Can I take the abortion pill after the first trimester?

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In recent years, medical abortions have increased in the United States, accounting for 54% of abortions performed in 2020 (up from just 39% in 2017). With last month’s abrupt reversal of deer v. Wade, that number is now expected to increase even more despite the legal risks in states where abortion is now criminalized. The reasons are obvious: medical abortion – aka “the abortion pill” – offers a safe way to terminate a pregnancy from the comfort of your home, even in places where abortion is criminalized. Clinics may close and doctors may refuse to perform abortions, but pills remain readily available online.

Like the disappearance of deer has gone from theoretical to imminent to reality, safe self-managed abortion with pills has become a popular topic of public conversation, with guides to telehealth abortion services and instructions for safely terminating a pregnancy with pills appearing in the media landscape. This is a major change from just a few years ago, when the idea that the abortion pill was something you could take on your own, without a doctor’s supervision, like you could take ibuprofen, was relatively marginal.

I first heard about self-managed abortion with pills in early 2017, when I read a guide published by the now-defunct reproductive rights organization International Women’s Health Coalition ( IWHC), where my sister worked. Looking back, there is a stark difference between this IWHC guide and the standard advice circulating today on self-managed abortion. Most resources relegate self-managed abortion to the first trimester, citing the FDA-approved regimen for mifepristone, which limits use to the first ten weeks of pregnancy, or WHO recommendations on self-directed abortion. care, which recognizes self-managed abortion as a safe option. practice during the first 12 weeks of pregnancy. The IWHC guide, which was developed with the help of experts from the Asia Safe Abortion Partnership, Gynuity Health Projects and the Reproductive Health Access Project, doubles that timeline: the resource I originally saw offers guidance on self-managed abortion up to 20 weeks; a later version, which now lives on the Asia Safe Abortion Partnership website, goes up to 24 weeks.

It’s not unusual for defense organizations to push the boundaries of what slower regulators suggest. But it’s not just that: Women on Waves, which facilitates self-managed abortion for people living under the criminalization of abortion, strongly advises versus using pills to terminate a pregnancy beyond 15 weeks; Aid Access, his American project, will not distribute pills to people who are more than ten weeks pregnant. What is the reason for such a discrepancy?

Let’s start with an indisputable fact: a pregnancy can be successfully terminated with pills – either the mifepristone-misoprostol combination or just misoprostol alone – until the second trimester of pregnancy. Regardless of the advancement of the pregnancy, mifepristone blocks the production of progesterone, interrupting the development of the fetus; misoprostol induces contractions, emptying the contents of the uterus in the process (which is why it can be safely used alone for abortions and can also be used to induce labour). Several studies have demonstrated that these pills are a safe and effective method of abortion later in pregnancy; the main difference is that in the last 12 weeks more misoprostol may be needed to ensure complete expulsion – whereas a first trimester abortion only requires four pills of misoprostol after the initial dose of mifepristone, subsequent abortions required up to 12 pills, taken two at a time times every three hours (IWHC guide contains instructions for misoprostol-only abortion, as misoprostol is often easier to obtain in places where abortion is criminalized – it is available without a prescription in many countries, including Mexico, and is commonly found in online pharmacies, often available without a prescription).

Notably, medical professionals already use this regimen to terminate second-trimester pregnancies: in its guide to safe abortion care, Médecins Sans Frontières (MSF) mentions that its guidelines include safe abortion with pills up to at (and sometimes beyond) 22 weeks. “The evidence shows that a second trimester abortion with pills is very low risk and very safe,” says Maura Daly, midwife and sexual and reproductive health counselor at MSF’s operational center in Amsterdam. Studies have shown medical abortion to be over 90% effective, with the main complication being incomplete evacuation of the uterus (a common problem with miscarriages and can be treated with simple vacuum aspiration or D&C – although than in states where abortion has been banned, these post-miscarriage procedures may also be more difficult to access). “In the contexts where MSF works, we have found that medical abortion has helped to significantly increase access to abortion in the first and second trimester, and is one of the key interventions to reduce maternal mortality. and the suffering associated with unsafe abortion,” Daly said. said. Crucially, these pills also don’t stop working after the second trimester: the WHO has issued guidelines on the use of abortion pills to manage intrauterine fetal death up to 28 weeks.

