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Harm Reduction for Abortion in the United States

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Harm Reduction for Abortion in the United States Current Commentary Harm Reduction for Abortion in the United States 09/23/2019 on osICWkWdw2WvTfE1Hlta/QhN7JHA3JipD7bK+Yf9bydO7vheWLKNAk0w2v/VG8ALDYntApebUxyEB8D1u5d9qHVCPzqX6WvcWhzqWSbJxsNwKM3bmvU6MGSmFF3ugE+n by https://journals.lww.com/greenjournal from Downloaded Julia Tasset, MPH, and Lisa H. Harris, MD, PhD Downloaded from ccess to abortion in the United States has been https://journals.lww.com/greenjournal Access to abortion in the United States has eroded A eroded to levels unprecedented since the significantly. Accordingly, there is a growing movement Supreme Court’s decision in Roe v Wade in 1973.1 to empower women to self-induce abortion. To date, Nearly one third of laws currently regulating abortion physicians’ roles and responsibilities in this changing — environment have not been defined. Here, we consider were passed since 2010 testament to the rapidly 1 a harm reduction approach to first-trimester abortion as changing climate for abortion. As access to abortion by is increasingly restricted, there is a growing move- osICWkWdw2WvTfE1Hlta/QhN7JHA3JipD7bK+Yf9bydO7vheWLKNAk0w2v/VG8ALDYntApebUxyEB8D1u5d9qHVCPzqX6WvcWhzqWSbJxsNwKM3bmvU6MGSmFF3ugE+n a way for physicians to honor clinical and moral obliga- tions to care for women, negotiate ever-increasing abor- ment to empower women to self-manage their abor- tion restrictions, and support women who consider tions at home guided by online information and abortion self-induction. Harm reduction approaches to online-sourced medications. Clinicians who see pa- abortion have been successfully implemented in a range tients in early pregnancy may increasingly encounter of countries around the world and typically take the form women who want to end a pregnancy but do not have of teaching women how to use misoprostol. When access to clinician-directed abortion care or who raise women self-administer misoprostol, rather than resort the possibility of self-induced abortion. Consequently, to other means such as self-instrumentation or abdomi- defining physicians’ roles and responsibilities in this nal trauma, to end a pregnancy, maternal mortality falls. changing environment is necessary. There are clinical and ethical benefits as well as limita- American doctors are not the first to consider this tions to a harm reduction approach to abortion in U.S. issue. Care providers across the globe have found settings. Its legal implications for patients and physicians ways to respect legal prohibitions on abortion while are unclear. Ultimately, we suggest that despite its simultaneously ensuring women’s reproductive rights limitations, a harm reduction approach may help both and well-being by using a harm reduction approach. physicians and patients. This typically involves sharing information about safe (Obstet Gynecol 2018;131:621–4) self-administration of abortifacient medications and DOI: 10.1097/AOG.0000000000002491 providing follow-up care. Here, we consider the role of a harm reduction approach to abortion in U.S. contexts and describe in See related editorial on page 619. broad strokes what such a program might look like. Although logistic, ethical, and legal limitations to this strategy exist, as discussed subsequently, we engage in From the University of Michigan Medical School, the Department of Obstetrics and Gynecology, Michigan Medicine, and the Department of Women’s Studies, a thought experiment and consider the potential benefits University of Michigan, Ann Arbor, Michigan. of a harm reduction approach for clinicians concerned ’ The authors thank Dan Grossman, MD, for his helpful review of the manuscript. with women s health and human rights in areas of the ’ country where access to abortion is restricted. on Each author has indicated that she has met the journal s requirements for 09/23/2019 authorship. Corresponding author: Julia Tasset, MPH, 1500 E Medical Center Drive, HARM REDUCTION FRAMEWORKS ’ L4000 Women s Hospital, Ann Arbor, MI 48109-0276; email: tassetjl@med. Harm reduction is a strategy that aims to reduce umich.edu. Financial Disclosure adverse consequences of a target behavior when The authors did not report any potential conflicts of interest. complete abstinence from or elimination of that behavior is not a realistic or desirable goal.2 In coun- © 2018 by American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. tries where abortion is illegal or severely restricted, ISSN: 0029-7844/18 health care providers have implemented harm VOL. 131, NO. 4, APRIL 2018 OBSTETRICS & GYNECOLOGY 621 Copyright Ó by American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. reduction strategies after witnessing