Misoprostol, mifeprisone and medical abortion: The facts you need to know.

2nd Year Medical Student and Pro-Choice Advocate at QUB

Misoprostol, mifeprisone and medical abortion: The facts you need to know.

Among the general public, there seems to be a very common misconception about what most early, first trimester abortions actually involve. Anti-choice activists would have you believe it’s a complicated and dangerous surgical procedure, which has a high rate of complications, but medical practice and the experiences of women show this to be baseless.

The general lack of knowledge around the issue, owing to a lack of unbiased education, means that the majority of people in Northern Ireland are in the dark about early abortions facilitated through the use of two pills: misoprostol and mifepristone (until a woman was recently prosecuted here for obtaining these medications online to induce her own abortion).

Misoprostol and mifepristone are a combination of pills used to induce what is known as a ‘medical abortion’. This is opposed to early surgical abortion, which uses manual uterine aspiration, another safe procedure when done by a trained professional, also with low rates of complications.

Misoprostol is commonly used to prevent the development of stomach ulcers while on non-steroidal anti-inflammatory drugs (NSAIDs), however when used during pregnancy, it can cause a miscarriage.

Misoprostol is usually used in combination with mifepristone to induce an abortion in the first 2-10 weeks of pregnancy. One dose of mifepristone is taken first; it is a synthetic steroid used to block the hormone progesterone, which is necessary for pregnancy to continue. 24 hours after taking mifepristone, multiple doses of misoprostol are taken sub-lingually (under the tongue) and held there to dissolve for 30 minutes. Finally, 4 hours after the first dose of misoprostol, 2 more tablets are dissolved under the tongue for 30 minutes. This induces the same process as a natural miscarriage. From reading the BNF, I know that tablets sometimes come in different dosages of misoprostol.

In countries where abortion is restricted, but misoprostol is readily available in pharmacies, an induced abortion with just misoprostol can be done just as well. This involves 3 separate doses, 3 hours apart of 4 tablets of misoprostol under the tongue.

All of this information, and more, is readily available from websites such as Women on Web, Women on Waves and Women Help Women.

One of the most common concerns about using pills to induce an abortion is: is it safe? The media has frequently warned about dangerous medications , stating that women will risk heavy bleeding when using these pills. These concerns are easily addressed, as both of these medications are safe when prescribed and used after a consultation with a medical professional, as is the case with WoW and WHW. Bleeding is to be expected, after all, the pills induce the same symptoms as a miscarriage, but the risk of an excessive amount of bleeding is less than 0.2%, and this can be easily treated in a hospital as a problematic miscarriage. If people take these pills and are concerned that they are bleeding too much, they are encouraged to seek medical advice, and do not require to give information that the miscarriage was induced my medication.

Mifepristone and misoprostol are both on the World Health Organisation’s Model List of Essential Medicine, and are prescribed by doctors all over the world to women who seek a first trimester abortion. These medications are also used to treat many women in Northern Ireland for incomplete miscarriages and postpartum complications. Anyone claiming the drugs are ‘dangerous’ is misinformed, and should be aware that this procedure has been researched and recommended for a safe first trimester abortion by the World Health Organisation. 

These drugs have even been approved for home use in certain countries. In South Africa, a scheme is being trialled, where women receive a text service from their clinic or hospital to let them know how their abortion process should be going, and telling them to seek medical help if it is abnormal. This is a stark contrast to Northern Ireland, where a woman was prosecuted for using the abortion pill at home. This process is completely safe, and easily managed as an outpatient procedure worldwide, so why do governments prevent women from accessing this procedure somewhere that is potentially more comfortable and less intimidating?

In my opinion, the decriminalisation of usage of misoprostol and mifepristone would be a vital step towards best medical practice whilst providing patients with autonomy and treating them as partners in their own medical care provision, rather than the dangerous outlaw method it is described as in the media.

Here are some links to the research on the safety and effects of Early Medical Abortion, including the Women on Web research into women’s own experiences of using the medicines in this way – legal permission notwithstanding.

Women Help Women: How to use the abortion pills at home

Women Help Women: How to use the abortion pills at home (Graphic Instructions)

Experiences and characteristics of women seeking and completing at-home medical termination of pregnancy through online telemedicine in Ireland and Northern Ireland: a population-based analysis

Misoprostol - In Women’s Hands: A Harm Reduction Strategy

Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review

Mifepristone Safety Overview
#misoprostol #mifepristone

28 September International action Day for Decriminalization of Abortion

September 28 Global Day of Action for Access to Safe and Legal Abortion forms part of the campaign activities undertaken by the  International Campaign for Women’s Right to Safe Abortion, that aims to build an international movement to promote universal access to safe, legal abortion as a women’s health and human rights issue.

