The International Consortium for Medical Abortion (ICMA) Information Package on Medical Abortion contains comprehensive information on medical abortion, addressed to a broad range of audiences, including women who may be seeking an abortion, women’s groups and organizations, health policymakers and health care providers.
This updated version of the ICMA Information Package on Medical Abortion has been revised in accordance with the WHO’s Safe abortion: Technical and policy guidance for health systems, second edition (2012) and other evidence-based technical guidances and recommendations.
- Introduction
- Past and present of abortion worldwide
- Why do women decide to have an abortion?
- What is medical abortion?
- What medicines are used for medical abortion?
- When during pregnancy can medical abortion be used?
- Are there any women who cannot use medical abortion?
- Can a woman use medical abortion if she is breastfeeding?
- Is medical abortion safe for women who are HIV positive?
- Is medical abortion safe for adolescents?
- Can a woman use medical abortion if she has a reproductive tract infection?
- Why do women choose medical abortion?
- How does a woman confirm that she is pregnant?
- How does a woman find out how many weeks she has been pregnant?
- How does medical abortion compare with surgical abortion in pregnancy up to 9 weeks?
- What are the different regimens used for medical abortion up to 9 weeks of pregnancy?
- What are the different regimens used for medical abortion after 9 weeks of pregnancy?
- Can misoprostol alone be used for medical abortion?
- What is the failure rate of medical abortion?
- How long does it take to terminate a pregnancy with medical abortion?
- How many clinic visits are required for a medical abortion? What happens during each visit?
- What about using medical abortion pills at home?
- What is the experience of medical abortion like?
- What are the side effects of medical abortion, and how can they be managed?
- What are the complications of medical abortion, and what can be done about them?
- How safe is medical abortion?
- How would a woman know if the pregnancy has not been terminated?
- Is there a concern about birth defects in case pregnancy is not terminated?
- How long after having a medical abortion can women resume sexual intercourse?
- How long after having a medical abortion can a woman become pregnant?
- How long after a medical abortion will a woman resume normal menstruation?
- When can a woman start using contraception after medical abortion?
- Does medical abortion have any long-term effects on a woman’s health?
- Will medical abortion affect a woman’s ability to have a child in the future?
- Are there any adverse effects associated with having more than one medical abortion?
- How expensive is medical abortion?
- What options do women have in countries where abortion is legally restricted?
1. Introduction
The International Consortium for Medical Abortion (ICMA) works to promote medical abortion and women’s right of access to safe, legal abortion worldwide, focusing on the needs of women in developing countries.
This information package on medical abortion was first published in 2007. This is an updated version, published in 2012. It has four chapters, each aimed at a specific audience: women seeking information about abortion, women’s groups and women’s health advocates, abortion service providers, and policymakers.
This chapter is for women wanting information on the “abortion pill”, or medical abortion.
2. Past and present of abortion worldwide
Throughout history, women have terminated unwanted pregnancies, using whatever means were available to them, safe or unsafe. Moreover, women have had abortions whatever the legal status of abortion and despite condemnation and barriers that made it difficult or impossible for them to obtain a safe abortion.
During the course of the 20th century, laws from the 19th century banning abortions began to be reformed worldwide as control of fertility became acceptable through campaigns for family planning and the development of safe methods of contraception and of induced abortion. These reforms have contributed to a more enabling environment for women to gain access to safe abortions from health care services, as part of public health policies. In 2011, some 67% of all countries in the world (129 out of 192 countries) allowed abortion under certain circumstances, particularly if there is a risk to the pregnant woman’s life, health or mental health. Some also allow abortions for socioeconomic reasons and on grounds of rape and foetal abnormality. As many as 44% of countries allow abortion at a woman’s request. Only four countries (Chile, El Salvador, Nicaragua and Malta) still outlaw abortion under any circumstances.[1],
Since the mid-20th century, the development of medical technology has made it possible for women to terminate a pregnancy safely, both surgically and medically. Indeed, abortion has become one of the safest medical procedures available. Three methods are currently recommended by the World Health Organization in its guidance for countries: Safe Abortion: Technical and Policy Guidance for Health Systems. They are:
- vacuum aspiration abortion, both manual vacuum aspiration up to 10 weeks of pregnancy, and electric vacuum aspiration up to 14-15 weeks of pregnancy;
- a combination of the medical abortion pills mifepristone and misoprostol, which can be used for both first and second trimester abortion; and
- dilatation & evacuation, a surgical method for second trimester abortions.
In 1988, France and China became the first countries to license mifepristone for use in combination with a prostaglandin for medical abortion (mifepristone was often called RU486 at that time).
In 2011, mifepristone had been approved in 44 countries. Misoprostol can be found in most countries (except a few sub‐Saharan African and Asian countries) as it is often registered for the prevention of gastric ulcers. Thus, misoprostol is often available in countries where mifepristone is not yet registered.
In many countries with legal restrictions on abortion, one or both of these drugs is available from drug sellers and pharmacies, and prices vary. They are also available through the internet,from bona fide sources, such as Women on Web, but also from untrustworthy sources, who may sell fake, ineffective and unsafe products.
In countries where abortion is legally restricted, the use of medical abortion by women through self-administration or on the advice of a health professional (including a mid-level provider) can be safer than other traditionally used methods, particularly unsafe methods such as sticks or tubes inserted into the uterus or hazardous substances.
In 2003, the World Health Organization (WHO) published its first technical and policy guidance for governments and health professionals on safe abortions. Medical abortion drugs were included as key elements, based on almost two decades of research which showed that medical abortion drugs are safe and effective.[2] In 2005, WHO added mifepristone and misooprostol to its Model List of Essential Medicines [3] which all countries are supposed to keep available for priority health problems.[3] In 2011, WHO also included both drugs in the List of Essential Medicines for Mothers and Children.[4]
Recent studies have shown that many women, especially in countries where access to legal abortion services is limited, are using and/or considering using these two drugs to self-induce early abortions. Hence, women need accurate information about when and how to use these abortion pills.[5], [6], [7], [8]
However, we urge women to seek medical help if they experience problems and never to try to use these medications at home on their own beyond 8-10 weeks after their last menstrual period.
