Overview
This lecture covers Whakatahe/abortion care in Aotearoa New Zealand: the terminology used post law reform, the legal framework governing access, counselling, later abortion and conscientious objection, and the four categories of abortion procedure (early/later, medical/surgical) with their regimens, mechanisms of action, patient-reported acceptability, and the clinical/legal factors that guide choice of method.
Terminology and Language
- The Aotearoa Abortion Legislation Act 2020 uses the term “woman” but does not define it to be inclusive; the lecturer notes it is unclear how this will be legally applied and acknowledges that abortion care is also received by people identifying as non-cis-female, for whom the term is inappropriate and discriminatory.
- NZ-adopted terminology (after provider consultation, subject to change with further consumer consultation): early medical abortion, later medical abortion, early surgical abortion, later surgical abortion.
- The te reo term for abortion differs across the motu (regions); NZCSRH (the professional college) has adopted Whakatahe.
Legal Framework (Post Law Reform)
- Abortion is classified as a health procedure.
- Self-referral: a qualified health practitioner may not require a woman to be referred by another health practitioner as a condition of providing abortion services.
- Counselling: a practitioner must advise a woman of available counselling services if she (a) seeks advice about continuing or terminating a pregnancy, (b) states a wish to terminate, or (c) has terminated a pregnancy. A practitioner may not make counselling a mandatory condition of providing services, either before or after the procedure.
- Later abortion (>20 weeks gestation): a practitioner may only provide services if they reasonably believe the abortion is clinically appropriate. To assess this they must consult at least one other qualified health practitioner and have regard to: relevant legal, professional and ethical standards; the woman’s physical health, mental health and overall well-being; and the gestational age of the fetus. This requirement does not apply in a medical emergency.
- Existing health and disability law continues to guarantee the right to an appropriate standard of care from a suitably qualified, competent practitioner.
- Conscientious objection: an objecting practitioner must disclose their objection to the pregnant person at the earliest opportunity, and must tell them how to access the contact details of a provider who will perform the service. This does not override the practitioner’s professional and legal duty to give prompt, appropriate medical assistance in a medical emergency.
Categories and Mechanisms
- Early medical abortion: up to 10 weeks gestation.
- Early surgical abortion (aspiration): up to 14+6 weeks.
The source gives this cutoff as "14 6 weeks"; the "6" may denote 14 weeks + 6 days, but this cannot be confirmed from the extracted slide text.
- Later surgical abortion: dilatation and evacuation.
- Later medical abortion: induction of labour, used over 22 weeks, performed with feticide.
Early Medical Abortion
Standard regimen (usually carried out at home):
- Mifepristone 200 mg orally.
- 36-48 hours later: Misoprostol 800 mcg (buccal/sublingual/vaginal).
- Most people complete the abortion around 6 hours after the misoprostol dose.
- Efficacy is gestation-dependent, 90-99%.
- The physical process is the same as for someone experiencing a miscarriage.
Mode of action, mifepristone:
- Detachment of the embryo, decreased hCG, luteolysis.
- Increased myometrial sensitivity (loss of quiescence).
- Opening and ripening of the cervix.
Mode of action, misoprostol:
- An analogue of prostaglandin E1.
- Causes myometrial contractility and opening/ripening of the cervix.
Acceptability study findings:
- Positives: described as better/easier/more harmless than expected; felt good, convenient, safe; home was more comfortable and private; partner support possible at home; less invasive; relieved, natural, safe (96% would recommend to a friend); participants valued awareness of the process, greater control, avoidance of anaesthesia, greater discretion; women who chose their own method reported more positivity than those assigned a method (95% vs 74%); 63% wanted to see what was expelled.
- Negatives: more pain and bleeding than surgical; bled for too long, distress at seeing products of conception; described as more painful than surgical abortion done under general anaesthetic; too time-consuming; not as quick or easy as expected.
Early Surgical Abortion
Aspiration abortion:
- Cervix primed with misoprostol 1-3 hours beforehand (up to 12 weeks), or mifepristone 24 hours beforehand for 12-14 weeks gestation.
- Local anaesthetic with light sedation.
- Cervix dilated to a degree equivalent to the gestation.
- Suction aspiration performed (e.g. via manual vacuum aspiration).
- The physical process is the same as for someone experiencing a miscarriage.
Choosing Medical vs Surgical (Early Abortion)
- Reasons to choose surgical: shorter procedure time; more effective, with lower risk of needing hospital readmission; usually no heavy bleeding at home; an IUD/IUS can be fitted at the same time; no follow-up tests required.
- Reasons to choose medical: no surgery required; no sedation or anaesthesia required; greater potential privacy; may give a greater sense of control over one’s body; may feel more “natural” to some women.
Later Surgical Abortion
Dilatation and evacuation:
- Cervix primed with laminaria and/or mifepristone.
- Cervix dilated; fetal tissue removed with forceps, with or without curette and suction, under ultrasound guidance to reduce complications.
- The physical process is the same as for someone experiencing a miscarriage/stillbirth.
Later Medical Abortion
Later medical, >10 weeks:
- Induction of miscarriage/labour, performed in a hospital setting.
- Same medications as early medical abortion, but the misoprostol dose is lowered as gestational age advances.
- Mifepristone, an antiprogesterone, enables gap junctions in the uterus to be activated.
- Misoprostol given 36-48 hours later to induce labour.
- The physical process is the same as for someone experiencing a miscarriage/stillbirth.
Stillbirth is defined as fetal death after 20 weeks gestation; before 20 weeks it is classified as a miscarriage. This matters because a stillbirth or a live birth at any gestation must have the birth registered.