As part of the International Campaign, WGNRR engages in September 28 annual campaigning activities, conducted by Campaign and WGNRR members, as well as allies around the world.

September 28 has been a regional campaign for decriminalisation of abortion in Latin America and Caribbean for nearly twenty years before being taken on by SRHR activists all over the world as a Global Day of Action for Access to Safe and Legal Abortion in 2011.

http://www.september28.org/how-this-campaign-works/

Unsafe abortion is a public health disaster and a major human rights issue. About 47,000 women each year are still dying from complications of unsafe abortion. Others are imprisoned for having abortions. In some countries women are dying or suffering serious injury because of the failure of their governments to provide safe abortions and life-saving treatment when they are too ill to continue with a pregnancy. This is why on 28 September - the International Day of Action for the Decriminalisation of Abortion- women's health and human rights advocates are demanding change. 

To find out about ASTRA Network's members' activities on that day go to: http://www.september28.org/

Press Release Monday 4th April 2016

Monday 4th April 2016

Alliance for Choice are dismayed at the decision today to hand a suspended prison sentenceto a young woman who couldn’t afford to travel to England for an abortion, so bought pills on the internet.

The Northern Ireland Assembly, the Westminster Government and the press should know that to arrest any UK citizen for taking one of the World Health Organisation’s safest recommended drugs in order to end her own pregnancy,  is the  criminalisation of women who can’t afford to travel. This conviction is a threat to all people without similar means, and is a clear signal that women are not recognised as full citizens. This is also an indictment on the State party with responsibility for our Human Rights, which is Westminster.

Alliance for Choice’s #trustwomen Campaign will keep abortion firmly on the political agenda in the run up to the Assembly Election.

The campaign will push for progress on abortion legislation in Northern Ireland, which is currently one of the most restrictive in the world.

We firmly believe that women should be trusted to know what is best for themselves and their families.

We encourage our MLA’s to:

1.    Trust Women to make decisions about their own lives

2.    Ask for legal change to allow greater access

3.    A free vote for all MLA’s should progressive changes come to the Assembly.

4.    We are urging all our supporters to contact their MLA’s and prospective candidates and tell them that women are not to be criminalised and that it is time we #TRUST WOMEN

For further information and images contact: alliancechoice4@gmail.com

Vice-Chair Emma Campbell – 07894063965 Twitter: @All4Choice

Open Democracy article on the Judicial Review

This piece was written originally in Open Democracy by Goretti Horgan and Emma Campbell.

Pressure is mounting on the Northern Ireland Assembly to make changes in the current abortion legislation.

On the 2nd February, the Northern Ireland Human Rights Commission (NIHRC) was granted the right to judicial review. They are seeking a change to allow for termination in the case of serious malformation of the foetus or sexual crimes, such as rape or incest.

Recently, the U.N.’s Committee on the Elimination of Discrimination against Women reiterated its recommendation of this change. Yet despite repeated advice from international rights bodies and recommendations from the World Health Organization, the Assembly at Stormont steadfastly refuses to engage coherently with women’s bodily autonomy. Importantly, the Department of Health has refused to be involved, underlining the public suspicion that it is guided by religiosity, rather than concerns for public health and women’s safety. 

At the end of October 2014, Amnesty International released figures from a Northern Ireland poll. The headline figures show that a majority think the law in Northern Ireland should make access to abortion available where the pregnancy is the result of rape (69%), the result of incest (68%), or where the foetus has a fatal abnormality (60%).

The NI Human Rights Commission has frequently warned the Department of Justice that it is currently violating the human rights of women and girls in Northern Ireland by upholding the law as it stands. The Department of Justice announced its own consultation, which is now closed and we await their response with, as yet, no timescale.  However, it only considers women dealing with lethal foetal abnormality, so it does not adequately address the needs of all women carrying a seriously malformed foetus. Neither did it suggest any legislation for women who are survivors of rape, incest and other sexual crimes. It merely sought to gauge opinion, thereby assuaging public feeling rather than properly addressing the real and dangerous impact the lack of clear legal guidance has for women in these circumstances.

This consultation lacks the breadth of vision to make any real change to the lives of the thousands of women from NI who seek abortions every year, only a small percentage of whom have to deal with the diagnosis of a fatal foetal abnormality.  Rather it would create a deserving/undeserving narrative around abortion access and provision, which is part of what the NIHRC recognises as serious failings in respect to the human rights of women and their reproductive healthcare in NI, in accordance with international human rights standards.