3. Why do women decide to have an abortion?
The main reason why women seek to have an abortion is that they are pregnant and do not want to have the baby. [9]
Unintended pregnancies are a fact of life. Even where contraceptive use is very high, women may end up with an unintended/unwanted pregnancy. The World Health Organization estimates that even if all contraceptive users were to use their methods perfectly all the time, there would still be six million accidental pregnancies annually. Moreover, some initially wanted pregnancies may become unwanted due to the diagnosis of serious foetal impairment or the woman’s life or health may become at risk during or due to the pregnancy. [2]
Other reasons for seeking abortion include problems in the woman’s relationship; social, economic or practical reasons; women may just have had a baby recently or may feel they are not ready or able to provide for and meet the needs of a child at this time; and some women don’t wish to be mothers at all. There may be serious health problems or mental health reasons why women don’t wish to continue a pregnancy, or they may learn the fetus has genetic anomalies.
Given these and other circumstances not listed here, women may resort to an abortion. We believe motherhood must be chosen and that women have a right to decide not to continue a pregnancy. We believe every abortion should be safe no matter the reasons women may have for this decision.
4. What is medical abortion?
Medical abortion is the termination of pregnancy through the use of a specific medicine or combination of medicines. It is sometimes called “abortion with pills”.
Box: Medical abortion is not the same as emergency contraception
Pills used for emergency contraception (EC), also known as the ‘morning-after’ pill, are used to prevent pregnancy in the several days following unprotected sex. Emergency contraceptive pills are not effective once implantation of a fertilised egg has begun, and will not cause abortion.
EC pills consist of a progesterone-like hormone in much higher doses than in oral contraceptive pills. It is meant to be used in situations such as:
- condom breakage, slippage, or incorrect use
- three or more consecutive missed combined oral contraceptive pills
- failed coitus interruptus (e.g., ejaculation in vagina or on external genitalia)
- failure of a spermicide tablet or film to melt before intercourse
- miscalculation of the periodic abstinence method or failure to abstain on fertile day of cycle
- IUD expulsion
- in cases of sexual assault when the woman was not protected by an effective contraceptive method.
The EC pills should be taken as soon as possible after unprotected sexual intercourse. The sooner they are taken, the more effective they are. If not taken within 120 hours, then EC will not prevent pregnancy.
Alternatively, an intrauterine device can be fitted within 5 days and can also be continued as an ongoing method of contraception.
EC pills are not 100% effective in preventing pregnancy. Taking EC pills does not protect against further acts of unprotected intercourse. They are not appropriate for regular use as an ongoing contraceptive method because of the higher possibility of failure compared to modern contraceptives. In addition, frequent use of emergency contraception would result in more side-effects, such as menstrual irregularities. However, their repeated use poses no known health risks.
EC pills do not protect against HIV or other sexually transmitted infections.
(For more information on emergency contraception see www.cecinfo.org)
5. What medicines are used for medical abortion?
The WHO-recommended combination of medicines for medical abortion is mifepristone and misoprostol.
- Mifepristone is an anti-progestogen
- Misoprostol is a prostaglandin
Mifepristone blocks progesterone receptors, and, if taken in early pregnancy, the uterus can no longer sustain the growing embryo. Mifepristone also triggers an increase in endogenous prostaglandins and dilates the cervix, thus making the uterus more responsive to misoprostol and facilitating abortion. [10] Misoprostol causes uterine contractions. Taken together in an effective dosage (see below), they induce an abortion, very much like a spontaneous abortion or miscarriage. Because mifepristone makes the uterus more sensitive to the muscle-contracting effects of prostaglandins, the combination of the two drugs increases their efficacy.
Brand names: Mifepristone is commonly available as “Mifeprex”, “Mifegyne”, “Mifegest”, or “Mifeprim”. Misoprostol is commonly available as “Cytotec”, “Oxaprost” or “Cytoprost” . Both drugs are also sold under other brand names by specific drug companies in different countries. Medabon® contains both medicines and is the first product to package them together and to be licensed as a combination product..
Misoprostol alone
Where mifepristone is not available, misoprostol is often used alone for medical abortion, but it is not as effective, the abortion can take longer, be more painful, and there may be more side effects. Although the likelihood of a complete abortion is lower than in combination with mifepristone, misoprostol still remains a safer option than invasive and unsafe abortion methods women are forced to resort to where safe abortion services are not available. Even if the abortion process is not completed with misoprostol alone, women can say they are miscarrying and get the abortion completed at a health facility without any need to disclose that misoprostol pills have been used.
Methotrexate and misoprostol
In a few countries where mifepristone is not available, including Canada, the medicine methotrexate has been used in combination with misoprostol, which is very effective but takes much more time. However, methotrexate is not recommended by the World Health Organization (WHO) for inducing abortion, because of concerns that it may increase the risk of fetal malformation in a continuing pregnancy [2].
6. When during pregnancy can medical abortion be used?
Medical abortion can be used from very early on in pregnancy, as soon as a woman misses her period, through the second trimester of pregnancy, and beyond that to induce labour. However, the dosage and regimens are different for pregnancies of gestational age up to 9 weeks, between 9 and 12 weeks and over 12 weeks .[2]
7. Are there any women who cannot use medical abortion?
Almost none. There are very few contraindications to medical abortion. They include if the women:
- has had a previous allergic reaction to mifepristone or misoprostol
- has inherited porphyria, an uncommon disorder of certain enzymes responsible for the formation of the iron-containing pigments in proteins.
