ARHP’s Monthly Commentary – February 2013

Misoprostol In Women’s Hands: A Harm Reduction Strategy For Unsafe Abortions

Alyson Hyman, Kelly Blanchard, Francine Coeytaux, Daniel Grossman, Alexandra Teixeira

On any given day in Cuernavaca, Cape Town, Quezon City or Calcutta, a woman with an unwanted pregnancy seeks out misoprostol to have an abortion. She does not visit a doctor or clinic but seeks a pill that she has heard can help her end her pregnancy without the risks of more dangerous self-induction methods. Women living in legally restricted settings where they do not have access to high-quality safe services or where stigma, cost or other barriers prevent them from accessing existing services are increasingly using misoprostol to self-induce abortion instead of using sticks, acid, brute force or unproven herbal remedies. In doing so, they are significantly reducing the harms caused by unsafe abortion.

Harm reduction is an evidence-based public health and human rights framework that prioritizes strategies to reduce harm and preserve health in situations where policies and practices prohibit, stigmatize and drive common human activities underground. The best-known application of a harm reduction model is in the field of HIV, where needle exchange programs and safe injection centers have been shown to be highly effective in preventing HIV/sexually transmitted infection. We propose that promoting the use of misoprostol for abortion using a harm reduction approach could dramatically increase access to safer abortions. The principles of harm reduction — neutrality, humanism and pragmatism — present a conceptual framework for making misoprostol information and care available directly to women and make the case for why it is imperative that we do so.

The three core principles, as described by Erdman,¹ and their application to abortion can be summarized as:

• Neutrality: Harm reduction strategies are absent of any moral judgement about an underlying activity, regardless of its legal or social status. Harm reduction is only concerned with the risks and health-related harms of an activity, not whether the activity is considered right or wrong.
  • Public health professionals have a responsibility to provide information about technologies, such as misoprostol, to minimize women’s personal and social harms of unsafe abortion regardless of the legal or moral status of abortion.
  • It is the obligation of all states to support and refrain from standing in the way of public health professionals’ duty to mitigate the harms associated with unsafe abortion.
    
  • Public health professionals should assure client confidentiality and not police women’s adherence to the abortion law.
    
• Humanism: All individuals have a right to having their health needs being understood and addressed by others, regardless of their assigned moral status or deviance from legal or social norms.
  • Public health professionals are obligated to proactively reduce barriers to care especially for women who face challenges accessing services when seeking to terminate a pregnancy.
  • Principles of woman-centered care must be prioritized and enacted. This includes meeting women “where they are” — in places they choose to seek abortion information and care.
    
  • Women have a right to participate in the design and implementation of all programs designed to serve them. Furthermore, every effort must be made to ensure the participation of those women who face major challenges accessing services.
• Pragmatism: Harm reduction recognizes that individuals may choose to engage in an activity regardless of legal or social prohibition. Harm reduction is grounded in realistic evidence-based assessments not moral imperatives.
  • Women are attempting to self-induce abortion in both legally restricted and liberal settings; public health professionals thus have a responsibility, in terms of respecting women’s choices but also in order to reach the most women possible and to mitigate as much harm as possible, to provide information about the safest and most effective services and methods that are available to women, including information on how to use misoprostol safely and effectively.
    

Evidence shows that misoprostol has made unsafe abortion safer; data from a range of settings in Latin America have shown that increased use of misoprostol is associated with a meaningful decrease in both the rate and severity of complications associated with unsafe abortion.^{2, 3, 4, 5, 7} Women can use misoprostol on their own and with accurate information; they do not necessarily need a health care provider to use it safely and effectively. Harm reduction can both give women more direct access and control over the abortion process and, where providers feel constrained by a restrictive abortion law, it can give them a framework to help women end an unwanted pregnancy.

Unfortunately, women often have inaccurate information on misoprostol use.⁷ Drug quality is also a major concern, with a variety of misoprostol products on the market that do not meet international standards, are poorly stored or have simply expired. Shopkeepers are also known to sell a range of pills such as hormonal contraceptive pills, analgesics and antibiotics when a woman requests a medicine to end a pregnancy. The harms of unsafe abortion could be significantly reduced with increased dissemination of accurate information on misoprostol use as well as access to high-quality drugs. Expanding efforts to promote a harm reduction approach and measuring the impact of these efforts will ensure that more women have access to safe abortion and provide rigorous data on the benefits of scaling up harm reduction programs.

The strength of the harm reduction approach is that it shifts the conversation about abortion from its legal status to a focus on protecting women’s health. The key challenge is how women can obtain information about safer abortion methods, including misoprostol. Harm reduction respects women’s autonomy and their right to complete and current information to aid in their decision making.

