Mifepristone for early medical abortion: experiences in France, Great Britain and Sweden - Special Report

Perspectives on Sexual and Reproductive Health, May-June, 2002 by Rachel K. Jones, Stanley K. Henshaw

MIFEPRISTONE AND TRENDS IN ABORTION

The availability of mifepristone does not necessarily translate into high levels of use or easy access to medical abortion. Different circumstances have resulted in varying levels of mifepristone use across the three countries and within each country.

Trends in Medical Abortion

More than half of abortions within approved gestational limits are performed using mifepristone in France (56%), Scotland (61%) and Sweden (51%). * (16) Mifepristone is least used for early abortion in England and Wales, where only 18% of eligible abortions are medical procedures. (17) Experts in all of the countries emphasize that there is substantial regional variation within their country. For example, as many as 60% of eligible early abortions involve mifepristone in some areas of Sweden, compared with 10% in other regions. (18)

In general, the proportion of early abortions involving mifepristone has increased steadily each year since its introduction (Figure 1, page 156). The exception was that it fell in France in 1991 and 1992. This short-term decline, which occurred shortly after mifepristone's introduction in 1988, was possibly because in 1991, a death was attributed to sulprostone, the prostaglandin used at that time. (19) In 1992, France registered misoprostol as the approved prostaglandin, and since that time, early medical abortion has increased steadily.

[FIGURE 1 OMITTED]

When a country extends its gestational limits for early medical abortion from 49 to 63 days, the proportion of women seeking pregnancy termination who are eligible for the method grows. Extending limits may also lead to an increase in the proportion of all abortions that are medical abortions. In Scotland and Sweden, where the gestational limit is 63 days, the estimated proportions of all abortions that are early medical procedures are 54% and 33%, respectively. (20) In France, which permits medical abortion up to 49 days from the last menstrual period, 56% of eligible early abortions involve mifepristone, but these procedures account for only 11% of all abortions. (21) In England and Wales, however, 8% of all abortions are early medical abortions, although the cutoff is 63 days. (22) This small proportion is likely a function of restrictive guidelines for service delivery, described below.

Trends in Early Abortion

Many providers require that a woman wait until at least the sixth week of gestation before they will perform a vacuum aspiration, although earlier aspiration abortions are becoming available. Medical abortions can be initiated as soon as a pregnancy is confirmed. Increased awareness of mifepristone abortion among women may lead them to seek abortion services very early in pregnancy to ensure that they are eligible. Hence, the availability of medical abortion may both allow and motivate women to obtain abortions at earlier gestations.

Since mifepristone was introduced, women have started obtaining abortions at earlier gestations. In France, the proportion of abortions performed at or before seven weeks from the onset of the last menstrual period increased from 12% in 1987 to 20% in 1997. (23) In Scotland, the proportion of all abortions that occur before 10 weeks' gestation increased from 51% in 1990 to 67% in 2000. * (24) In Sweden, the proportion of abortions performed before nine weeks increased from 45% in 1991 to 65% in 1999. (25) The increase has been less dramatic in England and Wales: Thirty-six percent of women who obtained abortions did so before nine weeks in 1990, and 43% did so in 2000. (26)