- suffers from chronic adrenal failure. Adrenal glands are small, triangular glands located on top of the kidneys which produce a variety of hormones including adrenaline, essential to help the body cope with stress.
- has or is suspected to have an ectopic pregnancy (see BOX Ectopic Pregnancy).
Caution is required if the woman:
- is on long-term corticosteroid therapy (including those with severe, uncontrolled asthma).
- has a haemorrhagic disorder affecting the blood´s ability to clot
- has severe anaemia
- has pre-existing heart disease or cardiovascular risk factors (e.g. hypertension).
If a woman has an intrauterine device (IUD) in place, this should be removed prior to use of medical abortion.
Women with mild to moderate anaemia (haemoglobin levels between 9 and 12 gm/dl) can use medical abortion; it may be beneficial for them to take iron pills no matter which abortion method they use. Women with severe anaemia should be treated for it under the supervision of their doctor/health care provider.
Box: Ectopic Pregnancy
Medical abortion pills will not work if a woman has an ectopic pregnancy, that is, a pregnancy that grows outside the uterus.
The vast majority of ectopic pregnancies occur in the fallopian tube (95%).
Ectopic pregnancy can be asymptomatic in the initial stages. Symptoms of an ectopic pregnancy can often be vague, and include vaginal bleeding, abdominal or pelvic pain (usually stronger on one side), shoulder pain, weakness or dizziness. These symptoms can also occur in other conditions such as ovarian cysts, miscarriages, or even in normal pregnancy.
Occasionally, the doctor may feel a tender mass during the pelvic examination. If an ectopic pregnancy is suspected, blood tests, and ultrasound can be used to help confirm the diagnosis.
A ruptured ectopic pregnancy can be life threatening and needs emergency care.
For more information on ectopic pregnancy please see:
http://www.medicinenet.com/ectopic_pregnancy/article.htm
8. Can a woman use medical abortion if she is breastfeeding?
It is likely that mifepristone passes into breast milk, but no clinical effects have been reported. Small amounts of misoprostol also enter breast milk soon after administration, but it is not known whether this could have any effect on the infant. As misoprostol levels decline rapidly, it has been recommended that misoprostol should be taken immediately after a feed. [11]
9. Is medical abortion safe for women who are HIV positive?
Yes. There is no reason why HIV positive women cannot use medical abortion. HIV positive women may be at risk of reproductive tract infection from retained products of conception if untreated, but this may occur with medical or aspiration abortion. [12]
HIV positive women may also be at risk for anaemia, especially if they have malaria or are taking certain antiretrovirals (ARVs) and iron pills may be prescribed. The small proportion of women, including but not only women with HIV, who develop heavy bleeding following medical abortion need to be treated promptly to avoid serious consequences. [13]
10. Is medical abortion safe for adolescents?
Yes. There is no reason why medical abortion is unsuitable for adolescents. [14]
The availability of medical abortion can be especially helpful for unmarried adolescents and other young women who do not have easy access to services that provide aspiration abortion due to community and/or family barriers or restrictive parental consent requirements.
Women who have never been pregnant before should note that medical abortion may be more painful than for women who have had previous pregnancies, and they may need more pain relief medication.
11. Can a woman use medical abortion if she has a reproductive tract infection?
For women seeking an abortion from a clinic, the health care provider will take a medical history and do a pelvic examination. If a reproductive tract infection (RTI) is suspected, a swab will be taken for a laboratory test or medication may be prescribed for immediate treatment. This can be done alongside use of medical or aspiration abortion; there is no reason to wait for RTI treatment to be completed.
A woman may suspect she has a reproductive tract infection (RTI) because of symptoms such as foul-smelling, white, yellowy or greenish discharge, itching or sores in the genital area, or frequent painful urination. Treatment for RTIs should not be delayed as untreated infection can have serious health consequences, including infertility.
12. Why do women choose medical abortion?
Pregnancy tests can now identify a pregnancy even before a woman misses her period. Where medical abortion is accessible, this means a pregnancy can be terminated very early and effectively.
If women have the choice of surgical or medical abortion, many though not all by any means prefer medical abortion. [5], [6], [7], [8] Studies show that women like medical abortion for a range of reasons:
- They regard it as a more natural process.
- It does not involve surgery or anaesthesia.
- It can be less painful and easier.
- It can be used as soon as a woman learns she is pregnant.
- Women feel more in control of the process because it happens in their bodies.
- They perceive it to be consistent with the body´s natural processes.
- Their privacy can be preserved.
- The medicines may be taken at home.
In most studies, most women who have used medical abortion have said they would use it again and would recommend it to a friend. [15], [16], [17], [18], [19], [20], [21]
Reasons why women prefer aspiration abortion include:
- It can be completed in as little as ten minutes.
- It takes place in a clinic.
- The products of conception are removed so there is less bleeding afterwards.
They don’t have to take any responsibility for the procedure.
13. How does a woman confirm that she is pregnant?
If a woman has been pregnant before she may recognize the symptoms—breast tenderness, frequent urination, nausea, no menstrual period. Pregnancy can be confirmed with a pregnancy test, usually available from pharmacies (See Box Pregnancy Tests).
Box: Pregnancy Tests
All pregnancy tests work by detect¬ing a certain hormone in the urine or blood that is only there when a woman is pregnant. This hormone is called human chorionic gonadotropin (hCG).
In most countries, a home pregnancy test kit is available. This is a urine test. Most of these tests can accurately detect pregnancy one week after a missed period. Also, testing your urine first thing in the morning may boost the accuracy. If this test is positive, it is fairly certain that the woman is pregnant. If the test is negative, it may still be too early to detect the pregnancy because the amount of hCG in the urine is still too low. The urine test is private and easy to use. Most drug¬stores sell them over the counter. They are inexpensive. But the cost depends on the brand and how many tests come in the box.
