In the wake of the Supreme Court overturning Roe v. Wade on June 24, a talking point has been circulating around pro-choice corners of the internet: You can’t ban abortion, you can only ban safe abortions. Accompanying these social media posts are often graphic images of coat hangers and horrifying statistics, like the fact that abortion death rates are 34 times higher in countries with laws that restrict the procedure.
But this hasn’t been the case in the U.S. in 2022. Medication-assisted abortion has changed the game when it comes to self-managed abortions. The two-drug regimen, mifepristone and misoprostol, are over 95% effective at ending a pregnancy. And they’re incredibly safe: major complications requiring hospitalization, surgery, or a blood transfusion occur in just 0.3% of cases, making medication abortion safer than Tylenol.
Dr. Diane Horvath, co-founder and medical director of Partners in Abortion Care, says that mifepristone and misoprostol “are far and away the safest, least expensive, most effective method that's out there” for a self-managed abortion. “They work beautifully together, and they work almost all the time,” she says.
The use of these pills for abortion has steadily increased over the past two decades, and they now account for more than half of all abortions in the U.S. Despite its prevalence, only one-fifth of adults (21%) and one-third of women between the ages of 18 and 49 (36%) have ever heard of medication abortion.
On June 24, Attorney General Merrick Garland noted that U.S. states can’t ban mifepristone, which is FDA-approved. “States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy,” he said in a statement, per USA Today. Though, almost half of the country has already banned or restricted abortion pills.
As access to abortion is threatened and restricted in many states, underground groups are working to help connect people seeking an abortion with service providers in other states, or even mail the pills directly to those who need them. Spreading awareness about mifepristone and misoprostol is more important than ever, especially for anyone interested in activism around reproductive rights — or with a uterus.
If you need a medication abortion, either managed in partnership with a provider or on your own, here’s what to expect.
How Do The Pills Work?
First, you’ll take a 200-milligram tablet of mifepristone, which blocks the action of the hormone progesterone. Progesterone is important for sustaining early pregnancy by thickening the lining of the uterus to help the embryo implant. Blocking progesterone causes the pregnancy to start to separate from the wall and can stop the embryo from growing.
You’ll take the misoprostol — typically four 200-microgram tablets — 24 to 48 hours later. Importantly, you don’t swallow the misoprostol; let the pills dissolve underneath your tongue or in the pouch between your cheek and gums.
Misoprostol falls into a class of medications called prostaglandins. Prostaglandins are also produced normally by the body (they’re similar to hormones) and are responsible for causing uterine contractions when you have period cramps or during labor. When taken for an abortion, misoprostol causes the cervix to open and the uterus to contract, leading to expulsion of the pregnancy.
What Will It Feel Like?
While these medications are very safe, they will cause unpleasant side effects similar to a miscarriage, especially after the misoprostol. You will feel cramping and abdominal pain and experience vaginal bleeding. You could also have nausea, vomiting, and a mild fever. These symptoms are all normal, but if they become extreme or persist too long, you should seek medical care.
“It's important that people get information about what are the normal side effects and what can be a sign of a possible complication,” says Dr. Daniel Grossman, a professor in the department of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.
Are There Any Dangerous Side Effects?
Grossman says to watch out for pain that is severe and not relieved by a painkiller like ibuprofen; bleeding so heavy it soaks through two menstrual pads an hour for two consecutive hours; and nausea, vomiting, or a fever that lasts for more than four hours or starts 24 hours after taking the misoprostol.
Excessive or delayed symptoms can be signs of an infection or hemorrhage and require immediate medical care.
“The overall risk of a serious complication like having to be in the hospital or getting a blood transfusion or needing emergency surgery, those are incredibly rare — less than half a percent,” says Grossman. “It's certainly more common that people may have bleeding that they're concerned about that requires evaluation. In some of the studies, as many as about 5% of people may go to an emergency department to get checked out. But the vast majority of them don't need treatment, they don't need a blood transfusion, they're just observed and reassured.”
There are a few situations in which these medications are definitively less safe. The first is for people who have a bleeding disorder that makes their blood less likely to clot or people who are on blood thinners. People taking steroids should also avoid mifepristone because the medications can interact. Finally, people who have an IUD in place, even if it failed to prevent the pregnancy, need to have the device removed first because there's a risk the IUD could be partially expelled with the medications.
How Do You Know If It Worked?
