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number in other recent periods. 4.3 FIGURE No. of abortion restrictions Albania, France, India, Nepal, Tunisia, Turkey and Vietnam. ABORTION WORLDWIDE 27 Misoprostol-only abortions are increasing in countries with restrictive laws The availability of combination medication abortion (mifepristone followed by misoprostol) gives women living where abortion is broadly legal a highly effective choice other than surgery. However, this option is essentially out of reach for the 687 million women of reproductive age who live where abortion is severely restricted. In these countries, only misoprostol—originally marketed to treat gastric ulcers, but which can be an effective method of medication abortion—is likely to be available.1,2 Compared with mifepristone, misoprostol costs much less and is far more widely available and accessible (officially with a prescription, but prescriptions are often not required at the point of sale in many countries); however, compared with the combination medication protocol, misoprostol alone is more likely to result in incomplete abortion and ongoing pregnancy, even when used correctly.3 When used in the first trimester, misoprostol-only regimens result in a complete abortion 75–90% of the time,4(p.46) whereas the comparable efficacy rates for the combination medication protocol at nine weeks cluster between 95% and 98%.4,5 Thus, WHO and the International Federation of Gynecology and Obstetrics recommend the use of misoprostol alone only when mifepristone is unavailable.4,6 USE IS WIDESPREAD IN LATIN AMERICA The advent of the use of misoprostol alone to induce abortion means that, in many countries, the once broad range of clandestine abortion methods—many of which are highly risky—has narrowed primarily to this one method.The transition started in the late 1980s, when medical personnel in Brazil first noticed the clinical results of a “natural experiment” in treating women who had learned about misoprostol by word of mouth and came in for care. The shift toward less-severe symptoms among postabortion patients was assumed to be attributable to increasingly widespread use of misoprostol alone for abortion.7,8 Its use is now common in much of Latin America and the Caribbean, a region in which nearly every country has highly restrictive abortion laws. Limited national-level data from surveys of health professionals and others familiar with abortion suggest that misoprostol alone was used in an estimated 30% of abortions in Mexico (2007)9 and in half of those in Colombia (2008).10 A survey using two methodological approaches similarly found that half of abortions in urban Brazil (2010) involved misoprostol alone.11 Postabortion care studies also provide a glimpse into the methods that women use, although by definition, these exclude women who did not need or were unable to reach care. In Gabon in 2008, for example, some two-thirds of postabortion care patients at the major hospital in the capital city had used misoprostol,12 as had nearly three-fifths in the second-largest hospital in Ghana in 2010.
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