Abortion care for women in their late first trimester and second trimester of pregnancy has been abolished in some states — even when the patient’s health or life is at risk during a miscarriage or other pregnancy crisis.
As increasing numbers of people turn to self-managed abortion (SMA) for ending their pregnancies, this option has not been seen as an alternative for U.S. women who are more than 10 weeks pregnant — until now.
The authors of an observational cohort study who recruited people in Argentina, Nigeria, and Southeast Asia found that a later term SMA, using mifepristone and misoprostol or misoprostol alone, was safe and effective between nine and 16 weeks of gestation.1
“Because the Food and Drug Administration only approved [mifepristone] through 10 weeks, there is a sentiment in the United States that the pills must not work after that,” says Heidi Moseson, PhD, MPH, lead study author and a senior research scientist at Ibis Reproductive Health in Oakland, CA. “Many countries allow medication abortion after 10 weeks. Most studies look at 10 weeks, but there is no magic line.”
Moseson and colleagues wanted to know whether medication abortion in later weeks could be performed safely by pregnant patients.
“Our study shows that when people use these pills on their own, the pills still work very well,” Moseson reports. “It’s around 90-95% effective, and you don’t need both pills.”
Other research shows that either combined medication abortion regimens or a single regimen with misoprostol will have the same range of effectiveness.1-3
“A lot of clinical trials have demonstrated the safety of medication abortion throughout pregnancy,” says Ruvani Jayaweera, PhD, MPH, study co-author and an epidemiologist and research scientist at Ibis Reproductive Health. “Our study was a prospective observational study that took place in countries where abortion was not legal or allowed in the formal healthcare sector. People were calling hotlines for access, and people were accessing [abortion] pills in a variety of ways, based on what was available to them.”
They accessed pills through pharmacies, trusted nonprofits, and other sources.
“The groups we partnered with provided people with information and support for medication abortion,” Jayaweera says.
There are providers in the United States that will offer medication abortion throughout pregnancy, but it is more commonly prescribed up to nine weeks’ gestation, Jayaweera notes.
“The real issue is access to medication and access to clinicians who are willing to provide medication abortion, access, and support for people who are self-managing their abortions,” she says.
“There is the issue of legal risk,” Jayaweera adds. “There is increased risk for criminalization for those later in pregnancy, when it’s harder to hide a pregnancy.”
An example is Celeste Burgess, a 19-year-old Nebraska resident who self-managed a medication abortion at 23 weeks, buried the fetus, and recently was sentenced to 90 days in jail for concealing or abandoning a dead body. Her mother, who helped her secure the pills, faces even more charges.4
Moseson, Jayaweera, and colleagues focused on physical safety and effectiveness, not on the potential for criminalization. Their study included 1,500 participants, focusing on the experiences of 264 people who were beyond nine weeks’ gestation.1
“These are feminist community-based organizations that have been doing this work for 15-plus years,” Jayaweera says. “They provide people with information for self-managed abortion.”
The findings suggest that regardless of when people used SMA, it was successful for most people, says Kristyn Brandi, MD, MPH, FACOG, the board chair for Physicians for Reproductive Health in New York.
“There is some concern about people taking medication outside of the window we know works well,” Brandi says. “Now, we have data that it works just as well for people who take medications later in pregnancy. I hope it is available for patients who are managing abortion.”
Ideally, women who are experiencing a miscarriage or who are in need of an abortion later in pregnancy could access the care they need in a healthcare system, Brandi says.
“It’s hard to self-manage abortion because we don’t know how many pills they are taking, and they’re not with us to be able to tell us,” she adds.
But the findings are reassuring because they support evidence that abortion is incredibly safe regardless of how it happens — whether procedural or through medication, Brandi explains.
“Most people seeking self-managed abortion are safe — and, most importantly, they shouldn’t be criminalized for doing this,” Brandi adds. “They shouldn’t have to face law enforcement for managing their own pregnancies.”
Investigators chose to study self-managed abortions after 10 weeks because data are lacking on outcomes for people who use the pills later in pregnancy, Moseson notes.