There are several examples of harm reduction already in action. Perhaps the most well known is from Uruguay where, through clinical consultation, clinicians provide information on correct use of misoprostol to women who do not wish to continue a pregnancy.^8,9 Although the women are not told where to obtain the drug, they are given clear instructions on its use and are invited back to the clinic for a follow-up appointment to address any problems. In the Palestinian territories, pharmacists are providing misoprostol to women under the rubric of conscientious objection, asserting that they object to the restrictions on women’s access to safe abortion care, including the onerous restrictions on travel to Israel; thus, it is their professional and moral obligation to help women safely end a pregnancy rather than resort to dangerous means. In Tanzania, framing the use of misoprostol with harm reduction principles has been effective in mobilizing local communities to shift from thinking of unsafe abortion as an unavoidable fact of life to something that is preventable. Additionally, an advocacy group took this further by procuring misoprostol from wholesalers and making it available to women, deciding that it was their obligation to let women know that this drug is available and can reduce health risks.

Policy makers, providers, advocates and researchers can promote a harm reduction approach and increase access to misoprostol through a range of strategies, including:

• Expand availability of high-quality misoprostol drugs.
• Ensure that pharmacists, chemists and drug sellers have accurate information on the use of misoprostol and that they provide user-friendly information to their customers.
• Develop and strengthen hotlines that women can contact for confidential, accurate information and referrals to formal or informal safe abortion services.
• Create interactive communication strategies, including automated voice-response technologies and web- and mobile-based interactive services to increase information and referrals.
• Encourage and facilitate public health providers’ ability to give information on the safe use of misoprostol.
• Introduce and improve access to mifepristone along with misoprostol wherever possible (mifepristone followed by misoprostol is more effective than misoprostol alone and thus is the recommended method according to the World Health Organization.^{10, 11}
• Support communities and advocates with the tools to push back when policy makers or bureaucrats try to criminalize abortion-related care or restrict access to misoprostol and mifepristone.
• Document and share lessons learned from successful harm reduction efforts.

A harm reduction approach provides a legal and ethical framework for health professionals and reproductive justice and human rights advocates to assist women in accessing misoprostol and obtaining correct information about its uses. While it is only one of a broader set of strategies to ensure that women have access to rights-based, high-quality services and should not stand alone, it is a pragmatic and evidence-based approach that can greatly support women’s ability to protect their reproductive health and live the lives they choose. We know women are using misoprostol. Let us work together to ensure they have the information, resources and support to do it safely.

For more information on medical abortion:

• International Consortium for Medical Abortion: http://www.medicalabortionconsortium.org/
• Ipas: http://www.ipas.org/medicalabortion
• Ibis Reproductive Health: http://www.medicationabortion.com/
• Women on Waves: http://www.womenonwaves.org/

References

1. Erdman J. Access to information on safe abortion: a harm reduction and human rights approach. Harvard J Law Gen.2011;34:413–462
2. Faundes A, Santos LC, Carvalho M, Gras C. Post-abortion complications after interruption of pregnancy with misoprostol.Adv Contracept. 1996;12:1–9
3. Miller S, Lehman T, Campbell M, et al. Misoprostol and declining abortion-related morbidity in Santo Domingo, Dominican Republic: a temporal association. BJOG. 2005;112:1291–1296
4. Rowlands S. Abortion pills: under whose control?. J Fam Plann Reprod Health Care. 2012;38:117–122
5. Faundes A. Misoprostol: life-saving. Eur J Contracept Reprod Health Care. 2011;16:57–60
6. Viggiano M, Faundes A, Borges AL, et al. Disponibilidade de misoprostol e complicações de aborto provocado em Goiânia. J Bras Ginecol.
7. Lara D, Garcia SG, Wilson KS, Paz F. How often and under which circumstances do Mexican pharmacy vendors recommend misoprostol to induce an abortion?. Int Perspect Sex Reprod Health. 2011;37:75–83
8. Briozzo L, Vidiella G, Rodriquez F, Gorgoroso M. A risk reduction strategy to prevent maternal deaths associated with unsafe abortion. IJGO. 2006;95:221–226
9. Fiol V, Briozzo L, Labandera A, Recchi V, Pineyro M. Improving care of women at risk of unsafe abortion: implementing a risk-reduction model at the Uruguayan-Brazilian border. IJGO. 2012;118:S21–S27
10. Jain JK, Dutton C, Harwood B, Meckstroth KR, Mishell DR. A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective terminatioon of early pregnancy. Hum Reprod. 2002;17:1377–1382
11. Safe abortion: technical and policy guidance for health systems, second edition.