life after roe

Why Are We Restricting the Abortion Pill to First-Trimester Pregnancies?

Photo-Illustration: by The Cut; Photo: Shutterstock

For the past few years, medication abortions have been on the rise in the United States, accounting for 54 percent of abortions performed in 2020 (up from just 39 percent in 2017). With last month’s gutting overturn of Roe v. Wade, that number is now expected to spike even higher despite the legal risks in states where abortion is now criminalized. The reasons are obvious: Medication abortion — a.k.a. “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 shut their doors and doctors may refuse to provide abortions, but pills remain readily available online.

As the demise of Roe went from theoretical to impending to reality, safe self-managed abortion with pills became a popular public conversation subject, with guides to telehealth abortion services and instructions for safely terminating a pregnancy with pills popping up across the media landscape. It’s a major change from just a few years ago, when the idea that the abortion pill was something you might be able to take all on your own, with no supervision from a doctor, the way one might take ibuprofen, was relatively fringe.

I first learned 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’s a stark difference between that IWHC guide and the standard advice that today gets circulated about self-managed abortion. Most resources relegate self-managed abortion to the first trimester, citing the FDA’s approved regimen for mifepristone, which limits use to the first ten weeks of pregnancy, or the WHO recommendations on self-care interventions, which recognize self-managed abortion as a safe practice through 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 advice on self-managed abortion up to 20 weeks; a later version, which now lives on the Asia Safe Abortion Partnership website, goes all the way up to 24 weeks.

It’s not unusual for advocacy organizations to push the boundaries of what more slow-moving regulatory bodies suggest. But this isn’t just that: Women on Waves, which facilitates self-managed abortion for people living under abortion criminalization, strongly advises against using pills to terminate a pregnancy past 15 weeks; Aid Access, its U.S.-facing project, will not dispense pills to people who are more than ten weeks pregnant. What’s the reason for so much discrepancy?

Let’s begin with an indisputable fact: A pregnancy can be successfully terminated with pills — either the mifepristone-misoprostol combo, or just misoprostol alone — well into the second trimester of pregnancy. Regardless of how far along a pregnancy has progressed, mifepristone blocks progesterone production, halting fetal development; misoprostol induces contractions, emptying the contents of the uterus in the process (which is why it can be safely used on its own for abortions and can also be used to induce labor). Multiple studies have demonstrated that these pills are a safe and effective abortion method later in pregnancy; the primary difference is that past 12 weeks, more misoprostol may be needed to ensure complete expulsion — while a first-trimester abortion requires only four misoprostol pills after the initial mifepristone dose, later abortions have required as many as 12 pills, taken two at a time every three hours (the IWHC guide contains instructions for a misoprostol-only abortion, as misoprostol is often easier to get ahold of in places where abortion is criminalized — it’s available over the counter in many countries, including Mexico, and is commonly found in online pharmacies, often available without a prescription).

Notably, medical professionals are already using this regimen to terminate second-trimester pregnancies: In its guide to safe abortion care, Doctors Without Borders/Médecins Sans Frontières (MSF) mentions that its guidelines include safe abortion with pills up to (and sometimes beyond) 22 weeks. “Evidence shows that a second-trimester abortion with pills has very low risks and is very safe,” says Maura Daly, a midwife and sexual and reproductive-health adviser at the MSF operational center in Amsterdam. Studies have found medication abortion to be over 90 percent effective, with the primary complication being an incomplete evacuation of the uterus (a common issue with miscarriages, and treatable with a simple vacuum aspiration or D&C — though in states where abortion has been banned, these post-miscarriage procedures can be harder to access as well). “In the settings where MSF works, we have found that medication abortion has helped to significantly increase access to abortion in both the first and second trimester, and is one of the key interventions in reducing maternal death and suffering related to unsafe abortion,” Daly says. Crucially, these pills don’t stop working after the second trimester, either: WHO has issued guidelines on using abortion pills to manage intrauterine fetal death all the way up to 28 weeks.

But whether the pills will work is only part of the equation when it comes to self-managed abortion. The further along a pregnancy is, the more intense the experience can be — not just physically, but emotionally as well. While a first-trimester medication abortion might feel similar to a heavy period, by the time a pregnancy has hit the 24-week mark, a termination can be closer to a “mini-delivery,” according to Dr. Suchitra Dalvie, M.D., MRCOG, a consultant gynecologist, coordinator of Asia Safe Abortion Partnership, and one of the experts who consulted with IWHC on its self-managed abortion pamphlet. Taking that on all by oneself can be overwhelming — though that doesn’t mean a doctor has to be involved in order for a second-trimester abortion to be a success. “Our experience shows that this is safe and effective, as long as the person has access to accurate information, quality medications, and appropriate backup support,” says Daly, who notes that pills can be lifesaving when someone can’t be, or doesn’t want to be, admitted to the hospital.

A recent study published in The Lancet backs up Daly’s assertion: The paper documents the work of abortion-accompaniment groups in Nigeria and Argentina, which provide a range of support services from outside the clinical system. The vast majority of the second-trimester abortions observed in the study were successfully completed without medical intervention, suggesting that it’s informed support, more than medical expertise, that enables a safe medication abortion even in the second trimester. Problems are most likely to arise when someone doesn’t take the proper dosage or can’t get to a clinic if they don’t fully expel the fetus or experience other complications, or if the pills they’ve taken aren’t actually mifepristone and misoprostol — issues that a network of abortion advocates have been diligently working to address through online education and pill provision.

A thornier issue to consider is the legal risks posed by a later self-managed 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 found guilty of feticide. Much of the trial hinged on the fetal remains that she had disposed of in a dumpster (Patel insisted that the birth was stillborn, and she was released from prison a year later after a judge overturned her sentence). Not only can fetal remains be used as evidence of an abortion themselves; several states have “fetal burial laws” that are easy to run afoul of. One way to navigate these challenges is to initiate the abortion at home, then head to the hospital midway through and tell the medical staff you’re in the middle of a miscarriage. But this, too, can be risky: Although it’s impossible to physically distinguish between a self-managed abortion and a miscarriage, numerous people have been reported to the police by medical staff who suspect an abortion (as happened recently with Lizelle Herrera). And once a person has been drawn 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 in the potential of being prosecuted 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 past 12 weeks. It’s one thing to tell people that WHO has declared self-managed abortion to be safe up to 12 weeks — that’s just sharing publicly available medical information. But openly advising people on how to have a second-trimester medication abortion when they don’t know what their support system looks like or whether they’re prepared to handle the legal risks can feel vastly more treacherous — particularly when 93 percent of abortions happen in the first trimester.

And yet, when we talk about safe self-managed abortion as a first-trimester-only possibility, we deny people access to crucial information that they could benefit from and use to prepare for a range of possible abortion scenarios, especially as abortion becomes harder to obtain and delays in obtaining pills become more common. A recent video from the New York Times documents the experience of a woman self-managing her abortion in Texas. The anonymous subject talks about racing against a 12-week “biological clock” for a safe self-managed abortion, a deadline that simply isn’t real. While an earlier abortion is far easier, there’s no reason to believe that abortion pills wouldn’t have worked if she’d taken them at 12 weeks and one day — nor that they would have suddenly become less safe.

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