The blood test for pregnancy is known as a beta hCG test. This measures the exact amount of hCG in the blood. This test is carried out in a clinical laboratory. The blood test can tell whether a woman is pregnant about six to eight days after she ovulates (release of an egg from the ovary). It is more often needed if an ectopic pregnancy is suspected.
A pelvic exam by a midwife or doctor can confirm pregnancy about six weeks after a woman’s last menstrual period. She does not have to wait till then to confirm pregnancy. If a woman does not want to be pregnant, she may prefer to have a pregnancy test as soon as she has missed her period, and make arrangements to have an abortion. [26]
14. How does a woman find out how many weeks she has been pregnant?
Women seeking an abortion will be asked how many weeks pregnant they are and this will be checked by the health care provider. It is important with medical abortion because the dosage differs at different stages of pregnancy.
There are different ways to find out the duration of pregnancy:
- Calculating the number of days that have passed since the first day of the woman’s last menstrual period (LMP). Many women make a note of the first day of each menstrual period on a calendar so that they can check it if needed.
- Through a pelvic examination carried out by a health care provider. An experienced provider will be able to assess the duration of pregnancy through a pelvic examination starting from around six weeks LMP.
- Having an ultrasound scan if:
– the woman is not sure of the date of her last menstrual period and a pelvic examination is also inconclusive, or
– she has become pregnant without resuming her period after an abortion or childbirth.
15. How does medical abortion compare with surgical abortion in pregnancy up to 9 weeks?
|
16. What are the different regimens used for medical abortion up to 9 weeks of pregnancy?
The following regimens and dosages are based on the latest recommendations from the World Health Organization:
The recommended regimen is 200 mg of mifepristone administered orally, followed 24–48 hours later by 800 micrograms of misoprostol administered vaginally, sublingually or buccally or 400 micrograms of misoprostol administered orally. With gestations up to 7 weeks (49 days) misoprostol may be administered by vaginal, sublingual, buccal or oral routes. After 7 weeks of gestation, oral administration of misoprostol should not be used.
17. What are the different regimens used for medical abortion after 9 weeks of pregnancy?
9-12 weeks (63-84 days) LMP
The recommended regimen is 200 mg of mifepristone administered orally, followed 36–48 hours later by 800 micrograms of vaginal misoprostol, administered in a health facility. A maximum of 4 additional doses of 400 micrograms misoprostol may be administered at 3-hour intervals, vaginally or sublingually, until expulsion of the products of conception.
After 12 weeks (>84 days) LMP
The recommended regimen for pregnancies between 12 and 24 weeks is 200 mg of mifepristone administered orally, followed 36–48 hours later by 400 micrograms of oral misoprostol or 800 micrograms of vaginal misoprostol, administered in a health facility. Subsequent misoprostol doses should be 400 micrograms administered either vaginally or sublingually, every 3 hours up to four further doses.
For pregnancies beyond 24 weeks, the dose of misoprostol should be reduced due to the greater sensitivity of the uterus to prostaglandins; the lack of clinical studies prohibits specific dosing recommendations.
The use of medical abortion after 9 weeks of pregnancy needs to be under medical supervision in a hospital or clinic setting because of increased risk of complications.
18. Can misoprostol alone be used for medical abortion?
Misoprostol alone is sometimes used for medical abortion in places where mifepristone is not available.
However, without mifepristone, a higher total dose of misoprostol, may be needed, and it is less effective than regimens combining it with mifepristone. In addition, the abortion process can be more painful and side-effects such as diarrhea and chills may be more severe [28]. There is also a higher rate of failed abortion and continuing live pregnancy.
Up to 12 weeks (84 days) LMP
The recommended regimen is 800 micrograms administered vaginally or sublingually. Up to three repeat doses of 800 micrograms can be administered at intervals of at least 3 hours, but for no longer than 12 hours. This regimen has been shown to be 75-90% effective. Sublingual administration is less effective than vaginal administration unless given every 3 hours, and this regimen has higher rates of gastrointestinal side-effects [45], [46], [47]. Oral administration is less effective and therefore not recommended.
After 12 weeks (84 days) LMP
Misoprostol used alone is effective after 12 weeks LMP but the time to complete abortion is usually longer than when used in conjunction with mifepristone. The recommended dose is 400 micrograms administered vaginally or sublingually every 3 hours for up to 5 doses [29], [30].
Caution is needed in the use of misoprostol alone for pregnancies above 9 weeks. The dosages of misoprostol must be reduced as the duration of pregnancy increases because the uterus gradually becomes increasingly sensitive to prostaglandin. There is a risk of rupture of the uterus, especially after 16 weeks of pregnancy and in women who have a scar from a previous caesarean section [2].
19. What is the failure rate of medical abortion?
A successful medical abortion is defined as complete termination of pregnancy without the need for a surgical procedure. Efficacy decreases as pregnancy progresses. The mifepristone and misoprostol regimen is the most effective (95%-98%) during the first nine weeks of pregnancy. The methotrexate and misoprostol regimen is highly effective in the first seven weeks of pregnancy (95%) but is less effective after 49 days (82% by the 8th week of pregnancy).
The most recent studies on the use of misoprostol alone for early pregnancy termination suggest an efficacy rate of 75%-85%. This efficacy is based on the vaginal administration of 800 micrograms of misoprostol followed 24 hours later with another 800 micrograms vaginally. (http://medicationabortion.com/questions/effective.html)
20. How long does it take to terminate a pregnancy with medical abortion?
When a mifepristone/misoprostol regimen is used for medical abortion in pregnancy up to 9 weeks, 2-3% of women may abort after taking the mifepristone and before using misoprostol. In the 4-6 hours after misoprostol use, almost two thirds of women, depending on gestational age, will expel the products of conception [31].
After 9 weeks of pregnancy, the more advanced the pregnancy, the longer it takes to have a complete abortion [32], [33]. In one study, the time it took for a complete abortion was about six hours for women with previous deliveries and about 8 hours for women with no previous deliveries. More than 70% of the women went home the same day [34].