On the other side of things, if you don’t have any cramping or bleeding at all it could be a sign that the medications didn’t work. Pregnancy symptoms like nausea or breast tenderness should go away within a week of taking the abortion medications. It takes longer — four to five weeks — for hormone levels to go back to normal and a home pregnancy test to turn negative. Be sure to test yourself a month after you take the medication to make sure it worked. When taken during the first 10 weeks of pregnancy, mifepristone and misoprostol are 97% effective, but if the pregnancy test is still positive, you should contact the clinic or online provider you received the pills from immediately.
What Should I Know About Potential Legal Risks?
Mifepristone and misoprostol’s safety and efficacy when it comes to ending a pregnancy is very straightforward. What’s less clear-cut is their legal standing.
Mifepristone was approved by the FDA in 2000 to be used to end pregnancies through 10 weeks. Misoprostol was originally developed as a treatment for ulcers in the 1980s, but shortly after it was discovered to induce labor. In countries where abortion was illegal, like Brazil, it became a popular off-label abortifacient. While misoprostol is not technically authorized by the FDA for abortion on its own, it was included in the 2000 approval of mifepristone. By itself, misoprostol is about 85% effective at ending a pregnancy; mifepristone alone is only 15% effective.
Because of political pressure, mifepristone is approved by the FDA under a Risk Evaluation and Mitigation Strategy. As a result, until 2021, mifepristone could only be obtained in-person from designated providers and not from pharmacies. (Misoprostol is available at pharmacies with a prescription.) The one small silver lining of the COVID-19 pandemic is that the FDA lifted several of these restrictions, and mifepristone is now available via mail with a telehealth appointment. Telemedicine abortion services like Abortion on Demand, Just the Pill, and Hey Jane can now ship both medications to a woman’s home using online pharmacies after a quick virtual appointment.
The catch is that several states are now banning mail access to medication abortion. If mifepristone and misoprostol are restricted in your state, there are still ways to obtain the medications. Groups such as Aid Access, Women on Web, and Plan C help people get mifepristone and misoprostol shipped from outside the country. Local abortion funds can also connect you with clinics in nearby states that offer these services.
Another gray area is how far into the pregnancy the medications can be used. Mifepristone and misoprostol are only approved to end a pregnancy up through 10 weeks, but they can be taken into the second trimester. In fact, misoprostol is often used off-label to induce labor in cases of stillbirth, although at much higher doses. In these situations, the medication is given at a hospital or in-patient facility because the pain and bleeding can be much more severe.
With restrictions on abortion looming, both Grossman and Horvath say they’re more worried about the legal repercussions than the health consequences for women who self-manage an abortion and need to seek medical care.
“My greatest concern is for legal jeopardy and criminal prosecution. I think that is far more risky than any of the potential medical concerns,” says Horvath. “I would love if everyone could be honest with every care provider that they encounter. But I know that there are people out there — there are physicians, nurses, emergency department workers, EMTs, things like that — that have and will continue to report people.”
This happened recently in the case of Lizelle Herrera, who was arrested after a Texas hospital reported she had a self-induced abortion.
How Can I Protect Myself Legally?
If you take mifepristone and misoprostol and require medical assistance, you do not need to tell a doctor, nurse, or anyone else that you took them.
“There is no way for a clinician to tell that someone has taken these medications. There's no commercially available blood test that can be done,” Grossman says. “The management of these complications of pregnancy loss is really the same regardless of whether the pregnancy loss was spontaneous or induced through a self-managed abortion.”
If you live somewhere abortion is illegal, it’s also important not to leave a digital trace of accessing medication-assisted abortion. The Digital Defense Fund has a thorough guide on how to avoid online trackers and stored searches that could be used against you. Their tips include using DuckDuckGo instead of Google; Firefox Focus instead of Chrome or Safari; and if you need to communicate about your abortion, use an encrypted messaging app like Signal.
This may sound dystopic, but it’s the situation Latice Fisher of Starksville, Mississippi found herself in after delivering a stillborn baby in 2017. Fisher was indicted on second-degree murder charges after her phone revealed internet searches for “buy Misoprostol abortion pill online.”
If you do find yourself in legal trouble because of a self-managed abortion, there are organizations like National Advocates for Pregnant Women and If/When/How that provide legal assistance for people criminalized for an abortion or miscarriage. These groups defended Fisher and Herrera and successfully got their charges dropped in both cases.
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