Groups including the Northern Ireland Family Planning Association, Precious Life, Alliance for Choice and religious leaders will be providing evidence from both sides at the Judicial Review, expected to begin in the summer of 2015. The human rights that will be cited by the groups in favour of change are enshrined in the European Convention on Human Rights. They are Article 3: Freedom from Torture and inhuman and degrading treatment or punishment (on which there are no limitations or exceptions); Article 8: Right to Privacy (including rights to family life) and Article 14: Discrimination (on grounds of sex, race, colour, language, religion, political, national or social origin, national minority, property birth or other status).

Why do women in Northern Ireland not have the same right to abortion as women in England, Scotland and Wales if we are all part of the “United Kingdom”?  The answer lies in a toxic mixing of religion and politics.  The Stormont Parliament had never extended the 1967 Abortion Act to the region. For decades, women had little choice but to travel to England if they needed an abortion. Then a series of court rulings in the 1990s indicated that abortion is legal in Northern Ireland under the terms of the 1939 “Bourne Judgement”,which said it is legal to end a pregnancy that would leave a woman “a mental or physical wreck”. Following these judgements, the law on abortion in Northern Ireland was said to be “so uncertain that it violates the standards of international human rights law”.  However, the Assembly has failed to provide the clarity needed to bring practice into line with the law.

Even before the Belfast Agreement was signed, there were indications that women’s right to full social citizenship in a ‘new’ Northern Ireland would not be protected. Rather, it became clear that, despite a rhetoric that equality was to be at the heart of a devolved administration, women’s rights to bodily autonomy or reproductive and health rights would be subordinated to the ‘peace process’. And so it proved; while the lack of civil and social rights to control their own bodies continues, women are denied full social and political participation.

Working class and marginalized women who cannot afford to travel to a private clinic are particularly at risk of having their personal, social and political autonomy diminished by an unwanted pregnancy. Poverty and access to travel documents, accommodation and childcare are particularly difficult additional barriers that women in Northern Ireland face when trying to access an abortion in another part of the UK.  The increased impact on these women is difficult to measure but the Abortion Support Network in London hears daily from Northern Irish women who are struggling to raise the funds to afford private healthcare, which becomes very costly, for women carrying foetuses diagnosed with serious impairments during a 20 week scan.

Religious influence on all the major parties is a large part of the reason for this situation. Several Democratic Unionist Party (DUP) Ministers are associated with the Caleb Foundation, set up in 2009 to promote law and government in line with biblical thinking. Those associated with the Caleb Foundation refer to themselves ‘jokingly’ as ‘The Caleban’.  As the Belfast Telegraph pointed out, where the Taliban is pushing for an ultra-hardline version of Sharia law based on its own reading of the Koran, Caleb wants to see a Bible-based society with every law measured against scripture.

The second largest party, Sinn Fein, has supported calls for abortion to be legal in cases of rape and fatal foetal abnormality. But that does not prevent it from trying to keep its Catholic credentials. When “Pro-life” group Precious Life for the first time included the party on its list of “pro-abortion” groups to be shunned at the polls, the party responded with a statement saying, “We are not pro-choice and we are not in favour of abortion (other than) where a pregnant woman’s life is in danger…This is a position shared by the SDLP, the DUP and Catholic Bishop John McAreavy.”  The SF statement was withdrawn when the bishop challenged the depiction of his position and complained about being drawn into a political wrangle.

Attitudes in Northern Ireland are certainly changing. As a recent example, an article in the Guardian about clinic escorts at Marie Stopes Belfast prompted hundreds to call and offer their support. Women make up almost half the workforce and over half of all 2012 births in Belfast (59 percent) and Derry (56 percent) were outside marriage, reflecting changed attitudes to sexual activity.  In spite of this, it is clear that the Assembly will allow abortion only in the very limited circumstances evangelical Protestantism and conservative Catholicism allows.

The legal challenge from the NIHRC is both necessary and welcome, then. Anything that opens up abortion access for women in Northern Ireland is an improvement to our diminished status as citizens.  Importantly, the legal challenge also values the rich and diverse lives that women lead, rather than seeing us as baby-makers only. But it remains a small step towards advancing the right of women in the North of Ireland to self-determination, to control over their own bodies, and to the same level of health care as women in Scotland, England and Wales.

The Guardian view on abortion in Northern Ireland: the wrongs of missing rights

Originally appeared in the Guardian on Tuesday 1st December 2015

Should a woman carrying a doomed foetus be required to carry it through to stillbirth? This, surely, is a question that can admit just one answer in any civilised mind. If doctors identify an abnormality that precludes all hope of independent existence, then to demand that a woman press on with the pregnancy is not only a vile intrusion of privacy. It is an affront unbalanced by any intelligible offsetting concern. It is not “unborn life” that is protected here, only the certainty of unborn death down the road.

