https://orcid.org/0000-0001-7582-1418
![Sample our Bioscience journals, sign in here to start your access, Latest two full volumes FREE to you for 14 days]({"type":"image" , "src" : "/sda/5925/TOC-Subject-Sample-2021-Bioscience.jpg"})
Abstract
Abortion pill reversal (APR) treatment aims to halt an initiated medical abortion, wherein a pregnant woman takes progesterone after having taken the first of the two consecutive abortion pills, typically because she has changed her mind and no longer wants to abort the pregnancy. It is a controversial intervention, generally supported by those identifying as pro-life and opposed by those identifying as pro-choice. This paper examines whether, in principle, those identifying with the pro-choice view should support APR. We firstly examine the commitments of the pro-choice stance. We then briefly outline the evidence supporting the APR. Following this, we discuss potential consequences of APR on women’s mental health and its safety. We conclude that those espousing the pro-choice standpoint should be, in principle, committed to supporting the availability of APR, while recognising that data on its efficacy may be difficult to obtain.
Acknowledgments
The authors wish to thank James E. Hurford, Calum Miller and Adrian Treloar for helpful comments on issues pertaining to this manuscript. The authors would also like to thank the reviewers for their helpful comments and suggestions. The views expressed are the authors’ and are not necessarily representative of the institutions they are affiliated with.
Disclosure statement
The authors are members of the Catholic Medical Association (UK), but this article was neither commissioned nor funded by this organisation.
Contributorship statement
While MP conceived the project, all authors contributed equally to the research and writing of the paper.
Notes
1 It should be noted that medical abortion using mifepristone and misoprostol is classified by the UK’s National Health Service (NHS) and legislation as distinct from emergency contraception (also known as the ‘morning after pill’), which involves the use of levonorgestrel or ulipristal acetate within the first few days after unprotected sex or contraceptive failure (NHS Citation2018). There is, however, debate about how the ‘morning after pill’ should be classified (ChoGlueck Citation2021), since, while the commonly accepted mechanism of its action is the prevention of ovulation (NHS Citation2018) some suggest that it might work by preventing implantation (FDA Citation2015). We do not wish to here take either side of that argument, and limit our discussion here to the use of APR in cases of medical abortion.
2 The restrictions on practice that were initially put in place on those doctors have now been cancelled; in the case of Dr Kearney no evidence was found to support the accusations brought forward against him(Adams and MacFarlane Citation2022, Christian Concern Citation2022, Catholic Union Webinar with Dr Dermot Kearney Citation2022).
3 Nor do we make any presumption here about whether abortion is morally right or wrong, whether or not it should be legal, or whether legal regulation should be more or less restrictive.
4 It is true that there are many complex and important metaphysical assumptions about human nature that are at play here (but the discussion of these is beyond the scope of this paper), and it is not to say that the pro-life movement is in opposition to autonomy. Nevertheless, the weight placed on women’s autonomy, over and against other considerations, is emphasised in the slogan ‘my body, my choice’, which is one of the most characteristic narratives of the pro-choice movement; for one example see Stevenson (Citation2019). This mantra is also exemplified in the type of arguments made in support of abortion by Thomson (Citation1971).
5 We thank one of the anonymous reviewers for highlighting this to us. We have based the assumption of little demand based on the statistics that we had for the current use of abortions by gestation time (see next footnote). This might not actually represent the demand for late-term abortions that might be present if these procedures became legal and abortion was available on demand, and this demand would similarly be hard to reliably estimate from population surveys.
6 We made two Freedom of Information requests (Department of Health & Social Care Citation2022a, Citation2022b) and obtained the following data about the number of medical abortions in which mifepristone alone was used, which we assume to be an indication of eligibility, if not potential demand, for APR. Between 2016–2020 in England and Wales, on average, 3,250 medical abortions in which mifepristone alone was used were reported (SD = 1,342), which equates to 2.3% of all medical abortions (mean = 142,082, SD = 24,456); see also supplementary table 1. This yearly figure is similar in scale to the number of both medical and surgical abortions performed after 20 weeks’ gestation (n = 2,748, 1.3%) and an order of magnitude larger than the number of abortions performed after 24 weeks gestation (n = 236, 0·1%) in 2020 (Department of Health & Social Care Citation2022a, GOV.UK Citation2022a).
