importance in the Mifegyne(R) counselling, as it lays the foundation stone for the relationship and thus also the course of the process. The telephone calls are often long, or the woman rings several times within two or three days.

It is therefore important that the same person also provides the continuing counselling and escort functions. As previously mentioned, the counsellor must go through a selection process with the patient in relation to the medical and psychological criteria in order to choose the most suitable method. If the women seems to be sure of her decision we make an appointment. Often, however, we also provide information on other establishments that are either nearer or which carry out surgical terminations under local or full anaesthetic. Despite the surge of interest in Mifegyne and the frequent calls to our advice line, only approximately 20 per cent of the callers actually go on to termination with Mifegyne(R).

The period from first contact to taking Mifegyne(R)

In this phase, women are confronted by unrealistic worries and illusions. Questions repeatedly arise what is really going to happen to me, what have I let myself in for, have I made the right decision? Seen as a whole it is the most uncertain and problematic phase.

2. Counselling at the hospital
The first personal contact in the hospital is divided into the medical examination and the counselling. Teamwork between the doctor and the counsellor is crucial in this. They must divide the consultation and reciprocally accept their competences in order to guarantee the best possible care.

Detailed information on the method and the process should, where possible, deal with any misconceptions. Women are particularly relieved when the are (still) no embryonic structures, and in particular no heart activity, visible on the ultrasound scan. Furthermore, it should be emphasised that the taking of Mifegyne(R) is the actual termination of the pregnancy. This is the point of no return. The prostaglandin two days later serves only to support the expulsion of the already terminated pregnancy. As already mentioned, an exact prediction of the further course of the process is not possible because of the great individual variations. The women should be advised of this. In particular, the varying courses of the process do not allow any conclusions to be drawn on whether the method functions or not. In our experience it is particularly important and helpful for the woman if the partner or a contact person is integrated into the course of the process, so that he/she can have a supportive effect. Naturally, this can only happen with the agreement of the woman concerned.

The period from the taking of Mifegyne(R) to the taking of Prostaglandin

In this phase, the problem with the body comes to the fore. The decision for termination has already been implemented. Now, the uncertainty over the further course of the process and the waiting for the period are the main issues.

3. Care after taking of Prostaglandin
The atmosphere is now essentially more relaxed than at the previous contact. The woman knows the doctor and counsellor and knows at least theoretically what awaits her. Further, there is no longer any decision to be made, only the continuation of a process that has already been started. For some women, morning sickness has already receded and in a few cases the women have already ejected the amniotic sac and bring it with them (in these cases the treatment is thereby concluded).

Most women are worried about possible pains after the taking of the Prostaglandin. The offer of an appropriate escort by a trusted person is therefore very important. As far as possible this should, however, remain an offer, and not be seen as a compulsory measure. Some women are hardly affected by the termination and therefore have no need of an escort. This should also be taken into account in the organisation of the process. In this phase, medical care recedes into background, in favour of escort by the counsellor and the partner/friend. Some 20-40% of the women require mild analgesics.

From the taking of Prostaglandin to the check-up

Heavy bleeding and cramps can occur in this phase. The main concern is the uncertainty as to whether the method has worked or not. Future fertility is suddenly also an important issue again.

4. After-care
The further medical check-up after a week to ten days is seen by most women as a great relief and the definitive conclusion of the process. For many women the period up to the check up is stressful because of the uncertainty over whether the pregnancy has actually been terminated. Most women are thus all the more pleasantly surprised if everything has gone well.

Occasionally, a second or third medical check-up is necessary, and in about three per cent of cases a curettage. For these women, too, appropriate counselling should be envisaged. As always, there is the question of psychological- psychotherapeutic after-care, which is, however, only rarely taken up after a medicinal termination.

Conclusion
Medical abortion does not essentially change the counselling in the conflict case of an unwanted pregnancy. The previous counselling only has to be supplemented when it comes to the specific implementation. Here, good information and counselling with sufficient time are necessary, so that each woman can arrive at the best decision regarding the method for her. This makes medical termination with Mifepristone a sensible alternative for many women. Moreover, we have the experience that the treatment proceeds essentially more calmly and less dramatically than the public debate.

Christian Fiala, MD

[christian.fiala@aon.at]

Dept. of Gynecology and Obstetrics

General Public Hospital

Wiener Ring 3-5

A-2100 Korneuburg, Austria

Tel.: (+4)32262-780 6901

Fax: (+43) 2262-780 285 (Sanne I just typed the way it is, need to check code?

Country                Availability                                                                                      Limitations to access

Austria               Available only in a few institutions in the Vienna area                 Approved only for hospitals and clinics, although most abortions are performed in private practice by gynaecologists or GPs

Belgium               Available since June 2000                                                               Centres have to obtain the product from a reference hospital with a pharmacy

Denmark             Available since April 2000

Finland                Available in (since?) May 2000

France              On the market since 1988                                                               Strong regional differences in availability

Germany           Available in some institutions mainly to private paying women    The Society of Gynaecologists imposed a "quality standard": should be used only when cardiac activity is visible (>42 DA); not fully covered by social security, in contrast to surgical abortion

Greece           Not yet available, although approved in October 1999                Approved for hospitals and clinics only, although most abortions are performed in private practice

Ireland            Not available                                                                                           No application

Italy                Not available                                                                                          No application

Luxembourg    Not yet available, although approved since December 1999

The Netherlands Not generally available although approved; two clinics are carrying out an acceptance study        Abortion providers judge that women do not need it

Norway            Approved since February 2000                                                        Not on the market yet, some institutions have used it the last year

Portugal           Not available                                                                                      No application

Spain                Available since February 2000                                                         Centres must be a pharmacy or a responsible pharmacist

Sweden              On the market since 1992                                                               Strong regional differences in availability

Switzerland       Available since December 1999                                                      Marketing after a legal debate as to whether Mifegyne is a medical product or not

UK                     On the market since 1991                                                              Strong regional differences in availability

Access to medical abortion still depends in all countries on the engagement of individual doctors and counsellors and therefore differs enormously from region to region. DA: Days of amenorrhea

From: Entre Nous No. 47-48 Autumn 2000