restricted access 3. Mifepristone in Tunisia: A Model for Expanding Access to Medication Abortion
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44 3 Mifepristone in Tunisia A Model for Expanding Access to Medication Abortion Angel M. Foster The legal status of abortion varies considerably across the Middle East and North Africa (MENA). In Tunisia and Turkey, first trimester abortion is legal and provided by the public sector, whereas in Yemen and the United Arab Emirates, abortion is prohibited in almost all circumstances. Throughout the region unmet family planning needs, changing premarital sexual behaviors, contraceptive failure, and sexual violence place both married and unmarried women at significant risk of unintended pregnancy (Foster 2014; DeJong et al. 2005; Roudi-Fahimi 2003; Beamish 2001; Ross and Winfrey 2001). Consistent with the rest of the world, abortion rates in countries in the MENA region are not correlated with the legal status of abortion (Sedgh et al. 2012; Singh et al. 2012). In areas of the region where abortion is legally restricted or inaccessible, many women resort to illegal, unregulated, and often unsafe alternatives (Singh et al. 2012; Dabash and Roudi-Fahimi 2008; Hessini 2007). Around 10 percent of maternal deaths in the region are directly attributable to unsafe abortion, and this is likely an underestimate (Dabash and Roudi-­Fahimi 2008). Expanding access to safe abortion services is of great medical, public health, and social importance for women, couples, families, and communities throughout the region. Medication abortion has the potential to expand safe and effective pregnancy termination options and is especially well suited for resource-poor settings (World Health Organization 2012; Winikoff and Sheldon 2012). However, Tunisia remains the only country in the Arab world to have registered mifepristone and integrated medication abortion into the national health system. Drawing from ethnographic fieldwork conducted in Tunisia since the late 1990s, this paper explores the journey of this relatively new technology. I argue that the availability and acceptability of mifepristone in Tunisia involves complex intersections between legal, regulatory, medical, religious, and sociocultural institutions. The experience of mifepristone in Tunisia offers important lessons for expanding safe abortion care and over- Mifepristone in Tunisia  45 coming the tremendous institutional barriers to incorporating medication abortion into reproductive and health services in other parts of the MENA region. What Is Medication Abortion? Although medications have been used to induce abortion for centuries, over the last three decades researchers have developed safe and effective methods of medication-based pregnancy termination (Berer 2005). Medication abortion , also known as medical, nonsurgical, or nonaspiration abortion, refers to a family of drugs used alone or in combination to induce an abortion early in pregnancy (Weitz et al. 2004). Worldwide, three methods of medication abortion are currently in practice: mifepristone (also known as the abortion pill or RU486) and misoprostol; methotrexate and misoprostol; and misoprostol alone. Although mifepristone/misoprostol is the preferred regimen , methotrexate/misoprostol and misoprostol-alone represent important alternatives when mifepristone is unavailable or unaffordable (World Health Organization 2012; Creinin and Pymar 2000). Researchers at the French pharmaceutical company Roussel Uclaf began developing mifepristone in the early 1980s. A synthetic steroid, mifepristone is an anti-progestin that blocks the action of progesterone, a hormone necessary to maintain a pregnancy. By blocking the action of progesterone, mifepristone alters the uterine lining, causing it to shed. Mifepristone also causes the cervix to soften and initiates uterine contractions. Although mifepristone alone was able to induce an early abortion about 60 percent of the time, by the late 1980s researchers soon realized that addition of a second medication —misoprostol—could greatly enhance efficacy (Creinin 2000). Misoprostol is a prostaglandin E1 analog. By interacting with prostaglandin receptors, it causes the cervix to soften and the uterus to contract, resulting in the expulsion of uterine contents. Numerous studies have overwhelmingly demonstrated the efficacy and safety of the mifepristone/misoprostol regimen for early pregnancy termination (American College of Obstetricians and Gynecologists 2014b; World Health Organization 2012). Indeed, around 98 percent of women will have a successful abortion when using mifepristone/ misoprostol within the first nine weeks of pregnancy (American College of Obstetricians and Gynecologists 2014b). More recent studies have also shown that a woman can use the regimen with high efficacy in the ten weeks after her last menstrual period (Winikoff et al. 2012). A multitude of studies from around the world have demonstrated that mifepristone/misoprostol is 46   Abortion Pills, Test Tube Babies, and Sex Toys highly acceptable to both patients and providers (Peña et al. 2014; Alam et al. 2013; Tamang and Tamang 2005; Ngoc et al. 1999; Winikoff et al. 1997). In 1988 France and China became the first...


Subject Headings

  • Human reproductive technology -- Middle East.
  • Human reproductive technology -- Africa, North.
  • Birth control -- Middle East.
  • Birth control -- Africa, North.
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