A Queen's University Pro Choice Society member in Belfast, 2015

How extraordinary, then, that there is a corner of the UK where such a termination is barred. Not only barred, indeed, but subject to arcane criminal law and the threat of life imprisonment. But that is where Northern Ireland’s macho, tribal politics has left things for its women. The only exceptions are where birth would kill the mother or render her, in a narrowly applied test that drips with misogyny, a “physical or mental wreck”. So if women need an abortion, they must first buy a ticket to Britain, and then pay for a private procedure. If they cannot raise the money, then they are fated to await the stillbirth.

Mr Justice Horner’s ruling on how this vicious law fits with human rights is meticulous, but glistens with controlled rage. His emphatic conclusion is that, in both the fatal abnormality case and the case of pregnancy caused by rape, basic rights are breached. It is a timely reminder of the importance of the Human Rights Act, which the constitutional vandals of the Conservative party wish to rip up. This judicial review came to court because of the HRA. And it is also only thanks to the HRA that the judge has the power to order that the relevant criminal legislation be read in new ways – to remove the threat of prosecution in these extreme circumstances. He invited fresh proceedings to that end.

But it will be hard to make even this minimal allowance for termination effective, at least for as long as the politicians continue their traditional lockdown on the abortion question. It is hard to exaggerate the foot-dragging: eight and a half years passed between a 2004 court of appeal ruling and the publication of 2013 official guidelines on those ultra-rare exceptions. The European rights framework will never open up the wider debate needed about reproductive rights for women who have not been raped and whose foetus will survive. Indeed, Judge Horner suspects that Ulster’s bar on terminating non-fatal abnormalities is a legitimate policy choice under the European convention. Nations have wide scope to weigh the interests of the unborn child against the mother, and so there will be no European Roe v Wade.

Women doing ‘very desperate’ things in efforts to abort

Director of UK-based support charity tells of abuse and threats over her work helping to fund terminations for Irish women. By Elaine Edwards for The Irish Times

Irish women seeking help from a charity that helps them pay for abortion in Britain have done “very desperate and dangerous things” in efforts to terminate their pregnancies, including drinking bleach.

View fullsize

Mara Clarke of Abortion Support Network. Photo by Emma Campbell

Director of the UK-based Abortion Support Network, Mara Clarke, said some women who contacted it had googled ways to abort and taken substances such as homeopathic remedies in their desperation.

In an interview broadcast on The Pat Kenny Show on Newstalk on Wednesday as part of a series on abortion in Ireland, Ms Clarke said she believed there were also at least “dozens” of “rogue” abortion counselling services which were giving women incorrect medical information.

The organisation had heard from women who had been threatened by such organisations that they would come to their homes or speak to their neighbours about their wish to have an abortion.

Ms Clarke said making abortion against the law did not stop it. It just stopped safe abortion for women and couples without money.

“I’m for abortion over drinking bleach. I’m for abortion over a dead mother and a dead foetus,” she said.

She said arranging an abortion and travel was often more difficult for women based outside Dublin or Cork and that they often stayed overnight with a network of volunteers in London, Birmingham, Manchester or Liverpool.

In the interview, Ms Clarke said the organisation did not provide counselling and did not try to deter or encourage women in relation to their decision.

“Usually when people come to us, we’re the last bit. They’ve made the decision about what they want to do. They’ve been deterred by logistics, by arranging childcare, by getting travel documents together,” she said.

The Abortion Support Network would provide “confidential, practical information” about the least expensive way to arrange an abortion and to travel.

It also gives grants to the women towards the cost, which can range from €500 up to €2,700 for a procedure later in pregnancy.

“We hear everything from couples who have several kids and can’t afford more, to younger women who want to continue their education and get themselves a little more financially settled before they have a baby; couples with wanted pregnancies diagnosed with catastrophic fatal foetal anomalies.”

It had heard from women aged from 13 to 51.

“The only thing they have in common is that they are pregnant and they don’t want to be pregnant and they’re poor and they never thought in 100 years that they would be calling us for help.”

She said she had suffered threats because of her work and had been sent a death threat against her daughter via Facebook.

“But honestly it’s not so bad. My friends in America have it much worse. We’re not wearing Kevlar vests to work.”

On Thursday, The Pat Kenny Show will hold a debate betwen pro-choice and anti-abortion sides.

Friday’s show will explore the legal, political and medical issues around repealing the 8th amendment of the Constitution, should that go ahead.