There is a lot of variability in the reported time needed for abortion with misoprostol alone up to 9 weeks of pregnancy, depending on the duration of pregnancy, dosage and route of administration. One study reported that 72%–86% of women aborted within 24 hours. [35]
21. How many clinic visits are required for a medical abortion? What happens during each visit?
There may be needed up to two or three clinic visits with pregnancies up to 9 weeks, and three clinic visits for pregnancies of more than 9 weeks’ duration.
First/second visit
When mifepristone/misoprostol combination is used up to 9 weeks of pregnancy the health care provider:
- explains abortion procedures and asks woman to choose the method she prefers
- takes a medical history. (It is important to advise the abortion provider if you are taking any other prescription or non-prescription drugs or herbal medicines or preparations when seeking medical abortion, in case they may interfere with the action of mifepristone. [36] )
- confirms length of the pregnancy
- gives her mifepristone to be taken orally
- either asks her to return in 24-48 hours for the misoprostol pills to be administered in the clinic (where the woman is kept under observation for 4-6 hours as 90% of women will abort during that time) or gives her the misoprostol pills to use at home and advises her how to use them.
- gives her a painkiller and an anti-nausea medication to help cope with the side effects the woman will experience once she has administered the misoprostol pills.
In many countries, women are not required to come back for the misoprostol and can use it at home. They only need to come back after about 14 days to confirm completion of the abortion and be offered a method of contraception.
For women who use the misoprostol in the clinic, if abortion does not occur within the observation period, the woman may be allowed to go home to abort.
If the woman leaves the clinic right after misoprostol administration, the woman needs to know that abortion may start or occur before she reaches home.
For pregnancies of more than 9 weeks duration, the woman is asked to return to the clinic 36-48 hours after she takes the mifepristone and the misoprostol is administered by a health care provider in the clinic. The misoprostol is administreted inserted vaginally, followed by several additional doses vaginally or sublingually orally until abortion takes place.
Follow-up visit
It is important to confirm that the pregnancy has indeed been terminated after medical abortion. If expulsion of the products of conception is confirmed by a provider or by the woman herself before or more usually after administration of misopostol, further follow-up is not absolutely necessary. Otherwise, a follow-up visit should be arranged about 2 weeks after the administration of misoprostol, at the convenience of the woman. [2]
During this visit, the health care provider:
- carries out a physical examination, or a hCG blood test to confirm that the pregnancy has been terminated
- if in doubt after the physical exam, performs an ultrasound exam to confirm termination of pregnancy
- if abortion is not complete, either asks the woman to come back after a few more days, as the abortion may be complete by then, or administers further misoprostol, or performs an aspiration procedure to complete the abortion.
- offers her an appropriate method of contraception.
22. What about using medical abortion pills at home?
In pregnancies of up to 9 weeks, there is no reason why home use of mifepristone and misoprostol or misoprostol alone should be unsafe, provided the woman has accurate information about whether she can safely use the two medicines, she knows the best dosage and regimen, she is prepared for the side effects and know what medication to use for them, and she is aware of possible complications and has access to medical care if needed.
After 9 weeks of pregnancy, however, misoprostol is recommened to be given in the health care facility .
23. What is the experience of medical abortion like?
Women who use medical abortion will experience period like/menstrual-like cramps, pain in the abdomen and bleeding. For most women, uterine cramps and vaginal bleeding start between one hour and seven hours after they take misoprostol. A few (5%) of women will start to have cramps as soon as they take mifepristone.
Vaginal bleeding is heavier than menstruation while abortion is occurring and the products of conception are being expelled. This heavy bleeding lasts only a short period of time, about 1-4 hours. Light bleeding and spotting will continue for 9-13 days. In rare cases, women may experience light bleeding for up to 45 days after the abortion occurs. [2] The amount of bleeding depends on the duration of pregnancy.
Many women compare the process to a miscarriage. Women may also notice passing of blood clots, tissue and/or products of conception.
Women may experience other side effects such as diarrhoea, nausea, vomiting, headache, dizziness, back pain and tiredness. These side effects occur after misoprostol administration but last only about 2-4 hours. Several studies show that nausea, vomiting and diarrhoea with vaginally administered misoprostol are fewer as compared to taking misoprostol orally. [37]
24. What are the side effects of medical abortion, and how can they be managed?
Bleeding
- A small number of women develop bleeding after mifepristone alone. It is a good idea to have sanitary pads available (bought from the shops or home-made).
- In settings that require women to return to the health facility to take misoprostol, again, the woman should go prepared with sanitary pads in case she develops bleeding before returning home.
- It is possible that some women cannot afford to buy sanitary pads from the pharmacy to last the entire duration of bleeding. It is important for a woman to wash and sun-dry home-made sanitary pads and make sure that she changes pads as soon as they get soaked and she begins to feel discomfort because of the wetness.
- It is important not to use tampons while the bleeding is going on.
Pain
- Cramps and pain experienced by women are variable. Three to six out of ten women experience only mild pain and do not even need pain relief. Others may experience cramps that range from those comparable to menstrual cramps to severe cramps.
- It may be good for the woman to be accompanied home from the health facility in case she develops pain and cramps.
- When at home, the woman may lie down or sit comfortably to relieve pain. She may try to relax by listening to music, watching television, talking to friends/family members, taking a warm shower (not a hot bath) or using a hot water bottle or heating pad on her abdomen for pain relief. [10]
- The woman may have been given pills for pain relief by the health provider on her first or second visit to the clinic. These may be taken as instructed. If no painkillers have been prescribed, she can take one available without prescription, such as Ibuprofen.