Feticide (used with later medical abortion over 22 weeks):
- Injection into the amniotic fluid or the fetus to cause fetal demise before induction is commenced.
- Example indication: a situation where inducing labour could otherwise result in the fetus being born alive.
Self-test
- List the four categories of abortion procedure used in NZ terminology, with their approximate gestational ranges.
- Explain the limitation the lecturer identifies with the term “woman” as used in the Aotearoa Abortion Legislation Act 2020.
- Describe the self-referral rule for accessing abortion services in NZ.
- Describe when a practitioner must advise a woman of counselling services, and state whether counselling can be made a mandatory condition of care.
- Describe the legal requirements a practitioner must satisfy before providing abortion services to a woman more than 20 weeks pregnant, and the exception to this requirement.
- Describe what conscientious objection requires of an objecting practitioner, and explain its limit in a medical emergency.
- Describe the standard early medical abortion regimen, including drugs, doses, and timing to completion, and state its efficacy range.
- Describe the mechanism of action of mifepristone.
- Describe the mechanism of action of misoprostol.
- List two positive and two negative patient-reported experiences of early medical abortion from the acceptability studies.
- Distinguish reasons a woman might choose a surgical abortion from reasons she might choose a medical abortion.
- Describe the steps of an aspiration (early surgical) abortion, including cervical priming.
- Describe the steps of dilatation and evacuation.
- Describe how later medical abortion (>10 weeks) differs from early medical abortion, and state the role of mifepristone in it.
- Define feticide and give the example situation in which it would be used.
- Distinguish miscarriage from stillbirth and explain why the distinction is legally significant.
- A woman at 24 weeks gestation requests a termination. Describe the legal steps required before a practitioner may proceed, and the clinical procedure most likely to be used.
Answers
Reveal answers
- Early medical abortion (up to 10 weeks); early surgical abortion/aspiration (up to 14+6 weeks); later surgical abortion/dilatation and evacuation; later medical abortion/induction of labour (over 22 weeks, with feticide).
- The Act uses “woman” without defining it to be inclusive, so it is unclear how it applies to people who identify as non-cis-female but receive abortion care; the lecturer states this terminology is inappropriate and discriminatory for that group.
- A qualified health practitioner may not require a woman to be referred by another health practitioner as a condition of providing abortion services.
- A practitioner must advise of counselling availability if the woman seeks advice about continuing/terminating a pregnancy, states a wish to terminate, or has terminated a pregnancy; counselling cannot be required as a mandatory condition of care before or after the procedure.
- The practitioner must reasonably believe the abortion is clinically appropriate, must consult at least one other qualified health practitioner, and must have regard to relevant legal/professional/ethical standards and to the woman’s physical health, mental health, overall well-being, and the gestational age of the fetus; none of this applies in a medical emergency.
- The objecting practitioner must disclose their objection to the pregnant person at the earliest opportunity and tell them how to access a provider who will perform the service; this does not override their duty to give prompt, appropriate medical assistance in a medical emergency.
- Mifepristone 200mg orally, followed 36-48 hours later by misoprostol 800mcg (buccal/sublingual/vaginal); most people complete the abortion around 6 hours after the misoprostol dose; efficacy is 90-99% depending on gestation.
- Mifepristone causes detachment of the embryo, decreased hCG, and luteolysis; increases myometrial sensitivity (loss of quiescence); and opens and ripens the cervix.
- Misoprostol, a prostaglandin E1 analogue, causes myometrial contractility and opening/ripening of the cervix.
- Positives: felt convenient, safe and more natural, with greater privacy and control, and 96% would recommend to a friend. Negatives: more pain and bleeding than surgical, and it was more time-consuming/less quick than expected.
- Surgical is chosen for a shorter procedure, higher effectiveness (less risk of readmission), usually no heavy bleeding at home, simultaneous IUD/IUS fitting, and no follow-up tests; medical is chosen to avoid surgery and sedation/anaesthesia, for greater privacy, a greater sense of control, and because it may feel more natural.
- Cervix primed with misoprostol 1-3 hours beforehand (up to 12 weeks) or mifepristone 24 hours beforehand (12-14 weeks); local anaesthetic with light sedation; cervix dilated to a degree equivalent to gestation; suction aspiration performed.
- Cervix primed with laminaria and/or mifepristone; cervix dilated; fetal tissue removed using forceps, with or without curette and suction, under ultrasound guidance to reduce complications.
- Later medical abortion uses the same drugs as early medical abortion but with lower misoprostol doses as gestational age advances, is carried out in hospital as an induction of miscarriage/labour, and is preceded by feticide over 22 weeks; mifepristone (an antiprogesterone) acts by enabling gap junctions in the uterus to be activated.
- Feticide is injection into the amniotic fluid or the fetus to cause fetal demise before induction is commenced; an example indication is a situation where inducing labour could otherwise result in the fetus being born alive.
- Stillbirth is fetal death after 20 weeks gestation; before 20 weeks it is a miscarriage. This matters legally because a stillbirth or a live birth at any gestation must have the birth registered.
- Because she is more than 20 weeks pregnant, the practitioner must reasonably believe the abortion is clinically appropriate, consult at least one other qualified health practitioner, and have regard to legal/professional/ethical standards and her physical health, mental health, well-being and the fetal gestational age. If proceeding, the likely procedure at this gestation is later medical abortion (induction of labour, with feticide as gestation is over 22 weeks) or, alternatively, later surgical abortion (dilatation and evacuation).