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A trend of mounting concern is occurring in abortion provision. When elective induced abortion was legalized in the United States, one frequently cited motivation was that legalization would improve abortion’s safety, as it was frequently claimed that many women were injured and sometimes died from illegal abortions.
Recently, abortion advocates have changed their strategy.
Whereas once they claimed they wanted abortion to be “safe, legal and rare,” now they favor immediate access and convenience to abortion for all women experiencing unintended pregnancies, regardless of whether it might be more dangerous for a woman. Recent Supreme Court cases have demonstrated that the argument for safety was false, as many state restrictions designed to improve safety for women have been overruled because they might pose an “undue burden” for women seeking abortion.
Chemical abortions (the abortion pill) are being increasingly promoted to women, and now comprise 39% of all U.S. abortions. The COVID-19 pandemic has fully exposed the agenda of the abortion industry, as the crisis has been leveraged to argue that all restrictions governing the use of abortion pills be removed, allowing women to access these drugs remotely without a physical examination, ultrasound, or laboratory evaluation.  This would allow online, telemedicine, and mail order provision of these dangerous drugs, and the ultimate goal is distribution over the counter without a prescription. A federal judge has sided with abortion advocates by invalidating the FDA’s Risk Evaluation and Mitigation Strategy (REMS) restrictions which have governed the use of one of the abortion pills, mifepristone, since its approval in 2000. Abortion advocates in the media are aggressively promoting “do-it-yourself” abortion to women.
What could be the risks for women if these plans become reality, and abortion pills can be obtained without ever interacting with a health care provider? While biased studies based on poor quality data published by the abortion industry report low complication rates of medical abortion, better-quality systematic reviews and records-linkage studies demonstrate high failure rates, often requiring surgery or hospitalization. These studies document failures resulting in ongoing pregnancy, hemorrhage, infection, or incomplete evacuation of pregnancy tissue in 5-8% of women who choose chemical abortion. Complications are four times more likely than with surgical abortion, and a review of 42,000 abortions found that complications occurred in one out of five women.
There are significant risks that come into play if the REMS requirements are invalidated. REMS…
1. Requires registration to prescribe mifepristone. An abortion provider must intentionally register to become a mifepristone prescriber. Removing this restriction will create pressure on all health care providers and pharmacists to provide this life-ending drug, even if it violates their conscience.
2. Requires provider training and standardized patient consent. This ensures that both the abortion provider and the woman seeking abortion are aware of the unique risks of the abortion pill regimen. The average woman undergoing a chemical abortion bleeds for 9 to 16 days, and 8% will bleed longer than a month. The side effects of cramping, vaginal bleeding, nausea, weakness, fever, chills, vomiting, headache, diarrhea, and dizziness occur in almost all women. By comparison — though not without risks — surgical abortion is completed faster with fewer complications.
3. Requires in-person provision of mifepristone. Dispensing mifepristone directly to the woman seeking abortion reduces the risk of reproductive coercion by ensuring that a woman is freely choosing the abortion. This prevents illicit use by others who may benefit from the loss of her baby, such as sex traffickers, incestuous abusers, and coercive boyfriends. Abused women are sometimes forced into multiple abortions. Interaction with the health care system is an opportunity for these women to be identified and helped, but ready availability of abortion pills to their abusers will remove this opportunity for intervention.
4. Requires accurate assessment of the duration of pregnancy. Underestimation of gestational age will lead to far higher failure rates. Women are frequently incorrect in calculating gestational age based on their last menstrual period. Studies show that <2% of chemical abortions fail before seven weeks gestation, but this rises to 7% by ten weeks (the upper limit of FDA approval) and reaches a staggering 38% failure rate when used in the second trimester, later than current FDA recommendations.
5. Requires documentation of intrauterine pregnancy. Ruling out pregnancy outside of the uterus through physical exam and ultrasound is critically important, because mifepristone has no effect on such a pregnancy, which can rupture, causing catastrophic bleeding or death. Although ectopic implantation occurs in only 2% of recognized pregnancies, ruptured ectopic pregnancies account for 13% of all maternal deaths. Half of women with ectopic pregnancies have no prior risk factors. A woman who experiences ectopic warning symptoms, such as pain or bleeding, while undergoing a chemical abortion may be less likely to report them, because she has been warned to expect such symptoms as a sign that the abortion drugs are working — and she is 30% more likely to die than a woman with an ectopic pregnancy who had not sought an abortion.
6. Requires documentation of Rh status. Evaluation of Rh status and provision of Rhogam, if indicated, has long been the standard of care for early pregnancy loss, including elective induced abortion. This action will prevent a mother from mounting an immune response to her future unborn children. If Rhogam is not given and isoimmunization occurs, 14% of untreated infants will be stillborn and half will suffer neonatal death or brain injury.
7. Requires ability to provide surgical intervention or have a relationship with a provider who can. Women will require surgical intervention in the 5-8% of cases when medical abortion fails. Without a physician-patient relationship or proximity to emergency care, a woman experiencing these common complications finds herself abandoned and at high risk for adverse events. These failure rates are not negligible, particularly when medical resources need to be conserved during a pandemic. Most of the women with failed abortions will present to an emergency room bleeding heavily, where they will often require immediate surgery and sometimes hospitalization for blood transfusion or intravenous antibiotics.
It seems clear that unregulated chemical abortion is not compassionate care for women, but rather, a dangerous “chemical coat-hanger.” Can’t we offer women in crisis a better option?
Raymond E., et al. (2020). No test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception, 101(6), 361-366. doi: 10.1016/j.contraception.2020.04.005.
Raymond E., et al. (2013). First trimester medical abortion with mifepristone 200 mg and misoprostol. Contraception, 87(1), 26-37. doi: 10.1016/j.contraception.2012.06.011; Mentula M., et al. (2011). Immediate adverse events after second trimester medical termination of pregnancy: Results of a nationwide registry study. Human Reproduction, 26(4), 937-942. doi: 10.1093/humrep/der016.
Niinimäki M., et al. (2009). Immediate Complications After Medical Compared with Surgical Termination of Pregnancy. Obstetrics & Gynecology, 114(4),795-804. doi: 10.1097/AOG.0b013e3181b5ccf9.
“Ethical Principles for Abortion Care,” National Abortion Federation, accessed September 27, 2019, http://prochoice.org/wp-content/uploads/NAF_Ethical-_Principles.pdf; Megan Hall et al., “Associations between Intimate Partner Violence and Termination of Pregnancy: A Systematic Review and Meta-Analysis,” PLOS Medicine. 2014;11(1):e1001581. doi:10.1371/journal.pmed.1001581. accessed September 24, 2019.
American College of Obstetricians and Gynecologists. (2018). Practice Bulletin 193: Tubal ectopic pregnancy. Obstetrics & Gynecology, 131(3), 613-615. doi: 10.1097/AOG.0000000000002559.
Atrash H.K., et al. (1990). Ectopic pregnancy concurrent with induced abortion: Incidence and mortality. American Journal of Obstetrics & Gynecology, 162(3), 726-730. doi: 10.1016/0002-9378(90)90995-j.
American College of Obstetricians and Gynecologists. (2017). Practice Bulletin 181: Prevention of Rh D Alloimmunization. Obstetrics & Gynecology 130(2), 481-483.
Bio: Ingrid Skop, M.D. is a Fellow of the American College of Obstetrics and Gynecology, and a Board Member of the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG).
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