Nausea, vomiting, chills and diarrhoea
- Eating lightly and consuming plenty of fluids will help if nausea, vomiting or diarrhoea develop. If these symptoms become severe, and a woman is unable to keep any food down, she should contact her health care provider for medication to control these. [15]
- Alcohol and narcotic drugs should not be taken when mifepristone and/or misoprostol have been taken, at least until after the completion of abortion. [37]
- If a woman vomits within half an hour of taking an oral dose of misoprostol, she should take a repeat dose of the drug.
- Chills and a mild rise in temperature usually occur immediately after misoprostol has been taken. These are side effects of the medication, not signs of infection, and usually last only about 2 hours.
25. What are the complications of medical abortion, and what can be done about them?
Heavy or excessive bleeding
In rare instances, the woman may experience excessive uterine bleeding. Such heavy bleeding usually occurs 1-3 weeks after taking the medications (this is different from the bleeding expected to happen after taking misoprostol).
A woman will know that bleeding is too heavy if
- two thick sanitary pads get soaked with blood within 1 hour, and
- this happens 2 hours in a row, i.e. she has to use four pads in two hours
About 1-2 in 1000 women experience bleeding that is so heavy that they need a blood transfusion. [38]
A woman should contact her health care provider without delay if she has such heavy bleeding.
On average, vaginal bleeding gradually diminishes over about two weeks after a medical abortion, but in individual cases spotting can last much longer. Generally, bleeding after medical abortion lasts longer than after vacuum aspiration. If the woman is well, neither prolonged spotting nor the presence of tissue in the uterus (as detected by ultrasound) is an indication for surgical intervention. Remaining products of conception will be expelled during the subsequent menstrual bleeding. Surgical evacuation of the uterus may be carried out at the woman’s request or if the bleeding is heavy or prolonged, or causes anemia, or if there is evidence of infection.
Infection
Less than 1% of women have been found to develop infection after medical abortion. [39] Infection may be suspected if
- a woman develops a fever above 100.4o F (38.0o C) that lasts more than 4 hours, or
- if fever starts 6 to 8 hours after she has taken misoprostol.
The woman needs medical help if she develops these symptoms. She may be treated as an outpatient and sent home, or may need to be admitted to hospital as an inpatient for treatment, depending on the severity of the infection and the need for observation and further tests.
26. How safe is medical abortion?
Eight deaths reported in the USA, one in Canada, and one in Portugal following medical abortion have been associated with infection from the anaerobic bacterium Clostridium sordellii [40], [41].
Clostridium sordellii is a spore found in soil. How and why it was involved in these deaths is not yet understood. However, in none of these deaths was there evidence suggesting that the use of mifepristone or misoprostol was implicated. The U.S. Centers for Disease Control and Prevention held a symposium in May 2006 and found no evidence that such deaths were linked to the drugs used for medical abortion. Fatal infections from Clostridium sordellii have been known to occur in women following childbirth and miscarriage as well. These infections, as well as those occurring after medical abortion, are extremely rare. It has been and remains standard practice in the United States, Sweden, the UK and in many other countries to administer misoprostol vaginally. In other countries, misoprostol has typically been administered orally. Again, there is no evidence to suggest that the route of administration of misoprostol was related to infection from Clostridium sordellii.
Moreover, no deaths from Clostridium sordellii infection have been reported among the more than three million women outside the United States who have used medical abortion to date. In China, where more than 22 million women have used medical abortion, there have been no reports of this infection either, though data are limited.
27. How would a woman know if the pregnancy has not been terminated?
A woman may suspect that the pregnancy is ongoing if
§ there is no or only slight bleeding after taking the drugs for medical abortion
§ she continues to experience symptoms of pregnancy.
If there is reason to suspect that pregnancy is ongoing, or that abortion is incomplete, a pelvic or ultrasound scan may be done and/or beta hCG pregnancy test.
If pregnancy is found to be ongoing, she may be given a further dose(s) of misoprostol. Or the pregnancy can be terminated surgically right away or as soon as possible using vacuum aspiration.
28. Is there a concern about birth defects in case pregnancy is not terminated?
Very few pregnancies are carried to term after using medical abortion. In the few cases reported, the infant was born normal.
The few studies that examined the risk of birth defects have concluded that there may be a slightly higher risk of birth defects in infants born after use of misoprostol that pertain to the central nervous system and lower and upper limbs. [42] Mifepristone does not cause birth defects. [2]
29. How long after having a medical abortion can women resume sexual intercourse?
After having medical abortion a woman should be recommended not to engage in vaginal sex or insert tampons or any other object into her vagina for about one week after the drugs have been taken, and/or until she feels ready to do so.
30. How long after having a medical abortion can a woman become pregnant?
If she does not use an effective method of contraception, a woman can become pregnant again before her first menstrual period. Conception can occur within 10 days to two weeks after having a medical abortion, depending on the length of her menstrual cycle.
31. How long after a medical abortion will a woman resume normal menstruation?
A woman can expect to have normal menstruation within about four to 6 weeks after medical abortion, provided she has not become pregnant again.
32. When can a woman start using contraception after medical abortion?
Ideally, pre-abortion counseling includes the discussion about future contraceptive needs. In helping a woman to choose the most appropriate contraceptive method for the future, it may be useful if providers explore the circumstances in which the unwanted pregnancy occurred. The goal of contraceptive counseling and provision in the context of abortion care is to begin the chosen method immediately after the abortion. If the woman chooses a method that cannot be started immediately should be encouraged to use condoms in the meantime.
A woman can start using contraception on the same day as she takes misoprostol. Suitable methods are: oral pills, hormonal injectables and implants. Barrier methods of contraception such as the condom, contraceptive jellies and foams, cervical cap and the diaphragm can be used when sexual intercourse is resumed.If a woman wants to have an intrauterine device (IUD) inserted, she will have to wait till the abortion is complete and all products of conception have been expelled. [15]
As for sterilization after medical abortion, the procedure may be carried out any time after the abortion.
The woman’s partner can have a vasectomy done at any time.
