Mifepristone, pictured, is one step in the most common medication abortion regimen. Access to it, and to clinical abortion, has become increasingly limited in the year since Roe v. Wade was overturned. | Getty Images/iStockphoto
The regimen is common and considered safe after 10 weeks, but the delays are cause for concern.
Medication abortion is a simple procedure.
A patient takes one medication, mifepristone, which stops the pregnancy from developing, followed one to two days later by another medication, misoprostol, which induces contractions that empty the uterus. The regimen, approved for abortions in the US since 2000, is effective and very safe, according to physicians and researchers, with a low incidence of serious side effects, and it’s the most common method of abortion in the US. It’s approved by the Food and Drug Administration for the first 70 days, or 10 weeks, of pregnancy, though the World Health Organization recommends medication abortion for up to 12 weeks.
Since the Supreme Court overturned Roe v. Wade last summer, however, nothing about abortion is simple anymore. With near-total abortion bans in place in more than a dozen states and gestational limits in several others, the procedure is growing harder to access by the day. Meanwhile, a federal court case is casting further doubt on the future of mifepristone’s availability in the US.
That ongoing march of bans and restrictions is causing delays for many patients — because they have to travel to other states to receive care, because the remaining clinics are overwhelmed with patients, or because they’re using pills mailed from overseas, which can take weeks to arrive.
“Up until the fall of Roe, we had maybe two calls ever asking for advice on using pills in a pregnancy that was over 12 or 13 weeks,” said Linda Prine, a family physician and co-founder of the Miscarriage and Abortion Hotline, which advises callers about self-managing their abortions. Now, she said, the hotline gets such calls as frequently as once a day.
So far, there is little hard data on how many people are using medication abortion after the first trimester. Counting abortions is difficult in an environment where they are often illegal, and existing efforts often do not track how far along a patient is in pregnancy. The increasingly limited access to abortion around the country, however, has experts considering a future in which people use the medications later in pregnancies, beyond the 10 weeks approved by the FDA and outside of clinical settings.
Abortion medications still work past 12 weeks — one study of 224 women between 12 and 20 weeks’ gestation found efficacy rates of 91 to 95 percent — and outside the US, medication abortion after 10 weeks is not uncommon. But the process comes with more severe side effects and slightly higher risk of complications, experts say, and can be frightening for patients who have to go through it alone and without guidance — a more common scenario as more people self-manage their abortions, and as stories of bans and prosecutions have patients unsure who they can trust.
“It’s infuriating and outrageous to me,” Prine said. “These laws are not stopping people from getting abortions; they’re stopping them from getting timely abortions.”
Medication abortions after 10 weeks are safe, according to doctors, but come with more severe side effects
Around the world, there is plenty of precedent for medication abortions later in pregnancy. This method is the norm for second-trimester procedures in Scandinavian countries, said Daniel Grossman, a physician and a professor of obstetrics and gynecology at the University of California San Francisco.
Even in the US, doctors are able to prescribe medication abortion off-label after 10 weeks — in one 2022 study, 33 percent of clinics provided medication abortion after that time period. In its most recent practice bulletin on the topic, the American College of Obstetricians and Gynecologists lists medication as one of the recommended methods of second-trimester abortion; the recommended regimen includes more doses of misoprostol than a first-trimester abortion but is otherwise similar.
Researchers have also studied the method into the third trimester, with some research conducted at up to 28 weeks. They’ve found that mifepristone and misoprostol “are very safe and effective medications and they remain so throughout pregnancy,” said Heidi Moseson, a senior research scientist at Ibis Reproductive Health, a research group focused on reproductive autonomy.
The FDA, for its part, does not continuously review the latest research, instead relying on pharmaceutical companies to submit applications to expand approval of their drugs. The agency expanded its approval of mifepristone from seven weeks’ gestation to 10 weeks in 2016, but has not acted to lengthen the period in which it can be used since then. “Just because the evidence is published in a peer-reviewed journal or even because practice is changing,” Grossman said, “it doesn’t happen automatically.”
Online pharmacies and other groups vary in their policies toward abortions later in pregnancy. Aid Access does not prescribe medication to people who say they are more than 11 weeks pregnant, but instead directs them to abortion funds or other resources, said founder Rebecca Gomperts. Plan C, which provides information and links to online stores that sell abortion medication, does not collect data on how far along visitors are in pregnancy, said co-founder and co-director Elisa Wells. (The website had 209,000 visitors this April, up from 76,000 in April 2022, before the Dobbs decision was announced.)