“The World Health Organization reviewed all the evidence of people self-managing a medication abortion up to 12 weeks of pregnancy and said we need more data after 10 to 12 weeks,” Moseson explains. “We wanted to do a specific analysis for those specific outcomes at nine or more weeks of pregnancy.”
The issue of SMA is becoming more important in the United States because of the 2022 state abortion bans passed after the U.S. Supreme Court overturned Roe v. Wade and the constitutional right to abortion care.
“In the U.S., we are seeing people pushed later in pregnancy at the time of having their abortion, and we’re seeing more people pushed to self-manage,” Moseson says.
Waiting lists for abortion care are longer in the states that have kept abortion legal. Plus, there is a lot of confusion over abortion bans, which can be enforced one minute and not enforced another due to court challenges. Pregnant women may not realize they cannot obtain their planned abortion until they arrive at a clinic.
Although medication abortions and SMAs are on the rise because of the changing legal landscape, reproductive health providers still may be hesitant to recommend SMA to patients — especially if they are past nine weeks of gestation.
“For some people, the concept is that we live in the United States and healthcare, in general, is very medicalized and abortion care is very medicalized,” Moseson explains. “There’s a sense that doing anything outside of the health system is risky.”
Part of Moseson and her co-investigators’ message is that pills work just as well when people are taking them at their home vs. the physician’s office.
“What this new analysis does is help shift the mindset that even beyond the 10 weeks where these pills are approved on label, the medications are a safe and effective way to end a pregnancy,” Moseson says. “These pills are safe and effective to 24 to 28 weeks, and we also see these medications are safe and effective in a self-managed context.”
Globally, about one in 10 abortions occurs after 12 weeks, Moseson adds.
For women who experience a miscarriage or other crisis later in pregnancy, medication abortion is safe and effective for miscarriage management.
Women with these health challenges should not be denied miscarriage care, and it is an outrageous human rights violation that some women are denied care in abortion-ban states, Moseson says.
“For OB/GYNs and clinicians, the message to take from this research is that the same medications we use earlier in pregnancy remain safe and effective ways of ending the pregnancy at nine or more weeks of pregnancy — whether it’s in the clinical context or self-management,” Moseson says. “They don’t stop working at 10 weeks. At 16 weeks, they recommend a lower dose of misoprostol because the uterus is more receptive to it.”
There are some increased risks for later gestation medication abortions.
“The major risks for medication abortions after 10-12 weeks include retained placenta and heavy bleeding — concerning for hemorrhage,” Moseson says. “However, medication abortion even after 12 weeks remains much safer than birth of a term fetus.”
The other risk that reproductive healthcare providers can keep in mind is that people who are pregnant past 10 weeks’ gestation and who do not want to be pregnant could attempt to self-manage their abortion in much more dangerous ways than using mifepristone and misoprostol.
“Medication abortion is similarly much safer and more effective than other methods people may try in self-managing — through physical trauma, ingestion of toxic substances, inserting objects into the vagina, etc.,” Moseson says.
REFERENCES
- Moseson H, Jayaweera R, Egwuatu I, et al. Effectiveness of self-managed medication abortion between 9 and 16 weeks of gestation. Obst Gynecol 2023;142:330-338.
- Tang OS, Chan CCW, Yan ASY, Ho PC. A prospective randomized comparison of sublingual and oral misoprostol when combined with mifepristone for medical abortion at 12-20 weeks gestation. Hum Reprod 2005;20:3062-3066.
- Wildschut H, Both MI, Medema S, et al. Medical methods for mid-trimester termination of pregnancy. Cochrane Database Syst Rev 2011;1:CD005216.
- Niemeyer K. A judge sentenced a Nebraska teenager who took abortion pills to 90 days in jail for ‘concealing a dead body.’ Yahoo News. July 22, 2023.
Abortion care for women in their late first trimester and second trimester of pregnancy has been abolished in some states — even when the patient’s health or life is at risk during a miscarriage or other pregnancy crisis. As increasing numbers of people turn to self-managed abortion for ending their pregnancies, this option has not been seen as an alternative for U.S. women who are more than 10 weeks pregnant — until now.
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