33. Does medical abortion have any long-term effects on a woman’s health?
No. Medical abortion has not been fund to have any long-term negative effects on a woman’s health. Instead, it may contribute positively to her well-being by removing the stress and negative consequences of unwanted pregnancy.
34. Will medical abortion affect a woman’s ability to have a child in the future?
No. Medical abortion will not affect a woman’s ability to become pregnant and have a child in future. One study from China that has looked at women’s subsequent pregnancies and their outcomes after one medical abortion found no adverse effects on the outcome. [43] Another large study found no adverse effects on subsequent fertility or pregnancy outcomes. [44]
35. Are there any adverse effects associated with having more than one medical abortion?
There are no data on a negative effect of having more than one medical abortion on women’s reproductive health.
36. How expensive is medical abortion?
Costs of medical abortion vary widely across countries depending on:
- cost of mifepristone (especially if imported)
- cost of misoprostol
- cost of clinic visit(s)
- cost of pregnancy testing
- cost of ultrasound (if used)
However, now that mifepristone is off patent and generic brands of these pills are available, the cost should be low.
The cost also depends on how abortion services are paid for, and whether medical abortion is covered by public financing or health insurance.
37. What options do women have in countries where abortion is legally restricted?
Every woman should have the right to terminate an unwanted pregnancy safely. Unfortunately, abortion is legally restricted in many countries.
In most countries where abortion is legally restricted it is unlikely that mifepristone will be registered. But misoprostol may be widely available since it is registered for treatment of gastric ulcer.
Use of misoprostol bought over the counter from pharmacies is widespread in Latin America, the Caribbean, Asia and in a growing number of African countries. Experience from countries such as Brazil and Chile showed as early as the late 1980s that medical abortion was safer than the invasive alternatives that women may be forced to use to induce an abortion. [2]
Accessing a health facility after home-use of misoprostol to complete the abortion will facilitate prevention or timely management of any complications. Misoprostol offers women living in countries with legal restrictions on abortion an important alternative to dangerous abortion methods.
In recent years in countries as diverse as Indonesia, Pakistan, Bolivia, Kenya, Uganda, Malawi, Tanzania, Chile, Ecuador, Mexico, Venezuela, etc., with legally restricted abortion, hotlines have been developed to provide women with good quality information and counselling on how to have a safe abortion at home using misoprostol. Some of these initiatives also assist women to find to friendly health care facilities for completing the abortion if needed. Many websites have also been launched which offer information on medical abortion.
Conclusion
We believe it is essential that women have enough information to be able to get a safe abortion when they need it. This information package is intended as a contribution to their knowledge, and we hope women will share the information in it widely with each other.
References
[1] – UNWomen. Progress of the World´s Women in Pursuit of Justice, 2011-2012, NY, 2011. [2] – World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: WHO, 2012. [3] – Essential Medicines: WHO Model List (revised March 2005) 14th edition from http://whqlibdoc.who.int/hq/2005/a87017_eng.pdf. [4] – WHO. Priority Medicines for Mothers and Children, 2011. WHO/EMP/MAR/2011.1, Geneva. [5] – Winikoff B. Acceptability of medical abortion in early pregnancy. Family Planning Perspectives 1995; 27 (4): 142-8, 85. [6] – Laufaurie MM, Grossman D, Troncoso E, Billings DL, Chavez S. Women´s perspectives on medical abortion in Mexico, Colombia, Ecuador and Peru: a qualitative study. Reproductive Health Matters 2005; 13 (26): 75-83. [7] – Beckman LJ, Harvey SM. Experience and acceptability of medical abortion with mifepristone and misoprostol among US women. Women Health Issues 1997; 7 (4): 253-62. [8] – Winikoff B, Sivin I, Coyaji K. The acceptability of medical abortion in China, Cuba and India. International Family Planning Perspectives 1997; 23:73-78,89. [9] – Abortion Rights Coalition of Canada, Position Paper # 26, Why do women have abortions?, 2006. [10] – Blumenthal P, Clark S, Coyaji KJ, Ellertson CH, Fiala C, Mazibuko T, Quy Nhan V, Ulmann A, Winikoff B. Providing medical abortion in low-resource settings: an introductory guidebook. Second Edition, New York, 2009. [11] – Vogel D, Burkhardt T, Rentsch K et al. Misoprostol versus methylergometrine: pharmacokinetics in human milk. American Journal of Obstetrics and Gynecology, 2004, 191:2168-2173. [12] – Delvaux T and Nöstlinger C. Reproductive Choice for Women and Men Living with HIV: Contraception, Abortion and Fertility, Reproductive Health Matters 2007;15(29 Supplement):46–66. [13] – 13. de Bruyn M. Safe abortion for HIV-positive women with unwanted pregnancy: A reproductive right. Reproductive Health Matters, 2003; Vol.11 No. 22: 52-61. [14] – Grimes DA and Raymond EG, Medical abortion for adolescents, BMJ 2011; 342:d2185. [15] – Gynuity. Providing medical abortion in developing countries: An introductory guidebook. New York, Gynuity Health Projects, 2004. [16] – Ashley Gresh and Pranitha Maharaj. A qualitative assessment of the acceptability and potential demand for medical abortion among university students in Durban, South Africa. The European Journal of Contraception and Reproductive Health Care, April 2011;16:67–75 [17] – Pak Chung