7 There is a potential risk of limb defects as a consequence of foetal exposure to mifepristone (Electronic Medicines Compendium Citation2021a). As such, the risk is associated with the medical abortion procedure, rather than APR itself. However, this is salient information that should be provided to a pregnant woman as part of counselling at every stage of decision-making, though it should equally be highlighted that none of the currently published APR studies have identified such an increased incidence of limb defects. We thank one of the reviewers for emphasising this point.
8 The safety data from this trial was misrepresented by some media outlets, which argued that the fact that the trial terminated prematurely due to these incidents (though the media outlets did not state in which arm of the trial these events occurred) meant that APR was not safe (see e.g. Archer Citation2021 and Glenza Citation2021).
9 We conducted a Medline(ProQuest) search of the literature to identify relevant comprehensive literature reviews on the effects of abortion on mental health published since 2011 using the following search terms (and a publication limit between 2011-01-01 and 2022-01-14): (ti(abortion) OR ti("termination of pregnancy")) AND (ti("mental health") OR ti(psychol*) OR ti(psychiat*)) AND (ti(review)OR ti(meta-analysis)). This search found 6 publications, of which the two most recent ones were published in 2018. After a title-abstract screen three publications (Kmietowicz Citation2011, Steinberg et al. Citation2012, Macleod, Chiweshe and Mavuso Citation2018) were not deemed to be in our scope. Two studies (Bellieni and Buonocore Citation2013, Reardon Citation2018) did not provide any information that would contradict any of the studies that we have discussed. Rather, they highlighted the general consensus on: the limitations of the evidence basis, and consistent conclusions that abortion is associated with increased rates of mental health problems. One study reported that it did not find any convincing evidence for worse mental outcomes after abortions (Steinberg Citation2011). As such, the majority of relevant identified literature reviews in our search agree with the evidence we have presented in the main body of this article.
10 Another reason for not applying abortion provision criteria to APR is that the Abortion Act Citation1967 provides a defence to criminal proceedings in relation to abortion offences only where certain conditions are met, and as such abortion provision in the UK warrants close scrutiny. Conversely, the aim of APR, i.e. preservation of the life of a foetus, is congruent with the aims standard medical practice (Gamble and Pruski Citation2019). As such, a requirement similar to that of two medical practitioners needing to sign-off an abortion would be superfluous and unneccessarily obstructive in the case of APR.
11 Delgado and Davenport (Citation2012) suggest monitoring viability as part of their APR protocol.
12 There is at least one currently ongoing trial of APR that we are aware of (Australian New Zealand Clinical Trials Registry Citation2021).
13 Recently, NICE published a guideline on the management of ectopic pregnancies and miscarriage, where it recommended the off-label use progesterone for pregnant women with vaginal bleeding and a history of miscarriage (NICE Citation2021, Electronic Medicines Compendium Citation2022c). There it states that ‘[t]he committee confirmed that the recommendations for the use of progesterone are only for women with early pregnancy bleeding and a history of miscarriage. The recommendations are not applicable in other circumstances, such as after the use of mifepristone.’ The accompanying evidence review states that ‘[t]he committee were made aware by stakeholders that progesterone may be prescribed for women who have taken mifepristone as part of an abortion process, but then have changed their mind, and wish to reverse the effects of the mifepristone. Although this population of women had not been included in the original evidence review, the committee were concerned about this practice, and were not aware of any evidence that suggested that the use of progesterone would be safe and effective in this situation. The committee therefore added this information to the rationale and impact section of the guideline’ (NICE Citation2021). As such, while NICE noted that it is aware of APR, it stated that it has not yet conducted an evidence review of APR and that APR is outside the scope of existing guidelines. As such, NICE has not recommended the use of APR but, equally, it has not recommended against its use either. A NICE guideline would be key to establishing best practice for the provision of APR in the UK.
Additional information
Funding
Notes on contributors
Michal Pruski
Michal Pruski is a Clinical Scientist. His academic background is in cellular neuroscience, bioethics and critical care. His current clinical practice focuses on vascular ultrasound imaging and medical technology evidence evaluation. He is also undertaking higher specialism training in clinical health informatics.
Dominic Whitehouse
Dominic Whitehouse is a consultant physician with a background in respiratory and palliative medicine, now based in a third-sector hospice and an NHS hospital. He is concurrently undertaking further study in bioethics and medical law.
Steven Bow
Steven Bow is a non-medical public health registrar, with a background in public health statistics and recent experience in academic public health ethics.