What we really know about abortion with pills: facts & data

As estimated by the World Health Organization (WHO) (2021), 61% (6 out of 10) of unintended pregnancies and 29% (3 out of 10) of all pregnancies end in induced abortion¹.

According to WHO, safe abortion is performed using its recommended guidelines, correct medications (mifepristone and misoprostol), and medical techniques under hygienic conditions ². When performed correctly, abortion is a safe procedure with risks comparable to those of common medical procedures like wisdom tooth removal or colonoscopy³.

There are two main safe abortion methods: abortion using pills (medical abortion) or an in-clinic abortion performed by medical professionals. The 2022 WHO Abortion Care Guideline recommends abortion methods considering access to medical professionals, availability of abortion services, and gestational age. For example, the WHO guidelines recommend self-managed (or performed by the pregnant person) medical abortion guided by medical professionals who provide information and guidance using telehealth before 12 weeks gestational age. For pregnant people past the 12 weeks gestational age, the WHO outlines medical abortion performed in-clinic by a trained medical professional as the recommended procedure. Overall, there are a variety of medical abortion regimens recommended depending on available medications and gestational age to keep medical abortions as safe and effective as possible ⁴.

In places where abortion is criminalized and stigmatized, abortion seekers are at risk because of a lack of resources available to them and great difficulties accessing safe abortion care ⁵ .

• What does it mean when abortion is criminalized?
  • Abortion is criminalized when it is not legal or banned. Even in places where abortion is legal in some circumstances (i.e., in Peru, it is legal for a pregnant person to seek an abortion when their life is at risk), abortion can still be considered criminalized because it is not safely available for all seekers ⁶ . 
• What does it mean when abortion is stigmatized?
  • Abortion stigma refers to when there is a “shared understanding that abortion is morally wrong and/or socially unacceptable” ⁷. Abortion is stigmatized when social institutions, including the government, media, local communities, and individuals, have negative attitudes and behaviors towards abortion and treat people who have had or who seek abortion as inferior. Abortion stigma makes it more difficult for people to seek safe abortions for medical providers to provide abortion care and contributes to harmful myths about abortion (i.e., that abortions are dangerous or unsafe)⁸.

Criminalization and stigmatization of abortion contribute to unsafe abortions. Despite methods that allow abortions to be safe, 45% of abortions are unsafe. 97% of unsafe abortion cases are in middle and low-income countries ⁹. Unsafe abortions are more likely to occur when abortion care is not affordable or not geographically available. Nearly all deaths caused by unsafe abortion procedures are preventable with contraception availability, safe abortion access, and appropriate post-abortion care¹⁰.

Therefore, medical abortion (abortion using pills) with telemedicine has become an essential option for reducing the number of unsafe abortions.

• Telemedicine: The WHO defines telemedicine as healthcare delivery through digital means, such as telephone and video calls, text messaging or email, or voice messages¹¹. 

In recent years, telemedicine has grown to be more common and effective, making it a viable and necessary resource for providing abortion care ¹² . In addition to telemedicine, the pills recommended for medical abortion are essential to abortion care because they have proven to be safe, effective, and a more affordable alternative to unsafe methods, especially for remote areas or restrictive contexts where healthcare facilities may not be as accessible ¹³. 

Medical abortion is an abortion with pills. It is crucial in the fight for decriminalized and safe abortions for all. Medical abortions can reduce barriers to accessing safe abortion care, as abortion medication can be delivered via mail and used outside a clinic setting. By eliminating the need for travel to receive safe abortion care, medical abortions significantly expand access¹⁴. 

Currently, the two medicines used for medical abortion are Misoprostol and a combination of Mifepristone with Misoprostol. Misoprostol alone is used when mifepristone is inaccessible or unaffordable ¹⁵. Misoprostol is used globally because of its lower cost, wide availability, fewer restrictions than mifepristone, straightforward instructions for use, and safety and effectiveness ¹⁶ .

