Over 19 million women globally resort to unsafe abortion each year, largely among the world's poorest and most vulnerable women, especially young women. The deaths of 68,000 women and injury to countless more each year represents a continuing injustice that cannot be tolerated. Governments across the world have committed themselves to achieving the Millennium Development Goal of reducing maternal mortality by three-quarters by 2015. Expanding access to safe abortion is an essential measure to realize this goal.
Women have the right to life and health and to the benefits of scientific progress. Advances in technology, including the development of safe, effective and acceptable regimens for medical abortion, have created increased options for women to exercise reproductive choice. However, medical abortion is still not available to many of the women who could benefit from its use.
Medical abortion involves the use of pills to cause a miscarriage that takes place over a period of several days, and is a fundamentally different experience from surgical abortion for both women and providers. Policymakers and health managers and service providers need to recognize the differences, as they affect service delivery requirements. Different regimens of medical abortion drugs exist for use up to nine weeks of pregnancy, for the remainder of the first trimester and for the second trimester of pregnancy.
The role of the provider of medical abortion is to give the woman information and access to the drugs, support the woman as required during the abortion process and check that the abortion is complete. A full surgical abortion service is not necessary in order to provide medical abortion; however, back-up with vacuum aspiration should be available if and as required.
Where both medical and surgical abortion are available, women should be able to choose between them, based on unbiased and accurate information. The focus should not be on promoting one or the other method but on ensuring that women can choose the method that best meets their needs.
Medical abortion services should be viewed as an integral component of comprehensive reproductive health care. For abortions up to nine weeks, the pills can be provided through primary health care services and women can safely use the method at home or in a clinical setting, according to their own preferences and personal circumstances. Medical abortion after nine weeks and in the second trimester can be carried out in a health centre or hospital.
Safe Abortion: Technical and Policy Guidance for Health Systems (World Health Organization, 2003) offers evidence-based standards and norms for providing medical abortion and may be utilized to determine requirements for specific national and local contexts.
Some of the first countries to approve medical abortion have now recognized that they instituted unnecessarily complex requirements for providers and facilities and over-medicalized medical abortion protocols. The avoidance of over-medicalization is essential for ensuring equitable access to medical abortion, particularly in low-resource settings.
Mid-level providers, including nurses, midwives, family planning workers and physician assistants, can and should be trained to provide early medical abortion services. The emphasis should be on providers who are closest to women geographically and socially. Pre-service and continuing education curricula in general medicine, nursing, family planning, midwifery and obstetrics and gynaecology should all include appropriate information on medical abortion methods so that providers are well informed and can help women to exercise their rights.
In legally restricted settings, there is a special need to build alliances across sectors, including doctors, mid-level providers, NGOs, policymakers, legal experts and women's health advocates to provide information about and access to safe abortion, including medical abortion, within national policies and standards. Even in legally restricted environments, governments must recognize their responsibility to provide safe abortion services to the full extent of the law.
Medical abortion can only become a real option for the majority of the world's women when the recommended drugs, mifepristone and misoprostol, are available, accessible and affordable. Both mifepristone and misoprostol have wider obstetric and gynaecological applications, in addition to induced abortion, and should be included in the WHO Model List of Essential Medicines.
Medical abortion is a safe, effective means of inducing abortion and has been shown to be widely acceptable to women in both developed and developing countries in all world regions. In legally restricted settings, medical abortion offers the opportunity to reduce the number of tragic and unnecessary deaths and injuries arising from complications of unsafe abortions. In all settings, medical abortion is contributing to women's ability to exercise the right to terminate an unwanted pregnancy safely.
The International Consortium for Medical Abortion consists of organizations and individuals around the world who support access to medical abortion within the context of support for safe abortion. For details of the conference and further information, go to: <www.medicalabortionconsortium.org>.