the consequences of which complete data exist.15,16 More recently, data unsafe illegal abortion. This usually entails teaching from Texas suggest a similar relationship: although women how to use misoprostol, a prostaglandin E1 ana- legal changes and health outcomes cannot be defini- log that causes expulsion of uterine contents. It is widely tively linked, the erosion of family planning and abor- available, shelf-stable at room temperature, and inex- tion care in the state since 2011 has coincided with pensive.3 When used for termination of pregnancy up a significant rise in maternal mortality.17 to 63 days of gestation, misoprostol alone has an efficacy rate of 85%.3 When combined with mifepristone, a pro- THE MOVEMENT TOWARD SELF-INDUCED gesterone antagonist, the regimen has a success rate of ABORTION IN THE UNITED STATES 95–99% up to 63 days of gestation and 93% at 70 days of In the wake of expanding state laws restricting gestation.3 Serious complications with either regimen abortion, there is increasing interest in self- are very rare.3 Harm reduction programs usually also management of abortion using medications. Since include ready access topostabortioncare—that is, safe 2011, Google searches for “how to have a miscarriage” uterine evacuation when women present with bleeding and related terminology increased 100% over levels in or partial tissue expulsion. the early 2000s according to a New York Times analy- Misoprostol harm reduction programs have been sis.18 After Texas’ state law and budget cuts curtailed implementedinIndonesia,4 Uruguay,5 Argentina,6 access to abortion and family planning care in that Zambia,7 Nepal,8 Kenya,9 and Tanzania.9 When state, a 2012 survey showed 7% of women seeking women self-administer misoprostol to end a pregnancy, abortion reported attempting self-induction—higher rather than resort to other means such as self- than the 2% observed elsewhere in the country.19 instrumentation or abdominal trauma, maternal mortal- The most common method women disclosed was mi- ity falls.5,6,10,11 Indeed, in Uruguay, which introduced soprostol ingestion; however, other methods were a successful and well-documented harm reduction pro- also mentioned—some ineffective (but harmless) such gram, the share of maternal mortality attributable to as taking herbs or homeopathic remedies and others unsafe abortion fell from 37.5% to 8.1% over the decade unsafe such as intentional abdominal trauma.19,20 in which a nationwide program was in use.12 In response to the restrictive climate for abortion, and to help steer women who seek an abortion toward ABORTION ACCESS RESTRICTIONS IN THE safe, effective methods of self-induction, a range of UNITED STATES national and international groups are attempting to In the recent era of safe, legal abortion in the United provide online and phone information regarding safe States, a harm reduction approach has not had a clear self-administration of misoprostol with or without role. However, the legal climate for abortion is mifepristone for ending a pregnancy. The Dutch shifting. Changes to laws in Kentucky, Mississippi, group Women Help Women launched a project— West Virginia, Missouri, North Dakota, South Self-Managed Abortion, Safe and Supported—which Dakota, and Wyoming have left each state with only provides information on medical abortion. New web- one abortion clinic.13 Health care providers in other sites continue to appear, like Plan C, which also pro- states also face a wide range of laws that impede their vides instructions for medication termination and ability to deliver evidence-based abortion care.1 Com- connects women to other trustworthy sources. pounding this is the possibility that Roe v Wade will be revisited and overturned by the U.S. Supreme Court. PHYSICIANS’ ROLES IN THIS NEW There are public health consequences of ABORTION ENVIRONMENT restricted abortion access. Data from Romania are After Roe, physicians nationwide could depend on instructive; in 1966, under the Ceausescu regime, their abortion-providing colleagues in and around abortion was severely restricted and maternal mortal- their communities (albeit with “desert” regions ap- ity attributable to abortion rose sharply, accounting pearing more recently) to care for women seeking for 87% of maternal deaths.14 After the dictator was abortion. However, if these local abortion providers deposed and his policies ended, maternal deaths continue to disappear, what will physicians suggest? If related to abortion fell dramatically.14 In the United available services require impossible travel, expense, States, legalization of abortion in 1973 also brought childcare, or missed work, what will they recom- about a precipitous decline in maternal mortality from mend? How do caregivers answer if asked
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