Regarding Misoprostol alone, a study that surveyed 12,829 women showed a 0.7% hospitalization rate¹⁷ . A study that surveyed 13,373 women who completed a mifepristone and misoprostol regimen with a gestation age of up to 63 days showed that this abortion method had an efficacy rate of 97.7%, with a 0.01% rate of infection demanding hospitalization and 0.03% rate of transfusion¹⁸ . These studies confirm that abortion by pills is safe and effective, making them a crucial tool in the fight against unsafe abortions.  

In their 2022 Abortion Care Guideline, the WHO added another safe abortion medication regimen to the medical abortion list: Letrozole in combination with Misoprostol. A 2021 study showed that the use of Letrozole for three days combined with Misoprostol resulted in a significantly higher rate of complete abortions in women up to 12 weeks gestational age compared to Misoprostol alone (81.0% vs. 54.0%) without increasing side effects¹⁹.

The WHO has recognized telemedicine as a harm-reduction strategy for abortion access in contexts where abortion is legally or socially criminalized and where there is a lack of medical providers or healthcare facilities ²⁰ . Medical abortion with telemedicine e-services contributes to substantial declines in abortion-related morbidity and mortality²¹ . It has been demonstrated to be an effective healthcare measurement to guarantee women’s health rights respectfully and non-judgmentally²² .

Telemedicine is used in cases of medical abortions to provide information about how to perform self-managed abortions, how to use the medication regimen, and to provide support and counseling pre- and post-abortion. The Schwangerschaftsabbruch-zuhause “Abortion at home” project in Germany asked their users to rate their telemedicine abortion service. 83% of the users indicated that they would opt for it again using the service, and 93.5% said that they would like the telemedicine service to continue beyond the pandemic²³ .

Participants were generally proactive in prioritizing their well-being and gathering the necessary resources during their abortion experience. However, finding a comfortable and private environment to take misoprostol proved difficult due to challenges like balancing work, childcare responsibilities, covid-19 lockdowns, and privacy issues. A strong emphasis on the need for physical comfort was evident across all participants²⁴ .

Feminist organizations have historically used telemedicine and counseling abortion services as a tool to provide safe abortion in restrictive conditions. The Jane Collective is one of the most recognized feminist hotlines to offer abortion services. It began as an underground service in Chicago that referred women to safe abortion providers when abortion was legally restricted in the United States²⁵ . Their volunteer work supported thousands of women in their ability to access safe abortions from 1969 to 1973. Although they relied on telephone use as a precursor to “telemedicine” their approach is still used by feminist organizations that support women worldwide. Currently, organizations such as Women Help Women, Women on Web, and safe2choose provide telemedical services worldwide, while organizations such as Socorristas en Red (Argentina) support women on the ground with a more local approach.

The WHO recognizes telemedicine and the safe practice of medical abortion when accompanied by non-medical professionals trained in using abortion pills as a harm reduction strategy. These non-trained companions are often feminist activists who follow a Feminist Accompaniment model of Abortion Care.

This approach is rooted in radical political activism and aims to help individuals access safe abortions and exercise reproductive autonomy, regardless of legal restrictions. According to Red Compañera, a Latin America Network of acompañantes,  they seek that abortion seekers can abort autonomously, supported by feminists who advocate for unrestricted abortion, who are accompanied by a place of social justice, happiness, pleasure, and joy²⁶ .

Abortion with accompaniment has proven to be safe; this can be demonstrated by a study that investigates the experiences of individuals who initiated self-managed medication abortions through three abortion-accompaniment groups in Argentina, Nigeria, and Southeast Asia, with a total of 1,352 participants enrolled. Out of these, 19.5% (264/1,352) chose to self-manage their medication abortion at 9 weeks of gestation or later: 75.0% between 9–11 weeks, 19.3% between 12–14 weeks, and 5.7% between 15–22 weeks. The average age of participants was 26 years. The majority (56.4%) used a combined regimen of mifepristone and misoprostol, while 43.6% opted for misoprostol alone ²⁷ .

