MEDICATION ABORTION AS A QUALITY INDICATOR FOR REGIONAL COMPARISONS IN SWEDEN

We were surprised by the extremely low medication abortion rates in Canada as presented by Erdman et al. in the October 2008 issue of the Journal.1 Sweden has relatively high medication abortion rates, but in an effort to further improve abortion care, an indicator on medication and surgical abortion rates is currently used. In 2007, the Swedish National Board of Health and Welfare, along with the Swedish Association of Local Authorities and Regions, published a report comparing 75 quality indicators of various medical outcomes among Sweden's 21 regions.2 One of the 5 indicators of maternal and prenatal care was the percentage of abortions performed before the 10th week of pregnancy. The percentage of medication abortions was included as supplemental data, though it is not specifically meant to indicate higher quality (Figure 1). In general, the higher the percentage of abortions performed before the 10th week of pregnancy, the higher the percentage of medication abortions. One way to interpret this is that the use of medication abortion increases access to abortion care. FIGURE 1 Medication and surgical abortions performed before the 10th week of pregnancy (with 95% confidence intervals) as percentages of all abortions: Sweden, 2005–2007. Fred Montgomery teaches preschool children in a Head Start class sponsored by the Coahoma Project on April 25, 1966, in Clarksdale, Mississippi. Photograph by Charles Kelly. Printed with permission of AP Wide World. The current Swedish law on abortion, which took effect in 1975, provides women with an essentially free abortion until the 18th week of pregnancy. It is wholly up to the woman to decide whether to have an abortion and request that it be performed. Sweden has 9 million citizens, of whom 1.8 million are women of childbearing age. Between 33 000 and 37 000 abortions (18–21 per 1000 women aged 15–44 years) are performed annually, with more than 70% of them done before the 10th week of pregnancy.3,4 Sweden's total fertility rate for 2007 was 1.88, among the highest in Europe. Sweden's personal identity number system enables linkage between the extensive national health care registers and social, economic, and demographic data.5 However, current legislation does not permit registration of a woman who has an abortion under her personal identity number, as it might discourage her from seeking care. Thus, it is not possible to analyze the social and economic patterns of either medication or surgical abortions—or the medical consequences for future pregnancy or health. There is no clear evidence that health care quality differs between medication and surgical abortions, though it has been shown that women prefer having the opportunity to choose among alternative procedures.6–10 However, there is no doubt that an early abortion is safer than a later one. Thus, we advocate the use of a quality indicator that measures the percentage of abortions performed before the 10th week, with supplemental data on the percentage of medication abortions.

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