Update Feb. 21, 2023: Listen to the two-minute audio version of this story, produced by Texas News Service reporting for the Ms. magazine-Public News Service Collaboration:
Mifepristone’s future is shaky—but women and pregnant people can still access misoprostol, a highly effective and medically safe method to end an early pregnancy.
Over half of clinician-supervised abortions in the U.S. in 2020 were done with a combination of two medications: mifepristone and misoprostol. A Trump-appointed judge in Texas will soon decide a lawsuit brought by anti-abortion extremists asking him to force mifepristone off the market in all 50 states. If he does, as anticipated, reproductive rights advocates are ready to offer a safe and effective alternative to end pregnancy through three months: a higher dosage of misoprostol taken alone.
Misoprostol is a widely available ulcer medication that can induce a miscarriage by causing contractions of the uterus to expel a pregnancy. In the 1980s, Brazilian women began using misoprostol to end their pregnancies because abortion was unavailable through the medical system. Self-managed abortion with misoprostol resulted in precipitous declines in infection, hemorrhaging and death from unsafe abortion.
Today in countries where abortion is legally restricted, misoprostol is often used alone for self-managed abortion because it is inexpensive and widely available, often over the counter, unlike mifepristone.
Many studies from around the world have found that self-managed abortion with misoprostol alone is 93 to 99 percent effective and very safe. Because of the widespread availability of mifepristone in the United States, the use of the misoprostol alone for abortion had not been studied here, until recently.
On Feb. 6, researchers at the University of Texas at Austin published peer-reviewed research on the use of misoprostol alone for abortion. The research found that misoprostol alone was over 88 percent effective, with few incidents of serious adverse events or signs of potential abortion complications.
“This is the first U.S.-based study on misoprostol alone for self-managed abortion and it’s coming at this critical time where we don’t know what’s going to happen with access to mifepristone,” said the study’s lead author, Dana M. Johnson, a Ph.D. candidate in public policy and demography at the University of Texas at Austin and a senior associate research scientist at Ibis Reproductive Health. “Our contribution with this study is to add to the broad evidence base we have from the international space on how safe and effective misoprostol is.”
The research was based on data from the Vienna-based telemedicine abortion provider Aid Access, which provides telemedicine abortion services with pills in all 50 states in the U.S. Due to pandemic-related challenges shipping mifepristone, Aid Access prescribed misoprostol alone to over one thousand U.S.-based patients in June of 2020. Aid Access physicians either mailed misoprostol directly to patients or sent prescriptions to local pharmacies for pick-up.
“We took a very conservative approach by including just the people who had a totally confirmed, complete abortion at four weeks and didn’t get a surgical intervention,” said Johnson. “That is why our finding is 88 percent effectiveness, which is much lower than the SAFE Study from Ibis, which showed 98 percent effectiveness.”
Published in November of 2021, the SAFE Study—which stands for Studying Accompaniment Feasibility and Effectiveness—showed that 98.8 percent of those who used the misoprostol-alone regimen had a complete abortion without surgical intervention. “SMA with misoprostol only is highly effective, and warrants renewed attention,” it concludes, calling it “no longer a second-tier method, but one that offers similar effectiveness, and often greater accessibility, than the mifepristone and misoprostol regimen.”
This is the first U.S.-based study on misoprostol alone for self-managed abortion and it’s coming at this critical time where we don’t know what’s going to happen with access to mifepristone.Dana M. Johnson
While this research shows misoprostol alone is a little less effective than the combination of mifepristone and misoprostol, extra doses of misoprostol can increase efficacy.
“We did take this conservative approach, but our findings were really, really good. There were very few people who had a serious adverse event. There were very few people who had any kind of treatment for that or a symptom of a potential complication,” added Johnson.
Johnson is now conducting follow-up interviews with the research participants to understand their experiences of using misoprostol alone, which can be more difficult than the combination of mifepristone and misoprostol because the misoprostol-alone regimen calls for multiple doses of the medication, as opposed to one dose if combined with mifepristone. Those who use misoprostol alone may experience stronger cramping. Side effects from misoprostol can include nausea, fever, chills, vomiting and diarrhea, which can be more severe when taking misoprostol alone because of the higher dosage.
Johnson is finding in her research that women’s experiences of using misoprostol are shaped by their mindset and how prepared they felt. Many found information on Reddit.com. The abortion Subreddit is curated by OARS (Online Abortion Resource Squad) with trained, expert volunteers who “ensure that every Reddit post asking for abortion-related help gets a quality, accurate, compassionate answer and referral to resources.”
“People asked a lot of questions and that brought a sense of comfort because if you know that you can prep your hot water bottle or your ibuprofen or your chamomile tea, you’re going into it with a little bit more of a mindset that you can manage this pain,” said Johnson.
Research from other countries has shown that patients can have positive abortion experiences with misoprostol alone when they have access to the information they need, feel prepared for what they will experience and are supported through the process.
If the Texas court imposes a nationwide ban on mifepristone, women and pregnant people can still access the highly effective and medically safe method to end an early pregnancy with misoprostol alone. And unlike mifepristone, misoprostol is inexpensive and widely available by prescription for different indications in pharmacies throughout the U.S.
While the FDA has not labeled misoprostol for abortion, U.S.-based providers can prescribe the medication off label for this use to patients in states where abortion remains legal. Many telemedicine abortion providers have already pledged to offer misoprostol off label to their patients if mifepristone is removed from the market, including Abortion on Demand, Aid Access, carafem, Choix, Forward Midwifery, Hey Jane and Just the Pill. Planned Parenthood has also said they will offer this service.
National Abortion Federation’s clinical practice guidelines suggest offering misoprostol alone where mifepristone combination is not accessible. The World Health Organization also has guidelines for misoprostol alone as a safe and effective options for abortion care. According to these guidelines, women in the first 12 weeks of pregnancy dissolve four 200 mg of misoprostol between their gum and cheek, three times at three-hour intervals.
“With clinical options for abortion severely limited post-Dobbs, these guidelines are important in affirming self-managed abortion as a safe and essential practice that can be empowering for those seeking to end a pregnancy,” concluded the U.T. Austin study authors. “There is potential for its use in the U.S. as a method of ensuring reproductive autonomy, especially for populations who have been systematically cut off from safe, affordable and non-coercive reproductive healthcare services.”
Plan C provides comprehensive information about where and how to get abortion pills in all 50 states. The Digital Defense Fund offers detailed information about how to protect one’s identity when searching for abortion pill information and purchasing medications online. The M+A Hotline offers free, compassionate and confidential medical support for anyone who would like to speak to a trained medical professional when self-managing an abortion. Repro Legal Helpline can answer legal questions about self-managed abortion.
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