But the effectiveness of the pills is only part of the equation when it comes to self-managed abortion. The further the pregnancy progresses, the more intense the experience can be, not only physically, but also emotionally. While a first-trimester medical abortion may feel like a heavy period, by the time a pregnancy has reached the 24-week mark, an abortion may be closer to a “mini-birth,” according to Dr. Suchitra Dalvie, MD, MRCOG, consultant gynecologist, coordinator of the Asia Safe Abortion Partnership and one of the experts who consulted IWHC on its booklet on self-managed abortion. Assuming this all on your own can be overwhelming – although that doesn’t mean a doctor has to be involved for a second trimester abortion to be successful. “Our experience shows this is safe and effective, as long as the person has access to accurate information, quality medication and appropriate rescue support,” says Daly, who notes that the pills can be a lifesaver when someone one cannot be or does not. ‘t want to be, admitted to the hospital.

A recent study published in The Lancet confirms Daly’s assertion: The article documents the work of abortion support groups in Nigeria and Argentina, which provide a range of support services outside of the clinical system. The vast majority of second-trimester abortions seen in the study were successful without medical intervention, suggesting that it is informed support, more than medical expertise, that enables safe medical abortion even in the second trimester. . Problems are more likely to arise when a person does not take the correct dose or cannot come to a clinic if they do not fully expel the fetus or have other complications, or if the pills that she took are not actually mifepristone. and misoprostol – issues that a network of abortion advocates have worked to address through online education and the provision of pills.

A thornier issue to consider is the legal risks posed by subsequent self-directed abortion, particularly in states where abortion is heavily criminalized. In 2015, an Indiana woman named Purvi Patel was sentenced to 20 years in prison after being convicted of feticide. Much of the lawsuit hinged on the fetal remains she threw in a dumpster (Patel insisted the birth was stillborn and she was released from prison a year later after a judge quashed his sentence). Not only can fetal remains themselves be used as evidence of an abortion; many states have “fetal burial laws” that are easy to break. One way to deal with these challenges is to start the abortion at home, then go to the hospital halfway through and tell the medical staff that you are in the middle of a miscarriage. But this too can be risky: although it is impossible to physically distinguish between a self-directed abortion and a miscarriage, many people have been reported to the police by medical personnel who suspect an abortion (as has happened recently produced with Lizelle Herrera). And once a person has been dragged into the legal system, their internet search history, text messages, emails, and other digital traces can be used to build a case against them (there are resources like Repro Legal Helpline for patients facing legal risks).

Add to that the possibility of being sued for “aiding and abetting” abortion, and it becomes easier to see why so many organizations have remained circumspect in how they talk about self-managed abortion over the past 12 last weeks. It’s one thing to tell people that the WHO has declared self-managed abortion safe for up to 12 weeks – it’s just sharing publicly available medical information. But openly advising people on how to have a medical abortion in the second trimester when they don’t know what their support system is like or if they’re ready to handle the legal risks can seem a lot more treacherous — especially when 93% of abortions occur in the first trimester.

And yet, when we talk about safe, self-managed abortion as a first-trimester-only option, we deny people access to crucial information they could benefit from and use to prepare for a range of scenarios. possible abortions, all the more so as abortion becomes more difficult. to obtain and delays in obtaining pills are becoming more frequent. A recent video from New York Time documents the experience of a woman who manages her own abortion in Texas. The anonymous subject speaks of a race against a 12-week “biological clock” for safe self-managed abortion, a deadline that simply isn’t real. Although an early abortion is much easier, there is no reason to believe that the abortion pills would not have worked if she had taken them at 12 weeks and a day – nor that they would suddenly have become less safe. .

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