By the end of the study, 89.4% of participants had a complete abortion without needing additional procedures. Some (5.3%) required a procedure like vacuum aspiration or dilation and curettage to complete the abortion. A few (4.9%) experienced incomplete abortions, and only one participant did not report their result. About 23.5% of participants sought healthcare during or after their self-managed abortions. Most sought confirmation that their abortion was complete (15.9%), while others required further medical assistance (9.1%), such as surgery, antibiotics, or additional medication. Participants who were 12 weeks or more pregnant were more likely to visit a clinic or hospital compared to those who were 9 to 11 weeks pregnant.

In conclusion, most people who used medication to manage their abortions between 9 and 16 weeks of pregnancy completed their abortions successfully. They also sought healthcare for reassurance or to address complications. These findings highlight the importance of supporting safe methods of self-managed abortion and ensuring access to healthcare for those who need it.

Another study that focuses on self-managed abortion up to 12 weeks of pregnancy reported similar results with high numbers of effectiveness without medical interventions ²⁸ . That research follows the abortion outcomes of 1006 participants. Most pregnancies were less than 12 weeks along. Participants managed their own abortions using either misoprostol alone (593 participants) or a combination of misoprostol and mifepristone (356 participants) during follow-up. By the end of the study, 99% of those using misoprostol alone and 94% of those using the combined regimen had successfully completed their abortions without needing further care. For pregnancies less than 9 weeks along, both methods were found to be equally effective compared to abortions managed by healthcare professionals in clinics.

These findings demonstrate that self-managed medication abortions, with support from accompaniment groups, are highly effective. They also show that for pregnancies under 9 weeks, these methods are just as effective as abortions administered in clinical settings.

Accessing abortion at home can be a safe medical experience when the person has the correct information. However, it is not only a medical experience but also a social and personal one. The experience of having an abortion at home can vary depending on the socio-political context of the individual. In a recent study run in the USA conducted with 80 abortion seekers, researchers found that according to the people who had an abortion with pills and telemedicine assistance is a “godsend,” “a safe alternative from the stigma,” “a private support,” and “an excellent attention and care.” Although the participants reported having a good experience with telemedicine, they also spoke of fears of being scammed, shipping delays, and police surveillance ²⁹ .

Furthermore, they mentioned keeping the process secret from family, partners, and friends and fear of being discovered by them. Although the abortion process with telemedicine is generally safe, those seeking abortions are often adversely affected by the stigma surrounding abortion. Therefore, the person’s personal experience can be influenced by those fears.

Another study done in the USA interviewed 31 people who performed a self-managed abortion with the misoprostol-only regimen using telemedicine. Telemedical support was provided through Aid Access, an organization that provides abortion pills and telemedical support to people throughout the US. Even though three participants in the study expressed a desire for the combined mifepristone and misoprostol regimen after having experiences with both combined and misoprostol-only regimens, most participants expressed the desire for an effective abortion method regardless of the medication or regimen. Researchers found that these women faced some challenges in creating a comfortable and private space for themselves during their abortion; this included navigating their work schedule, finding childcare, and privacy concerns. Overall, a need for physical comfort was crucial for participants across the study. The study also found that Aid Access provided these people with the necessary knowledge about misoprostol, instructions for use, and what to expect during a self-managed abortion; that those who had experienced a prior abortion, miscarriage, or reproductive event felt more confident in managing their own abortion; and that choice over medication regimen and ability to create a comfortable physical environment is important in the fight for reproductive autonomy and safe abortions ³⁰ . 

Medical effects 

The experience of having an abortion with pills can vary in duration, amount of bleeding, and potential side effects. A study by Women on Web with 62 women in Japan found that those who used medical abortion had a high satisfaction rate. Of the 62 women, 10 reported having more pain and bleeding than an average menstrual period (which is normal). However, all women said the discomfort and bleeding had decreased within 24 hours. Of the 46 women who used the abortion pills to terminate their pregnancy, 9 visited a doctor to ensure the procedure was successful. Due to the similarity of symptoms between an abortion with pills and a spontaneous abortion, the 9 people who visited the doctor to ensure their abortions were successful were diagnosed with a miscarriage³¹ . This study provides insight into what an abortion with pills looks like and confirms that it is a safe and effective method when following the WHO’s guidelines. 

Misoprostol and Mifepristone are listed on the World Health Organization’s List of Essential Medicines [25]. Mifepristone, which is exclusively used for abortions, is registered in only 96 countries [26]. In contrast, Misoprostol is registered in 122 countries due to its various medical applications, such as treating gastric and duodenal ulcers. Despite its broader medical uses, Misoprostol remains subject to restrictions in many countries [27].

The following map shows where Misoprostol and Mifepristone are registered:

Medical abortions with telemedicine are essential healthcare for girls, women, and people who can become pregnant worldwide. Telemedicine can provide factual and accurate information about pregnancy and abortion, increase access to trained health professionals, and ensure safer abortions. For those seeking abortions in contexts where abortion is criminalized or stigmatized, where access to trained health professionals is limited, or where demographic factors such as rural location and economic status may impact access, telemedicine offers a safe, effective, and more accessible alternative to unsafe methods.

Sources

1. WHO. (17 May 2024). Abortion. Retrieved from https://www.who.int/news-room/fact-sheets/detail/abortion ↩︎
2. ibid. ↩︎
3. ACOG. (n.d.) Abortion Access Fact Sheet. Retrieved from https://www.acog.org/advocacy/abortion-is-essential/come-prepared/abortion-access-fact-sheet ↩︎
4. WHO. (2022). Abortion Care Guideline. Retrieved from https://iris.who.int/bitstream/handle/10665/349316/9789240039483-eng.pdf?sequence=1 ↩︎
5.  Doctors Without Borders. (7 March 2019) Unsafe Abortions: A Preventable Danger. Retrieved from https://www.doctorswithoutborders.org/latest/unsafe-abortion-preventable-danger#:~:text=People%20resort%20to%20unsafe%20abortion,access%20to%20safe%20abortion%20care ↩︎
6.  WHO. (2022) Abortion Care Guideline:Chapter 2. Abortion regulation including relevant recommendations Law & policy Recommendation 1: Criminalization (2.2.1). Retrieved from  https://srhr.org/abortioncare/chapter-2/recommendations-relating-to-regulation-of-abortion-2-2/law-policy-recommendation-1-criminalization-2-2-1/ ↩︎
7. Cockrill, Herold, et al. (n.d.). Abortion Stigma in Brief: What is Abortion Stigma? retrieved from https://assets.website-files.com/58dbdbdd9253572852dfd9f4/593dced4b16e23436d971b5b_White-Paper-SUMMARY-1.pdf ↩︎
8. ibid. ↩︎
9.  WHO. (17 May 2024). Abortion. Retrieved from https://www.who.int/news-room/fact-sheets/detail/abortion ↩︎
10. ibid. ↩︎
11. WHO. (2022). Abortion Care Guideline. Retrieved from https://iris.who.int/bitstream/handle/10665/349316/9789240039483-eng.pdf?sequence=1  ↩︎
12. Ndwabe, Basu, and Mohammed. (Feb 2024). Post pandemic analysis on comprehensive utilization of telehealth and telemedicine. Retrieved from https://www.sciencedirect.com/science/article/pii/S2588914123000333 ↩︎
13.  Jayaweera, Moseson, and Gerdts. (28 Oct 2020). Misoprostol in the era of COVID-19: a love letter to the original medical abortion pill. Retrieved from https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1829406 
    ↩︎
14. Jones, Nash, et al. (Feb 2022). Medication Abortion Now Accounts for More Than Half of All US Abortions. Retrieved from
    https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions
    ↩︎
15.  Jayaweera, Moseson, and Gerdts. (28 Oct 2020). Misoprostol in the era of COVID-19: a love letter to the original medical abortion pill. Retrieved from https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1829406  ↩︎
16. Johnson, Ramaswamy, and Gomperts. (March 2024). Experiences with misoprostol-only used for self-managed abortion and acquired from an online or retail pharmacy in the United States. Retrieved from https://www.sciencedirect.com/science/article/pii/S0010782423004651
    ↩︎
17. Raymond, E. G., Harrison, M. S., & Weaver, M. A. (2019). Efficacy of Misoprostol Alone for First-Trimester Medical Abortion. Obstetrics And Gynecology, 133(1), 137-147. https://doi.org/10.1097/aog.0000000000003017
    ↩︎
18. Gatter, Cleland, and Nucatola. (Apr 2015).  Efficacy and safety of medical abortion using mifepristone and buccal misoprostol through 63 days. Retreived from https://pubmed.ncbi.nlm.nih.gov/25592080/ ↩︎
19. World Health Organization (2022) Introducing telemedicine medical abortion in Germany.
    https://www.who.int/europe/news/item/14-06-2022-introducing-telemedicine-medical-abortion-in-germany
    ↩︎
20.  WHO. (2022). Abortion Care Guideline. Retrieved from https://iris.who.int/bitstream/handle/10665/349316/9789240039483-eng.pdf?sequence=1
    ↩︎
21. WHO. (17 May 2024). Abortion. Retrieved from https://www.who.int/news-room/fact-sheets/detail/abortion
    ↩︎
22.  WHO. (2022). Abortion Care Guideline. Retrieved from https://iris.who.int/bitstream/handle/10665/349316/9789240039483-eng.pdf?sequence=1 ↩︎
23.  World Health Organization (2022) Introducing telemedicine medical abortion in Germany.
    https://www.who.int/europe/news/item/14-06-2022-introducing-telemedicine-medical-abortion-in-germany
    ↩︎
24.  Johnson, Ramaswamy, and Gomperts. (March 2024). Experiences with misoprostol-only used for self-managed abortion and acquired from an online or retail pharmacy in the United States. Retrieved from https://www.sciencedirect.com/science/article/pii/S0010782423004651
    ↩︎
25. Horwitz. (7 Aug 2017). The Jane Collective (1969-1973). Retrieved from https://embryo.asu.edu/pages/jane-collective-1969-1973
    ↩︎
26. Red Compañera. (n.d.). ¿Qué hacemos? Retrieved from https://redcompafeminista.org/que-hacemos/ ↩︎
27. Moseson et al. (2023). Effectiveness of Self-Managed Medication Abortion Between 9 and 16 Weeks of Gestation. Retrieved from https://www.google.com/url?q=https://www.ibisreproductivehealth.org/sites/default/files/files/publications/Effectiveness_of_Self_Managed_Medication_Abortion.810.pdf&sa=D&source=docs&ust=1725126750964082&usg=AOvVaw1DoNeQ4QgNnKXqX-UaFm9i
    ↩︎
28. Moseson et al. (2021). Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): a prospective, observational cohort study and non-inferiority analysis with historical controls. Retrieved from  https://static1.squarespace.com/static/61783165d6d024580fd2a9de/t/6195c3e5d9f6c95d6d087628/1637204965342/21TLGH09
    ↩︎
29. Madera, M., Johnson, D. M., Broussard, K., Tello-Pérez, L. A., Ze-Noah, C., Baldwin, A., Gomperts, R., & Aiken, A. R. (2022). Experiences seeking, sourcing, and using abortion pills at home in the United States through an online telemedicine service. SSM – Qualitative Research In Health, 2, 100075. https://doi.org/10.1016/j.ssmqr.2022.100075
    ↩︎
30. Johnson, Ramaswamy, and Gomperts. (March 2024). Experiences with misoprostol-only used for self-managed abortion and acquired from an online or retail pharmacy in the United States. Retrieved from https://www.sciencedirect.com/science/article/pii/S0010782423004651
    ↩︎
31. Japanese Women’s Experiences of Bleeding and Pain with Medical Abortion. (2021). Women On Web. https://www.womenonweb.org/en/page/21662/japanese-women%E2%80%99s-experiences-of-bleeding-and-pain-with-medical
    ↩︎