Access to medical abortion
Marge Berer, Editor, Reproductive Health Matters and Chair, International Consortium for
Medical Abortion, London, UK
Although more than one method of abortion has been available for many years, in most
countries the provider chooses the method and may be skilled in one method only. This
paper discusses choice and acceptability of medical abortion from the perspective of both
women and abortion providers and argues that choice of method is important for both.
Safety, efficacy, number of visits, how the method works, how long it takes for the abortion
to be complete and cost all affect acceptability. Medical abortion is considered more
natural because it happens in women’s own bodies and can take place at home before
nine weeks of pregnancy; surgical abortion with vacuum aspiration is simple and over
quickly. Unless the costs of both methods are similar, however, women and providers will
tend towards whichever is the cheaper option, limiting choice. Medical abortion is effective
from when a woman misses her period through 24 weeks of pregnancy, and more women
and providers need to be made aware of this. In legally restricted situations, complications
tend to be less serious and easier to treat with early medical abortion than after unsafe
invasive methods. Ideally, both medical and surgical methods should be available, but
each can be provided without the other.
Consequences of the laws for women and political challenges in Europe
Marge Berer (Great Britain)
London, United Kingdom
There will always be some women who seek abortion after 12 weeks of pregnancy and in fewer cases at 20-24 weeks and even later, with the numbers diminishing rapidly at later gestations. Late abortions, the women who have them and the providers who do them are especially stigmatised. The number of providers willing to carry out abortions drops rapidly after 12–16 weeks of pregnancy and even more beyond 20 weeks. Many abortion laws do not permit second trimester abortion at all, except perhaps to save the life of the woman. Those that do distinguish second trimester abortion usually have more restricted grounds and/or bureaucratic approval processes.
Abortion “tourism” is a long-standing reality in Europe. The illegality of abortion after 12 weeks is less of a public health problem because women can travel for abortions, and the problems for women are hidden. In countries where abortion is legally restricted, morbidity and mortality are greater from complications of second trimester abortion than first trimester. The reasons are due not just to pregnancy being more advanced but due to greater risks from self-medication, the conditions in which the abortion is performed, lack of access to training in best practice for providers, less safe methods used and lack of access to timely, skilled follow-up care in case of complications. Moreover, deaths from second trimester abortions may be hidden in mortality statistics.
Women seeking late abortion are often in a precarious position personally (e.g. very young). Fetal indications are mostly not identified until 20–22 weeks. Where abortion for fetal indications is legal, many of the barriers women otherwise face don’t occur. Indeed, abortion may be encouraged. Where it is not legal, women may be forced to continue pregnancies and deliver even though the baby will certainly die soon after birth.