Self-managed abortion with pills: Medically safe, legally risky

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Abortion has been severely restricted or altogether banned in 28 states, with more to come. A national ban was proposed last week in the Senate. This, coupled with stigma around abortion care altogether, has created a big gap between rhetoric and reality around abortion options, like pills.

As more people learn about the option of self-managed abortion with pills, there are understandably questions about safety, effectiveness, and legal risk. I partnered with Dr. Heidi Moseson, a reproductive epidemiologist and scientist, who studies abortion access in the U.S. with a particular focus on self-managed abortion with medications. These are the options people have. Their safety. Their effectiveness. And, unfortunately, their legal risks.

State of Affairs

Abortion clinics in the U.S. are quickly dwindling, and access deserts now blanket much of the country. Currently abortion is “illegal” in 11 states, and in an additional 18 states abortion is “not protected” and/or “hostile.” With new state and federal bans on the table, access to care deserts will only get bigger with time. 

Abortion Laws by State (Source: Center for Reproductive Rights)

The banning of a basic public health service that dramatically reduces pregnancy-related morbidity and mortality by state governments (and possibly the federal government) is unprecedented, and catastrophic. As a recent Lancet editorial put it: “shocking, inhuman, and irrational,” and “a judicial endorsement of state control over women—a breathtaking setback for health and rights.”

But even as access to clinics dwindle, access to safe and effective medications remains an option for many people. In fact, people are turning to medication abortion more than ever. As I’ve written before, requests for abortion pills increased 1180% after Texas’s restrictive law took effect in September 2021. Since Dobbs, some sites have seen requests increase by ~2000%.

Medication options

One option people have for an abortion between 0-24 weeks is medication. There are two pills used to self-manage abortions: misoprostol alone, or misoprostol in combination with mifepristone (known as the “combined regimen”). These two medications are the same medications one would use if they went to a clinic for medication abortion, and are FDA and WHO-endorsed. The WHO-recommended regimen for medication abortion can be found here. 

Regarding access, mifepristone is highly restricted in the U.S. under a REMS, while misoprostol is easier to access, and is widely used for other indications including postpartum hemorrhage, labor induction, and stomach ulcers. REMS is a program the FDA has for putting extra precautions on medications that are dangerous/risky. Mifepristone has a REMS, but it is entirely politically motivated. There is no other medication with the safety profile like mifepristone’s that has a REMS.

Settings 

There are a variety of settings in which people use medication abortion: in-person with a physician in a clinic setting, online via telemedicine visit with a clinician, or self-managed without clinician involvement. In fact, an international nonprofit medication abortion service—Aid Access—sends pills in the mail by connecting people with overseas doctors and pharmacies.

For all of these models, pregnant people take the pills themselves and have the abortion in a place of their choosing. The difference with self-managed abortion is that people evaluate themselves on their own or access pills on their own without evaluation or counseling from a clinician, and without pre-screening ultrasound.

Since the onset of the COVID pandemic, many clinical abortion appointments shifted to telemedicine appointments without requiring ultrasound or other screening assessments either. Researchers tracked whether these pre-screening steps mattered, and found that they did not. Medication abortion remained as safe and effective. Thus, telemedicine has been established as a safe, effective, and FDA-approved way to provide abortion care. 

Medically safe and effective

The research is overwhelmingly clear that use of these pills is medically safe—safer than Tylenol and other medications we routinely use, and certainly safer than childbirth. The National Academies of Sciences, Engineering and Medicine even released a comprehensive report emphasizing the safety of abortion care, including medication abortion. 

These medications are also highly effective for ending pregnancies, and result in a complete abortion in nearly all cases. In fact, in March 2022, the WHO strengthened their guidelines on medication abortion taking into account evidence over the past decade on self-managed medication abortion as a safe and effective model of abortion care (not “just” as a last resort). 

Recent evidence included a study published in the Lancet that assessed self-managed abortion using medications compared to clinician-managed in a health facility among more than 1,000 people aged 14-50 years old. Most pregnancies were less than 12 weeks’ duration, while 5% of participants had pregnancies from 13-22 weeks gestation. The study found that 96.9% of people who self-managed had a complete abortion using pills alone—the same high effectiveness seen in clinical studies of medication abortion effectiveness.

Source: Aiken et al., 2022 Lancet Here

While major complications following medication abortion are rare, people are advised to monitor for signs of possible hemorrhage and infection. These complications occur in approximately 0.14% and 0.13% of medications abortions, respectively. If any of these symptoms are present, people are advised to consult with a clinician—for instance, contacting the M+A hotline staffed 24 hours a day by clinicians.

Legally risky

Despite crystal clear evidence on the safety and effectiveness of these pills for ending pregnancies, legal risk remains—and varies by state. Some states are not only making abortion care illegal, but are also actively criminalizing people who seek or support someone in obtaining abortion care. The public health harms of these bans, and of the criminalization they entail, are impossible to overstate.

Each state has different laws as to which of the above models of care is legally available. In the wake of the June 24th Dobbs opinion, abortion-related laws—and particularly laws targeting medication abortion—are rapidly changing. Check out this state-by-state guide to medication abortion-related laws. It’s up to each person to decide how much clinician support they wish to have, and the legal risk they may face and are willing to tolerate depending on their state. Guidance on legal risk with self-managed abortion can be found here. Here is another comprehensive set of resources shared by Drs. Caitlin Gerdts and Ruvani Jayaweera at the Society for Epidemiological Research.

Bottom line

There is a big gap between rhetoric and reality around abortion pills because of stigma around abortion care. This creates a lack of knowledge, and confusion for patients and providers. However, the evidence resoundingly establishes that medication abortion is a safe and effective mode of care. It is devastating that, contrary to overwhelming public health evidence and all best practice, this now has to be weighed with legal risk.

Love, YLE and Dr. Moseson

P.S. We would like to thank the If/When/How organization for working with us, pro bono, as we wrote this. The fact that we have to weigh legal risk when drafting an epidemiologic newsletter is an outrageous sign of the downward spiral we are in.

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In case you missed previous posts:

• Banning abortions will not stop abortions

• Epidemiology of abortions

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Heidi Moseson, PhD, is a reproductive epidemiologist and scientist at Ibis Reproductive Health. She studies abortion access in the U.S. with a particular focus on self-managed abortion with medications.

“Your Local Epidemiologist (YLE)” is written by Dr. Katelyn Jetelina, MPH PhD—an epidemiologist, biostatistician, wife, and mom of two little girls. During the day she works at a nonpartisan health policy think tank, and at night she writes this newsletter. Her main goal is to “translate” the ever-evolving public health science so that people will be well equipped to make evidence-based decisions. This newsletter is free thanks to the generous support of fellow YLE community members. To support the effort, please subscribe here: