By Jeffrey T. Jensen, MD, MPH, Editor
SYNOPSIS: Restrictive abortion laws increase the chance that a woman will self-manage her abortion, a practice associated with an increased risk of complications.
SOURCE: Harris LH, Grossman D. Complications of unsafe and self-managed abortion. N Engl J Med 2020;382:1029-1040.
The New England Journal of Medicine published this review by Harris and Grossman of complications of unsafe and self-managed abortion on March 12, 2020, just as most of the country began to adopt stay-at-home measures to combat the spread of COVID-19. Although not intended as a commentary on the pandemic, recent events have made the publication particularly timely.
The authors wrote this review to provide guidance to clinicians on the management of complications caused by self-managed abortion. The increase in state-level regulations on abortion care in the United States has led to circumstances where women in many regions do not have access to timely care. They noted that women and their healthcare providers look for solutions outside of formal medical care to end pregnancies when access to abortion is legally restricted or otherwise made inaccessible. Although the types of complications from medically supervised and self-managed abortion are similar, a number of factors can obfuscate presentation and delay diagnosis when a woman does not have access to legal safety and confidentiality regarding her care.
Although not all techniques of self-managed abortion are safe, a substantial amount of literature supports the efficacy and safety of medication abortion with mifepristone and misoprostol, or misoprostol alone, at least in the first trimester. Since self-managed abortion with these medications has rare complications and follows a similar course to spontaneous abortion, clinicians can provide care and management without the need to document knowledge of whether the abortion is self-managed or spontaneous. Given the high efficacy and safety of medication-induced abortion, most patients who seek care will only require confirmation of complete abortion in an outpatient setting. Although seven states criminalize self-managed abortion, and several others have laws with similar language, no state mandates that healthcare providers report suspected or confirmed self-managed abortion, including for minors. In fact, reporting may violate federal law regarding privacy and result in penalties for those who report. Studies also document racial and income bias when caregivers involve the police.
The authors urge emergency department physicians, obstetrician-gynecologists, family physicians, and internists to understand the presentation and management of abortion complications. The paper provides an excellent overview of strategies used to diagnose and manage bleeding, infections, and anatomic injuries. They close with a call that “doctors and health care institutions must develop strategies that favor effective, compassionate clinical care over legal investigation of patients.”
A month ago, I wrote a commentary regarding the COVID-19 pandemic, and the difficulties in managing the problem. I sit today (April 24, 2020) writing this, still complying with mandatory stay-at-home orders. We did not experience the expected surge in cases in Oregon, most likely as the result of early and effective messaging and broad public support for safety. We shut down all elective clinical services and surgeries. However, our state and local leaders recognized the importance of timely access to abortion care. This position aligns with the joint statement issued by the American College of Obstetricians and Gynecologists, American Board of Obstetrics & Gynecology, American Association of Gynecologic Laparoscopists, American Gynecological & Obstetrical Society, American Society for Reproductive Medicine, Society for Academic Specialists in General Obstetrics and Gynecology, Society of Family Planning, and the Society for Maternal-Fetal Medicine. The statement, released on March 18, 2020, affirms that “abortion is an essential component of comprehensive healthcare. It is also a time-sensitive service for which a delay of several weeks, or in some cases days, may increase the risks or potentially make it completely inaccessible. The consequences of being unable to obtain an abortion profoundly impact a person’s life, health, and well-being” and that “community-based and hospital-based clinicians should consider collaboration to ensure abortion access is not compromised during this time.”1
Unfortunately, despite this strong statement from leading women’s healthcare organizations, many states have used the COVID-19 crisis to increase hardship for women seeking abortion by classifying the procedure as elective. The list includes Alabama, Arkansas, Iowa, Kentucky, Louisiana, Ohio, Oklahoma, Tennessee, and Texas. A recent analysis by the Guttmacher Institute found that the burden increases further when a cluster of states act together to create a new restriction.2 For example, shutting down legal abortion care in Texas will increase the median one-way travel distance to an abortion clinic from 12 to 243 miles (a 1,925% increase) for the 6 million women of reproductive age in the state. However, the collective impact of the cluster of states listed here banning abortion under COVID-19 rules increases the travel distance for Texas women to 447 miles, a 3,625% increase in one-way travel.
Faced with this dilemma, many women will delay abortion care, resulting in a shift to later gestation procedures with greater cost and higher morbidity. The states that have enforced a COVID-19 abortion ban also have the greatest restrictions and poorest access for abortion at later gestational ages. The result, forced pregnancy and unwanted birth, will occur in states that also have poor social safety nets. All of this, with record unemployment and the greatest economic crisis since the Great Depression — a very different situation from a delay in a knee replacement.
This is my last commentary for OB/GYN Clinical Alert. I took over as editor from my dear friend and colleague Leon Speroff in 2009. In my first commentary, I reported on the use of routine prophylactic antibiotics to decrease the risk of infection with medical abortion. In the early 2000s, a cluster of five deaths associated with medical abortion patients in the United States and Canada and caused by infection with an unusual pathogen, Clostridium sordellii (a common soil bacterium), shocked the family planning community. In response, we changed the protocol for medical abortion, switching from vaginal administration of misoprostol to buccal, and to the use of prophylactic antibiotics. Although enthusiasm for prophylactic antibiotics for medication abortion has diminished (as new evidence has been presented), the episode highlights the importance of a science-based approach to practice. This commitment to evidence-based practice has improved outcomes and quality of life for women requiring abortion care. Women are better off with access to a caring and informed clinician. Closing my OB/GYN Clinical Alert tenure with a commentary on self-managed abortion saddens me.
I believe strongly in the patient-clinician relation-ship. Politics has no business in healthcare. I urge you to advocate for reproductive rights to ensure the highest level of care for women.
- The American College of Obstetricians and Gynecologists. Joint Statement on Abortion Access During the COVID-19 Outbreak. March 18, 2020. https://www.acog.org/news/news-releases/2020/03/joint-statement-on-abortion-access-during-the-covid-19-outbreak
- Bearak J, Jones RK, Nash E, Donovan MK. COVID-19 Abortion Bans Would Greatly Increase Driving Distances for Those Seeking Care. Guttmacher Institute. Updated April 23, 2020. https://www.guttmacher.org/print/article/2020/04/covid-19-abortion-bans-would-greatly-increase-driving-distances-those-seeking-care