Misoprostol for self-managed abortion is safe and effective

Self-managed Medication Abortion Using Misoprostol Provided by an Online Telemedicine Service Has a High Rate of Effectiveness and a Low Rate of Serious Adverse Events

Dana M. Johnson, Mira Michels-Gualtieri, Rebecca Gomperts, and Abigail R. A. Aiken

Introduction

In the wake of the U.S. Supreme Court ruling in Dobbs vs. Jackson Women’s Health Organization, which ended the constitutional right to abortion, many states have banned or severely restricted abortion access. As a result, women, transgender men, and gender non-binary individuals capable of pregnancy face unprecedented difficulties obtaining abortion care – either through an abortion procedure or with medication – in clinics in those states.

In recent years, information has spread across the internet about ordering medication abortion pills from online sources to end a pregnancy on one’s own. Many people, in turn, have used this process, known as self-managed medication abortion, to end a pregnancy. In 2018, Aid Access, an organization based in Vienna, Austria, became the first online telemedicine organization to offer a low-cost option for self-managed medication abortion in the U.S.

World Health Organization guidelines recommend that people can self-manage their abortion during the first 12 weeks of pregnancy using a combination of the medications mifepristone and misoprostol or misoprostol alone. Typically, Aid Access provides the medications mifepristone and misoprostol. However, the service temporarily provided prescriptions for misoprostol alone because of challenges shipping mifepristone internationally during the COVID-19 pandemic. This brief reports on a recent study [1] in which the authors assessed the safety and effectiveness of self-managed medication abortion using misoprostol acquired from Aid Access for 568 U.S. residents.

Misoprostol was accessible through Aid Access to women, transgender men, and gender non-binary individuals with the capacity for pregnancy who were up to 10 weeks pregnant at the time of their request. Users completed an online consultation, which was reviewed by a physician to check for any contraindications. If the individual was deemed eligible for treatment, the physician prescribed three doses of 800 micrograms of misoprostol. The medication was either mailed directly to the abortion seeker or the physician sent a prescription to a retail pharmacy for pick-up.

The authors obtained follow-up information from individuals who confirmed that they used the misoprostol for abortion care. That information included questions about whether the individual experienced a serious adverse event and whether they experienced any symptoms of a potential complication. See figure below for definitions of serious adverse events and symptoms of potential complications.

Key Findings

• Self-managed medication abortion using misoprostol provided by an online telemedicine service has a high rate of effectiveness and a low rate of serious adverse events.
• By the numbers (see figure): Of 568 people who obtained and used misoprostol alone for self-managed medication abortion:
  • 88% had a successful abortion without the need for surgical intervention
  • 2% experienced one or more serious adverse events
  • 4% experienced a symptom of a potential complication
• Outcomes compare favorably to other service delivery models using a similar regimen. The 88% success rate is on par with clinical trials using misoprostol alone and other observational studies of self-managed abortion using misoprostol alone.

Serious adverse events = admitted to a hospital, received a blood transfusion, received treatment from an emergency department, or received antibiotics administered intravenously. Potential complications = heavy bleeding of more than two maxi pads an hour for more than 2 hours, a fever of 102 degrees Fahrenheit or higher, discharge with a bad odor, or severe pain that would not go away after the abortion.

Policy Implications

The high rate of effectiveness of self-managed medication abortion using misoprostol alone, along with the low rate of serious adverse events are encouraging, particularly because misoprostol is available in many health care settings in the US. Misoprostol is used to treat stomach ulcers and postpartum hemorrhage; it is also used to manage miscarriages and soften the cervix in preparation for delivery. Because of these uses, misoprostol is readily stocked in hospitals, clinics and pharmacies.

Misoprostol is a lower cost medication, especially compared to mifepristone, which is a clear advantage for abortion seekers who struggle to pay for clinical abortion or other telemedicine services. Misoprostol is also not subjected to the same onerous Food and Drug Administration restrictions that have long limited access to mifepristone.

As mifepristone continues to be over-regulated and the 2022 U.S. Supreme Court ruling allows states to severely restrict access to in-clinic abortion care, a misoprostol alone regimen is a promising option for self-managed abortion in the U.S. In 2022, state lawmakers introduced 118 restrictions on medication abortion [2], while others have challenged FDA approval of mifepristone [3]. These existing and potential bans substantially limit access to mifepristone, and because misoprostol has far fewer legal constraints, people may increasingly consider misoprostol for self-managed abortion.

References

[1] Johnson, D.M., Michels-Gualtieri, M, Gomperts, R., & Aiken, A.R.A. (2023). Safety and effectiveness of self-managed abortion using misoprostol alone acquired from an online telemedicine service in the United States. Perspectives on Sexual and Reproductive Health: 1-8. https://doi.org/10.1363/psrh.12219

[2] Guttmacher Institute. (2023). Medication abortion. https://www.guttmacher.org/state-policy/explore/medication-abortion

[3] Sobel, L., Salganicoff, A., & Felix, M. (2023). Legal challenges to the FDA approval of medication abortion pills. KFF. https://www.kff.org/womens-health-policy/issue-brief/legal-challenges-to-the-fda-approval-of-medication-abortion-pills

Suggested Citation

Johnson, D.M., Michels-Gualtieri, M, Gomperts, R., & Aiken, A.R.A. (2023). Self-managed medication abortion using misoprostol provided by an online telemedicine service has a high rate of effectiveness and a low rate of serious adverse events. PRC Research Brief 8(2). http://dx.doi.org/10.26153/tsw/44476.

About the Authors

Dana M. Johnson, danajohnson@utexas.edu is a PhD candidate in public policy and demography at the Lyndon B. Johnson School of Public Affairs and a Population Research Center graduate research trainee, The University of Texas at Austin and a senior associate research scientist at Ibis Reproductive Health; Mira Michels-Gualtieri is a graduate student at the Mailman School of Public Health, Columbia University; Rebecca Gomperts is the founder and executive director of Aid Access; she is also the founder and research director of Women on Web International. Abigail R. A. Aiken is an associate professor and fellow of the Richter Chair in Global Health Policy, LBJ School of Public Affairs and a PRC faculty scholar, UT Austin.

Acknowledgements

This study was funded by two grants from the Society of Family Planning, (SFPRF15-ES8 and SFPRF12-MA1). The authors received infrastructure support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2C HD042849), awarded to the Population Research Center at The University of Texas at Austin. None of the sources of funding had any involvement in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.