The Use of the Abortifacient Mifepristone (RU-486) in the Developing World

Association for Interdisciplinary Research in Values and Social Change
by Donna Harrison, M.D.
Director of Research and Public Policy,
American Association of Pro-Life Obstetricians and Gynecologists
Volume 24, Number 2 -- Summer 2012
Reproduced with Permission

The use of non-surgical (medical) abortion in the developing world has had great appeal for abortion advocates. Surgical procedures in third world countries with poor medical infrastructure, lack of dependable transportation to emergency centers, and even inadequate water supplies pose health risks for patients electing to have a surgical abortion. On the other hand, simply taking a pill to undue the pregnancy appears to be a good solution for third world women. The reality is that surgical abortions are still necessary in a number of cases because the pill fails; medical abortions are being attempting in settings with inadequate backup to care for complications; and hemorrhaging, a common side-effect of RU-486 abortions, is harder to control in third world environments. Unfortunately, there is a tendency to disregard such problems by enthusiastic abortion advocates, eager to expand abortion use in these countries.

In a moment of unguarded honesty, an ironic article entitled "Medical abortion: is it a blessing or curse for the developing nations?" was published in the medical literature in 2011[1]. Despite the requisite opening praise of medical abortion, which is a requirement for publication in most medical journals, this article gives a rare glimpse into the reality of willy-nilly access to drugs which can end a pregnancy, in the setting of rural Sri Lanka. The abstract opens with this statement

"Medical abortion is definitely a safer and a better option but in developing countries, its widespread misuse has led to partial or septic abortion thereby increasing maternal mortality and morbidity."

The article goes on to state that less than half of the women had complete abortions [49.62%], while the remaining had "incomplete (41.54%), septic (6.54%) or failed abortion (1.15%) or ectopic pregnancy (1.15%)." And further on the authors state:

"When the medical methods of abortion were launched in developing countries like India it was thought that frequency of illegal unsafe abortions by local dais and unregistered practitioners will decrease to a large extent and it will help in managing such unwanted pregnancies through safe and legalized abortions in peripheral health centres (PHCs), community health centres (CHCs), and civil hospitals. No doubt, though unsafe surgical abortions have decreased largely due to strict legislations but these have been replaced by increasing number of unsafe medical abortions."

Another article[4] from Vietnam, published in Contraception, reveals the complications from misoprostol abortions vs. combined mifepristone+misoprostol abortions:[2]

"… the misoprostol alone regimen tested had a success rate of 76.2%." [This means that for every four women treated, one would have to have surgery to complete the abortion]

"The rate of ongoing pregnancy was… 16.6% with misoprostol-alone. This means that for every seven women treated with misoprostolalone … one ongoing pregnancy would occur."[3]

The authors go on to discuss the promotion of medical methods of abortion:

"Use of misoprostol-alone has been advocated in the absence of mifepristone availability in many regions, particularly sub-Saharan Africa and Latin America. Yet, the results from the present trial clearly document the inferiority of misoprostol-only compared to a combined regimen."

The Sukwinder and the Ngoc article demonstrate what could have been easily predicted from an understanding of the adverse events associated with medical abortions even under the very best conditions in the West. A recent large registry based study from Finland demonstrated that under the best conditions, medical abortion had four times higher total number of adverse events than surgical abortion (20% vs. 5.6%, p<0,001). Medical abortion patients hemorrhaged over seven times more often than surgical abortion patients (15.6% v. 2.1%, p<0.001). Medical abortion patients had incomplete abortions at a rate of 6.7% compared with 1.6% of failed surgical abortions, (p<0.001). 5.9% of medical abortion patients had to have surgery to complete their abortion or manage complications, vs. 1.8% of surgical abortion patients (p<0.001). And medical abortion patients had 20 times greater risk of operative injuries from the emergency surgeries required as did surgical abortion patients (medical 0.6% vs. surgical 0.03% p<0.001) These findings led the authors of the Finnish study to conclude:

"Because medical abortion is being used increasingly in several countries, it is likely to result in an elevated incidence of overall morbidity related to termination of pregnancy."

So, we know from multiple studies that first trimester medical abortions with mifepristone and misoprostol result in:

What about second trimester terminations?

Another study from the Finnish registry reveals that women who have a second trimester medical abortion are 7.8 times more likely to need subsequent surgery than women who have a first trimester medical abortion, and twice as likely to get infected.

So, who is promoting the false idea that medical abortion is somehow safer than surgical abortion? Let's contrast the reality of the Sukhwinder and Ngoc articles to the wildly glowing claims of one of the organizations responsible for the irresponsible promotion of abortion drugs: Ipas, a global nongovernmental organization "advancing women's reproductive rights." In their publication entitled, "Providing Medical Abortion without Technology in Nepal,"[5] Ipas claims that without ultrasound or pre-operative testing, and without physicians or clinics staffed to handle emergencies:

Can it be that women who go to rural clinics in Nepal somehow magically do better than Scandinavian women with nationalized health care, or women in Sri Lanka or Vietnam? Or could it be that Ipas is counting on no one checking their claims?

Ipas makes even more frankly fraudulent claims:

"Before the legalization of abortion in Nepal in 2002, it was estimated that up to half of the maternal mortality was due to unsafe abortion. The maternal mortality rate prior to legalization of abortion was 539 per 100,000 live births"

But, how does IPAS's claim relate to peer-reviewed medical literature on maternal mortality? Hogan[6] reports the maternal mortality rate for Nepal by year as:

Rate Year

865 1980

471 1990

343 2000

240 2008

Abortion was legalized in Nepal in 2002, at which point the maternal mortality rate was 343 per 100,000 live births, not 539 per 100,000 live births as Ipas claimed. Clearly, the maternal mortality rate was dramatically falling in Nepal BEFORE the legalization of abortion. Yet, these false claims by Ipas and others about the rate of maternal mortality due to "unsafe" abortion are used to persuade governments to not only legalize abortion, but also to allow for the unsupervised use of abortion drugs, which will actually increase maternal mortality in the developing world.

Donna Harrison, M.D. graduated from the University of Michigan Medical School in 1986 and completed her residency in Obstetrics and Gynecology in Ypsilanti, MI in 1990. She worked in Haiti as a consultant physician from 1989 to 1994. She has been actively involved in pro-life public policy activities since medical school. She has testified before state and national hearings on the abortion issue, including the House subcommittee on Criminal Justice, Drug Policy and Human Resources of the U.S. House of Representatives regarding adverse events related to the use of mifepristone (RU-486) and before the Reproductive Health Advisory Committee of the Food and Drug Administration, regarding the approval of RU-486 for use as a chemical abortifacient. In 2000, Dr. Harrison retired from clinical practice to pursue a more active role in pro-life public policy work. She is currently serving as chairman-elect of the board of directors of the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG). She is chairperson of the AAPLOG subcommittee on RU-486 and co-authored the Citizen Petition filed with FDA to remove RU-486 from the market. She has published several medical journal articles on the adverse effects of RU-486 on women. She is board certified by the American Board of Obstetrics and Gynecology.