Complications such as hemorrhage or a retained placenta are slightly more likely after 10 weeks than when the medication is taken earlier. However, one review of the available research found that less than 1 percent of patients had heavy bleeding that required transfusion. “For the most part, in our experience, the pills work very well, and it isn’t common to need to get extra care,” Prine said.
Still, the process of undergoing a second-trimester abortion with medication can be challenging, especially at home. “People who are further in gestation have more pain associated with medication abortions,” Grossman said. Because of the pain and the elevated complication risk, the standard of care in the US has been for medication abortions in the second trimester to take place in medical facilities.
The experience can also look different from a first-trimester abortion. Earlier procedures tend to produce fairly consistent cramping and bleeding over the course of several hours, while later medication abortions more often result in “a big gush of fluid and then passage of the fetus and then some bleeding after that,” Prine said.
Sometimes patients call the hotline frightened, saying things like, “I just passed my pregnancy and it’s the size of my fist.” Others call because the umbilical cord is still connected, or because they haven’t passed the placenta yet and want to know what to do. Much of what they’re experiencing is expected for a second-trimester abortion, but patients don’t necessarily know that.
For now, most callers to the hotline are using a combination of mifepristone and misoprostol. People can self-manage second-trimester abortions with misoprostol alone if mifepristone becomes unavailable, but it is harder to determine when a misoprostol-only abortion is finished. Patients could end up having to take several additional doses of misoprostol, each of which comes with side effects like nausea and diarrhea, Prine said.
Bans and restrictions could push more people to use medication abortion later in pregnancy
Today, 13 states ban abortion, and several others impose strict gestational limits — restrictions that apply to both surgical and medication abortions.
That has left patients there scrambling to access reproductive options. Some are able to travel elsewhere to seek care: In the six months following Dobbs, states such as North Carolina and Illinois, which border states with bans and have fewer restrictions, experienced surges in the number of abortions performed, according to the abortion reporting effort #WeCount. That influx of patients has caused an increase in wait times for clinic appointments in the states that still allow abortion, a phenomenon that can push patients past the legal limits as some states without bans still shrink the window in which people can get care.
Faced with fewer options within the US, more patients are turning to pharmacies and other groups that provide abortion medication from overseas. One study, for example, found an almost 120 percent increase in orders through the Austria-based nonprofit Aid Access in the two months after Dobbs. “Most people can’t travel to other states,” Prine said. So their only option is to get pills “either from underground community networks or online.”
Overseas groups get around US abortion law because they are outside the American legal system and thus more difficult to prosecute or sue. However, the pills can take longer to arrive than if they were shipped or prescribed domestically, meaning that patients will potentially have abortions later in pregnancy.
The confusion and logistical difficulties caused by new abortion restrictions may be causing more delays, too. Patients may first seek an abortion nearby and go online only when that’s impossible to access. “When we see bans go into effect, it delays people,” Moseson said. “Many people will still obtain care, but it pushes them later in pregnancy.”
It also means that clinical care may not be an option, particularly in states with bans. Patients in these areas are often on their own, unsure of what to expect or how to get medical care if they need it — or whether they’ll be criminalized for doing so.
Only two states have laws explicitly banning self-managed abortion, and there are no laws requiring health care providers to report to law enforcement if they believe such an abortion took place, Moseson said. There’s also no blood test or other screening that can determine if someone took abortion medication.
However, many patients remain afraid of legal repercussions if they do end up needing to go to a doctor or hospital for complications. Prosecutors have used laws against mishandling human remains and other crimes to prosecute people suspected of self-managing abortions. In a 2022 analysis of such criminalization by the reproductive justice legal group If/When/How, the vast majority of abortions that led to investigation or arrest took place in the second or third trimester. High-profile cases of criminalization in the news can also make people afraid of going to the hospital. “There are real instances when people need care quickly to save their lives and the confusion around these laws and the real legal repercussions have a very harmful chilling effect,” Moseson said.
“People are just living in such fear in these restricted states,” Prine said. “They just don’t know what’s safe.”
Prine and other abortion rights advocates are calling for shield laws to protect doctors in blue states who want to prescribe abortion medication by telemedicine to patients in red states. Massachusetts already has such a law, and New York state is considering one. The laws could allow more patients to get the medication through US mail, avoiding the long waits sometimes associated with shipping from overseas.
For now, however, legal barriers and logistical hurdles are combining to leave some patients with few options other than a medication abortion later in pregnancy. “I feel for the people who are experiencing this,” Prine said. “This should not be having to happen.”