Ho, Women’s perceptions on medical abortion. Contraception 74 (2006) 11 – 15. [18] – Selma Hajri, Jennifer Blum, Nabiha Gueddana, Habib Saadi, Leila Maazoun, Hela Che´lli, Rasha Dabash, Beverly Winikoff. Expanding medical abortion in Tunisia: women’s experiences from a multi-site expansion study. Contraception 70 (2004) 487– 491 [19] – Anneli Kero, Marianne Wulff and Ann Lalos. Home abortion implies radical changes for women, The European Journal of Contraception and Reproductive Health Care, October 2009;14(5):324–333. [20] – Ganatra B, Kalyanwala S, Elul B, Coyaji K and Tewari S. Understanding women’s experiences with medical abortion: In-depth interviews with women in two Indian clinics, Global Public Health Vol. 5, No. 4, July 2010, 335-347. [21] – Moreau C, Trussell J, Desfreres J, Bajos N. Medical vs. surgical abortion: the importance of women’s choice. Contraception. 2011 Sep;84(3):224-9. [22] – Ganatra B. Contrasts and Common Ground: The Context of Abortion in Asia. Presentation at Medical Abortion: An International Forum on Policies, Programmes and Services, 17-20 October 2004, Johannesburg, South Africa [23] – Elul B, Peralman E, Sorhaindo A, et al. In-depth interviews with medical abortion clients: Thoughts on the method and home administration of Misoprostol. Journal of the American Medical Women’s Association Volume 55, no. 3 supplement 2000 pp 169-172. [24] – Gresh A and Maharaj P. A qualitative assessment of the acceptability and potential demand for medical abortion among university students in Durban, South Africa. The European Journal of Contraception and Reproductive Health Care, April 2011;16:67–75 [25] – Mitchell EMH, Kwizera A, Usta M, Gebreselassie H . Choosing early pregnancy termination methods in Urban Mozambique. Social Science & Medicine 71(2010) 62e70. [26] – http://www.womenshealth.gov (as at September 2011) [27] – Shannon CS, Winikoff B. (editors). Misoprostol: An emerging technology for women’s health. Report of a seminar. New York, Population Council, 2004. [28] – Ngoc NT, Shochet T, Raghavan S, et al.Mifepristone and misoprostol compared to misoprostol alone for second-trimester abortion. Obstetrics & Gynecology 2011;118(3):601-8. [29] – Wildschut H, Both MI, Medema S, Thomee E, Wildhagen MF, Kapp N. Medical methods for mid-trimester termination of pregnancy. Cochrane Database of Systematic Reviews 2011;(1): CD005216. [30] – Ho PC, Blumenthal PD, Gemzell-Danielsson K, Gómez Ponce de León R, Mittal S, Tang OS. Misoprostol for the termination of pregnancy with a live fetus at 13 to 26 weeks. International Journal of Gynaecology and Obstetrics 2007;99 Suppl 2:S178-81. [31] – Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. New England Journal of Medicine 1998;338(18):1241-7. [32] – Clinical Guidelines: medical abortion 13–20 weeks. London: bpas, 2005. [33] – Hamoda H, Ashok PW, Flett G, et al. Medical abortion at 9–13 weeks’ gestation: a review of 1,076 consecutive cases. Contraception 2005;71:327–32. [34] – Fiala C, Swahn ML, Stephansson O, et al. The effect of non-steroidal anti-inflammatory drugs on medical abortion with mifepristone and misoprostol at 13-22 weeks gestation. Human Reproduction 2005;Aug 11 (Abstract only, e-publication). [35] – Jain JK, Dutton C, Harwood B et al. A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy. Human Reproduction 2005;17(6):1477-1482. [36] – US Food and Drug Administration. FDA Alert for Healthcare Professionals: Mifepristone (marketed as Mifeprex), 22 July 2005. At: http://www.fda.gov/cder/drug/InfoSheets/HCP/MifepristoneHCP.pdf and http://www.fda.gov/cder/drug/infopage/mifepristone/mifepristone-qa20050719.htm . Accessed 29 August 2005. [37] – www.ppnyc.org/services/factsheets/mifep.htm referred on 2 June, 2005. [38] – Gynuity. Providing Medical Abortion in Low-Resource Settings: An Introductory Guidebook. Second edition. New York (NY, USA): Gynuity Health Projects, 2009. (http://gynuity.org/resources/info/medical-abortion-guidebook/) [39] – Shannon C, Brothers LP, Philip NM, et al. Infection after medical abortion: a review of the literature. Contraception 2004; 70:183–90. [40] – Meites E, Zane S, Gould C; C. sordellii Investigators. Fatal Clostridium sordellii infections after medical abortions. New England Journal of Medicine 2010;363(14):1382-3. [41] – Zane S, Guarner J. Gynecologic clostridial toxic shock in women of reproductive age. Current Infectious Disease Reports 2011;13(6):561-70. [42] – Consensus Statement: Instructions for use – Abortion induction with misoprostol in pregnancies up to 9 weeks LMP. Expert Meeting on misoprostol sponsored by Reproductive Health Technologies Project and Gynuity Health Projects. July 28, 2003, Washington D.C. [43] – Chen A, Yuan W, Meirik O et al. Mifepristone-induced early abortion and outcome of subsequent wanted pregnancy. American Journal of Epidemiology 2004;160(2):110-117. [44] – Jasveer Virk, M.S., M.P.H., Jun Zhang, Ph.D., M.D., and Jørn Olsen, M.D., Ph.D.Medical Abortion and the Risk of Subsequent Adverse Pregnancy Outcomes. New England Journal of Medicine, Volume 357:648-653, August 16,2007, Number 7. [45] – 45. Kulier R, Kapp N, Gülmezoglu AM, Hofmeyr GJ, Cheng L, Campana A. Medical methods for first trimester abortion. Cochrane Database of Systematic Reviews 2011(11):CD002855. [46] – 46. von Hertzen H, Piaggio G, Wojdyla D, et al. Two mifepristone doses and two intervals of misoprostol administration for termination of early pregnancy: a randomised factorial controlled equivalence trial. BJOG: an International Journal of Obstetrics & Gynaecology 2009;116(3):381-9. [47] – 47. Faúndes A, Fiala C, Tang OS, Velasco A. Misoprostol for the termination of pregnancy up to 12 completed weeks of pregnancy. International Journal of Gynaecology and Obstetrics 2007;99 Suppl 2:S172-7.
