Medical abortions are generally perceived to be less invasive and risky than surgery, but that’s not always the case
Carla made it to the bin just in time, fingers tightening around the edges as vomit splashed against the cold plastic.
As her body spasmed, trying to evict what little was in left in her stomach, she momentarily savoured the brief respite from the vice-like contractions gripping her pelvis.
So, this was the “bad period pain” Carla was told might be in store after swallowing the second lot of abortion pills.
This was only two hours into a process she had been warned would take around four hours, and she would have done anything to escape it, even if that meant still being pregnant.
Unlike a surgical abortion, which, all up, takes a few hours and includes sedation, a medical abortion involves taking one pill to terminate the pregnancy and a second lot of pills around two days later to trigger the uterine contractions that push the tissue out.
Medical abortions are generally perceived to be less invasive and risky than surgery. For women in the community, medical abortions are often seen as a preferable option where, instead of waiting in a sterile, cold clinic you can cuddle up with a hot-water bottle and chocolate and watch movies in the comfort of your own home.
But about six minutes into the dystopian sci-fi Netflix series, Altered Carbon, it became pretty clear that wasn’t going to be possible in Carla’s case. Complete sentences were replaced by groans and pathetic whimpers of pain that the Panadeine Forte did little to assuage.
Instead, she assumed the fetal position, as her longtime friend and ICU nurse, Scott, stroked her alternatingly sweaty and goose-pimply back.
Carla certainly hit the jackpot when it came to getting the listed potential side effects – nausea, vomiting, diarrhoea, dizziness, abdominal cramps, pain, headache, fatigue, chills and fever, breast tenderness and hot flushes. As she retched over the plastic bin, Scott started rifling through the information pamphlet. Did she need to be taken to hospital? How bad did she have to get before seeking help?
But she hadn’t yet bled through two or even one maxi pad, and so they turned up the volume on the “Relaxing Buddhist Music” and held on.
Two hours later the pain stopped. And that was that, Carla thought.
Unfortunately, two weeks later she discovered that wasn’t that. The abortion hadn’t actually worked.
The next six weeks were long and tortuous. Relentlessly bleeding from one end and being bled by needles from the other – being repeatedly hit with ongoing urine and ultrasound tests and seemingly never-ending consultations.
On the face of it, Carla had been tremendously unlucky.
Most women have medical abortions with cramps that are, at worst, like a bad period and maybe have to contend with a few weeks of on-and-off bleeding afterwards.
But up to 5%, or one in 20, women will have an incomplete abortion.
The pregnancy has definitely ended, but the woman is left with retained products that haven’t been expelled by the contractions. Women in this position are at risk of infection and heavy bleeding, not to mention the psychological toll of knowing that they are still managing an unwanted pregnancy (even if it is unviable).
The woman then has one of three choices: to wait and see if the body dispels the tissue on its own, to take another dose of the second medication misoprostol, or to have a dilatation and curettage operation.
While somewhere between 70,000 to 100,000 Australian women have terminations each year, the stigma surrounding abortion and unplanned pregnancies often keeps women from coming forward and sharing their experiences publicly. This creates an environment where much information is passed on through conversation among friends or potentially dubious sources on the internet.
While Carla’s experience is uncommon, several clinicians who manage medical terminations say it is not rare. One explained that when considering the chance of an incomplete abortion combined with the chance of severe side effects, as many as one in 10 women might have a very bad experience with medical abortion.
To put it in perspective, incomplete abortions can also occur with surgical abortions, but it only affects one or two women per 1000.
There are no good figures on medical terminations across the country, but a commonly used estimate is that around one in three abortions are now done medically. This means that thousands of women might go through an experience similar to Carla’s each year.
While reluctant to quoted by name, more than one doctor spoke about the growing awareness of the burden that these complications had on women and the tension within the medical community of ensuring women were fully informed about these risks while not scaring them off.
In such a politically and emotionally charged environment, reproductive and sexual health workers have had to fight hard to ensure women could access this incredibly valuable service. Doing so might have led some doctors to want to be slightly more positive about the procedure and not fully communicate the possible realities of it, several sources said.
