Historical background of abortion with an emphasis on medical abortion
Marc Bygdeman, Department of Obstetrics and Gynecology, Karolinska Hospital,
Marc Bygdeman is since 1978 professor of Obstetrics and Gynecology at the Karolinska hospital in Stockholm, Sweden. M. Bygdeman has previously been Head of the department, Medical Director of the hospital as well as President of the Swedish Association of Obstetrics and Gynecology. M. Bygdeman is honorary member of the Royal College of Obstetrics and Gynecology and the American College of Obstetricians and Gynecologists and has been awarded the King of Sweden gold medal for outstanding achievements in education and research. M. Bygdeman has published more than 400 scientific articles mainly concerning infertility, contraception and abortion.
The methods used at present for termination of early pregnancy is vacuum aspiration and the antiprogestin, Mifepristone, in combination with an suitable analogue, either misoprostol or gemeprost. Vacuum aspiration was first described in China in 1958 and started to be introduced in Europe shortly thereafter. It replaced the surgical procedure dilatation ond curettage (D&C). The development of a medical method started when prostaglandin analogues became available. In late 1970 and early 1980 it could be demonstrated that repeated administration of e.g. gemeprost by the vaginal route was highly effective resulting in a frequency of complete abortion of 95% or higher. However, effective dose schedules were associated with a high incidence of side effects such as vomiting and diarrhoea. Even home treatment was shown to be a possibility
In 1982 Herrman and co-workers (Herrman et al. Comptes Rendus 1882; 294;933-940) demonstrated that treatment with mifepristone could terminate early pregnancy. Although mifepristone induced a bleeding in almost all early pregnant patients the frequency of complete abortion, 60 to 85% depending on duration of pregnancy at treatment, was not sufficient for clinical use. Treatment with mifepristone converts the quite early pregnant uterus into an organ of spontaneous activity, ripens the cervix and very importantly increases the sensitivity of the myometrium to prostaglandin by around 5 times. The increased sensitivity and contractility of the uterus can be demonstrated after 24 hours and is fully developed 36 to 48 hours after the administration of mifepristone. We could also demonstrate that the treatment with mifepristone followed 36 to 48 hours later by a prostaglandin analogue was a very effective method to terminate early pregnancy (Bygdeman and Swahn, Contraception 1985; 32:45-51). The high sensitivity of the uterus allowed a low dose of prostaglandin to be used and the prostaglandin related side effects to be significantly reduced. After extensive clinical trials, mifepristone in combination with a prostaglandin analogue, initially sulprostone or gemeprost later mainly misoprostol, was licensed 1988 in France and China for induction of abortion up to 7 weeks, followed in the United Kingdom in 1991 and in Sweden in 1992 up to 9 weeks. Today the procedure is licensed in around 30 countries in different parts of the world including a number of countries in Europe and in the United States. In most of these countries the upper limit for the procedure is 7 weeks.
Mifepristone alone is also used to soften the cervix prior to vacuum aspiration and to induce labour in case of intrauterine foetal death and in combination with a prostaglandin analogue for termination of second trimester pregnancy.
Should gynaecologists be obliged to perform abortions?
Marc Bygdeman (Sweden)
Department of Woman and Child Health, Division for Obstetrics and Gynecology, Karolinska Hospital, S171 76, Stockholm, Sweden
In 1999 the U.N. General Assembly agreed that “where abortion is not against the law, health systems should ensure that such abortion is safe and accessible”. The woman has the right to be treated with respect, empathy and understanding of there difficult situation. However, some health care providers may find that providing care would present for them a personal moral problem – a problem of conscience. Respect for conscience is important but the effect when exercised by physicians and/or other health care personal is to fustrate or negate patients’ legal right of access to abortion. To force gynecologists to perform abortion may therefore not be in the best interest of the woman. It should, however, be stated that conscientious refusal is only valid for performing the abortion. All health care providers, independent of their attitude to abortion, must provide the woman with accurate and unbiased information about their legal rights, the procedure and have the duty to refer the woman in a timely manner to other providers willing to perform abortion. Conscientious refusal to perform abortion is a personal matter and should not be applied to health-care institutions. As in some European countries medical care should be organized so that a woman can obtain an abortion at anytime and to ensure the availability of an adequate number of providers so that women are able to exercise their right to abortion.