From Bench to Bed into the Hands of Women: Medical Abortion
Medical abortion has been a revolutionary discovery for sexual and reproductive health care worldwide.
We talked with Prof. Kristina Gemzell Danielsson, Head of the Women’s and Children’s Health Department at Karolinska Institut in Sweden, on the impact of medical abortion and the future for telemedicine abortion.
Interview by Hazal Atay*
Can you tell us a bit more about yourself?
I am the Chair of Obstetrics and Gynaecology at Karolinska Institut in Sweden. I am also Director of the World Health Organization (WHO) Collaborating Center, which has been in place since 1972 when the WHO started a special program in human reproduction. I also have a large research group, and its translations are multidimensional in a way; I like to call it research from bench to bed, but then also into the hands of women. One very good example of this is medical abortion.
You have been involved in initial research on medical abortion. Can you take us back to those times?
The innovation is actually from our research group at the WHO Center. When we were working on this, prostaglandin was already discovered. Sune K. Bergstrom and Bengt I. Samuelsson from Karolinska Institut were awarded the Nobel Prize in 1982 for their discovery. And one of Bergstrom’s PhD students became a gynaecologist and he became my supervisor, and we worked closely with the WHO. The challenge of the time was to develop safe abortion and contraception methods to reduce maternal mortality and that’s what we were working towards. We were testing prostaglandin, but we did not have the results we wanted. And in the meantime, Mifepristone was discovered in France and Emile-Etienne Beaulieu, who discovered the pills, immediately recognized it’s potential. The topic then became politically very sensitive in France. There was a lot of pressure on the company to stop manufacturing Mifepristone and in fact to withdraw the pills from the market. In response to the pressures, the French Minister of Health took a stance and said that “This is the property of women. We cannot withdraw it.” This was very important. And then, after all these political struggles, it was a bit disappointing that Mifepristone alone was not effective to induce abortion. Then, we came up with the idea to combine prostaglandin with Mifepristone, and that formed medical abortion that we practice today by using Misoprostol (which is a synthetic prostaglandin analogue) and Mifepristone. So, this was a collaborative work of scientists with the WHO and from Sweden and France. Then of course, studies multiplied elsewhere.
Once medical abortion was discovered, how was it perceived?
Medical abortion was a very important discovery, not only from a medical perspective, but also from a human rights perspective. In my personal career, I could, for example, observe a huge change in perceptions since the discovery of medical abortion. I remember women coming for abortion when I was a medical student, I remember how they were treated and how abortion stigma was still so strong in Sweden. And now, working on abortion has become something popular and important. Of course, medical abortion has contributed to this. Medical abortion is also a method that is still developing, we work to produce evidence to ensure high quality care, to make it even safer and also to simplify the procedure to turn it to something women can self-manage themselves. I think sometimes also of the development of pregnancy tests. You know, from the start, it was very complicated. When the first biomedical pregnancy tests were developed [it was my relative who discovered that actually, Kristina adds humbly], it was also like a revolution. But quickly after, it was argued that women cannot do it themselves. People asked whether women can read the results correctly and what would they do, if they get a positive result, and argued that someone else was needed to do the test for women. I think this discussion is similar to what we discuss today about contraceptives and medical abortion. So I’m glad that medical abortion is now being developed into a method women can self-manage.
That is very interesting. I didn’t know for example that pregnancy tests were initially restricted like this. It is now very mainstream, we just go and buy from the pharmacy, and do it ourselves.
Yes, I think it is one example of how things become mainstream. In Sweden, for example, all gynaecologists have to offer abortion. I like this a lot, because it means that abortion is part of mainstream care. I think this was something which helped reduce the abortion stigma, as well. So, abortion is not something that we keep outside of regular care. In Sweden, we do not allow conscientious objection. We see abortion an important and integral part of healthcare. So in Sweden, if you are trained to become a gynaecologist, you cannot refuse performing an abortion, just same as you cannot choose not to do a cesarean section or not to do a penectomy if you are trained to become a surgeon. It is also very important for our students to see for example, this is not a special procedure or these are not special women. It is the same kind of women that they can meet in the delivery room or in clinic. I think it is also very important to keep it like that. I am worried to see countries where this service is moved out, because it is extremely important to keep this balance: to make abortion easily available but also to “protect” women and maintain high quality of care.
I am also curious to know your opinion about the regulation of the abortion pill. In large parts of the world, the abortion pills are not available in pharmacies and individuals are required to visit a clinic to take the Mifepristone in presence of a medical practitioner. What do you think about this requirement?
This also relates to the question: “Do we need abortion laws?” For example, in Canada, they don’t have an abortion law, but they have problems of access. In Sweden, abortion is legal and it’s decriminalised so it’s not in the Penal Code, which is unusual. But the law came in 1970s and it was implemented to “protect” women from unsafe abortions. So, the law said that abortion should be performed in a clinic by a medical practitioner. This was to “protect” women and at that time we only had surgical abortion method. The law was good in the sense that it required all obstetrics and gynaecology clinics to provide the service, it basically told them “you cannot opt out.” So, in this regard, the law has helped maintain quality care and ensure access. Then, medical abortion was developed, and we have not been brave enough to change the law, but we tried to get the support of lawyers to reinterpret the law in light of recent changes. We really need good lawyers to help us work around this, because it is ridiculous to ask people to come to a clinic to swallow Mifepristone, when they can do everything else at home. It is also very important to remove abortion from Penal Codes, because it contributes to stigma. Probably, there is no one solution that fits for all countries, but we can learn from each other. So I like how in Canada this remains a medical decision, not a legal one, but maybe this won’t be a medical decision anymore either.
You also have been involved in research on telemedicine abortion. How do you see telemedicine abortion and maybe also the role of Women on Web in research and advocacy on telemedicine abortion?
When Women on Web was founded, we thought that it is very important to publish this work to provide evidence for policy makers and service providers. I think this has worked out and Women on Web made a significant contribution to scientific research on medical abortion. With the publications from Women on Web, we have been able to make evidence-based policy recommendations on safe abortion access, even in countries with restrictive settings. I have to say that initial reactions to our publications and work were very strong. I was actually surprised to see this, but it’s perhaps the same reaction that we see always. The main concern was safety, and of course, it is very important to think about safety. But many things in practice were not evidence based either. For example, we got rid of pelvic examination before the prescription of abortion pill, because it was not evidence-based and it was not necessary. I think it’s a little bit the same development we witness with telemedicine abortion, and the work of Women on Web has provided many evidence and insights on this. But of course, change takes time.
With COVID-19 pandemic, we saw however some rapid changes! Telemedicine became very popular and was also adopted for the provision of abortion care. How do you see the impact of the pandemic on abortion care provision in general and on telemedicine abortion in particular?
This is extremely interesting to understand, how did it happen in these countries like the United Kingdom and in France, where it happened so quickly. In the United Kingdom for example, there has been a long struggle to make the home-use of Misoprostol possible. Maybe it was just the right time, because home-use was just made possible there, and this was in the same wave or spirit perhaps. How it happened in France? I do not really know, and we are trying to understand this through research now.
How do you see the future from now on beyond the pandemic? Do you think telemedicine abortion should stay with us?
Absolutely. For women who choose it, telemedicine should remain as an option. I think it’s very important to listen to women: some women prefer to come to a clinic to have an abortion, but some would choose telemedicine. I think we need to offer women both options.
I think I asked all my questions. Would you like to add anything?
Thank you. I just think that it’s important to do this work on this together, not only from a medical perspective, but also from a human rights perspective.
*Hazal Atay is researcher at Sciences Po Paris and coordinator at Women on Web.