Brisbane GP and antenatal expert Dr Wendy Burton says that it has been hard to find the right balance between informing women of the risks of complications and not alarming them.
“A couple of bad media reports that get social media traction can absolutely shoot down a lot of good work, and then deny the majority a safe and effective, well tolerated means of termination.”
It’s a sentiment echoed by women’s health expert and GP, Dr Magdalena Simonis.
“Right-to-lifers really like to grasp onto any potential side-effect, a bit like anti-vaxxers, and then blow that out of proportion,” she told The Medical Republic.
The knowledge that there is a large, vocal lobby group dedicated to making abortion illegal is something that advocates for reproductive rights for women are really mindful of, she adds.
“But that doesn’t mean that the statistics that we quote are any different to reality. We are science-driven and we are evidence-based and we would never put our patients, nor our community, at risk if we believed there was a significant risk.”
The American College of Obstetricians and Gynaecologists outlined this tension in a management guideline, saying that most women chose medical abortions “because of a desire to avoid surgery, a perception that medical abortion is safer than surgical abortion, and a belief that medical abortion is more natural and private than a surgical procedure”.
However, it added that compared with surgical abortion, “medical abortion takes longer to complete, requires more active patient participation, and is associated with higher reported rates of bleeding and cramping”.
Most of the time, women undergoing a medical abortion will pass the tissue and products at home, but some will need a follow-up surgery to finish the job.
On the other hand, “an early surgical abortion takes place most commonly in one visit and involves less waiting and less doubt about when the abortion occurs compared with medical abortion,” the college says.
“In addition, women who undergo surgical abortion will not see any products of conception or blood clots during the procedure.”
But while women in metropolitan areas might have the choice between a surgical and medical abortion, the medical option has become particularly valuable for women in regional and rural Australia.
Up until recently, Australian women everywhere who were unexpectedly and unwelcomely pregnant had only one real option – to find a clinic that would provide a surgical termination.
And for many women the reality was that accessing such a clinic wasn’t easy, says Professor Caroline de Costa, professor of obstetrics and gynaecology at James Cook University in Queensland.
“Providing a surgical abortion service requires a lot of infrastructure.
“You need to have an operating theatre, anesthetics and nursing staff and you need to have enough numbers to justify it or a number of gynaecologists who are willing to do surgical abortions as part of their practice,” she says.
This just isn’t the case across a lot of Australia right now.
This made the TGA’s approval of these drugs in 2012 a welcome one to reproductive and sexual health groups, who were buoyed by the opportunity to give women, especially those in rural and remote Australia, another option for early and unwanted pregnancies.
Women who don’t live close to a clinic offering surgical abortions face paying the costs of transport, accommodation, childcare and lost work on top of what might be $500 or more for the procedure itself.
Now health professionals who may not have had the skills, resources or desire to perform surgical terminations especially in more remote locations are able to provide this service through medical means.
Medical abortions can now even be accessed through telemedicine by the Tabbot Foundation, which reports outcomes on par with face-to-face clinics, claiming successful complete abortion rates of around 95%.
But regardless of whether a woman is opting for a medical termination because of accessibility or because she believes it will be safer or more comfortable for them, there remains the very real risk of complications.
And a major difficulty for women and their managing clinician is that there appears to be very few predictors as to which women are more likely to have problems.
Some research has shown a small increase in the risk of adverse events if the woman is older or if she takes the medication later in the pregnancy.
But Dr Philip Goldstone, medical director at Marie Stopes, says women’s experiences with medical termination “are incredibly variable”.
Some women don’t bleed much, experience much pain and the process doesn’t last that long. Unfortunately, other women may have severe pain, heavy bleeding and need ongoing medical intervention afterwards.
Their data showed about one in three women described their pain as severe and one in five said they either had no pain or mild pain.
When it came to bleeding, around half said they had heavy bleeding and just under half described it as moderate.
While it’s easy to assume that someone who has had a vaginal birth might have an easier time with the process, Dr Goldstone says he has seen 16-year-olds report back to the clinic that it was fine, and 30-year-olds with a history of at least two vaginal births have a “really bad time”.
However, interestingly, when they asked those who had had the worst experience whether they would opt for a medical abortion again, the vast majority said they would, he says.
But not for Carla.
