Last reviewed: January 10, 2020

Recommendation:

  • Women may take mifepristone in a facility or at home.
  • Home use of misoprostol following mifepristone or in a misoprostol-only regimen may be offered up to 11 weeks gestation.
  • After 11 weeks gestation, misoprostol should be used in a facility.

Strength of recommendation: Strong

Quality of evidence:

  • Up to 70 days gestation: Moderate
  • Over 70 days gestation: Very low

Mifepristone and misoprostol regimen

Traditionally, providers have given mifepristone to women in a facility to start the abortion process. Then 1-2 days later, women may take misoprostol in a health facility, their own home or another safe location. Because of women’s individual preferences for privacy, support and timing, they should have options about the location of mifepristone and misoprostol use.

Home use of mifepristone

Two prospective, non-randomized multicenter cohort studies conducted in the United States, which together included 701 women, showed that between a third and a half of women offered home or facility use of mifepristone chose home use (Chong et al., 2015; Swica et al., 2012). Women who used mifepristone at home were highly satisfied and had similar success rates and need for telephone or emergency room support as women who took mifepristone in the clinic. In similar studies conducted in Azerbaijan (Louie et al., 2014), Nepal (Conkling, Karki, Tuladhar, Bracken, & Winikoff, 2015) and Kazakhstan (Platais, Tsereteli, Grebennikova, Lotarevich, & Winikoff, 2016), 74%, 72% and 64% of women, respectively, chose home use. The most commonly cited reasons for the choice to take mifepristone at home were flexibility, ability to schedule abortion around duties, partner’s presence and a more private experience. Abortion success rates were the same in the home use and clinic use groups. When a woman chooses home use of mifepristone, she should take it within one week of the clinic visit at which she received the prescription or medication, provided her pregnancy does not exceed 11 weeks at that time.

Home use of misoprostol up to 70 days

A systematic review of nine prospective comparative cohort studies including 4,522 women up to 56 days gestation showed that complete abortion rates and adverse event rates were the same for home- and facility-based misoprostol use (Ngo, Park, Shakur, & Free, 2011) as part of a mifepristone-misoprostol regimen. Women found home use as acceptable as clinic use. A non-randomized comparative trial including 731 rural and urban Indian women up to 63 days gestation found no difference in abortion success or adverse events between home and facility administration of misoprostol (Iyengar et al., 2016). Large observational studies up to 59 days (Fjerstad et al., 2009) and 63 days (Gatter, Cleland, & Nucatola, 2015; Goldstone, Walker, & Hawtin, 2017; Lokeland, Iversen, Engeland, Okland, & Bjorge, 2014; Louie et al., 2014; Raghavan et al., 2013) also confirmed the safety and effectiveness of home use of misoprostol. The Royal College of Obstetricians and Gynaecologists (RCOG, 2015) recommends home use of misoprostol up to 63 days gestation. The World Health Organization (WHO) suggests that when women have access to a source of accurate information and to a health care provider, they can self-manage the abortion process up to 12 weeks gestation.  The WHO also calls for rigorous research to establish the safety, efficacy and acceptability of medical abortion in the outpatient setting for pregnancy from 9-12 weeks gestation (WHO, 2015; WHO, 2018).

A multicenter study of 729 women in the United States comparing a single dose of buccal misoprostol 800mcg at home from 57-63 days and from 64-70 days as part of a mifepristone-misoprostol regimen showed no difference between the groups in success rates, ongoing pregnancy or adverse events (Winikoff et al., 2012). A prospective, open-label trial conducted in India, Georgia, Tunisia and Ukraine compared outcomes of 703 women who received mifepristone followed by 400mcg of sublingual misoprostol in the home for pregnancies of 57-63 days or 64-70 days gestation (Bracken et al., 2014). Success rates and ongoing pregnancy rates did not differ between groups, although women in the later gestational age group were more likely to receive an additional dose of misoprostol or require intervention for bleeding. Additional smaller studies have shown similar results (Boersma, Meyboom-de Jong, & Kleiverda, 2011; Platais et al., 2016; Tan et al., 2018). The American College of Obstetricians and Gynecologists (ACOG, 2014) and the National Abortion Federation (NAF, 2017) recommend offering home use of misoprostol up to 70 days gestation.

Home use of misoprostol from 10-13 weeks

One small retrospective cohort study compared safety and effectiveness of home use of misoprostol for medical abortion at gestational age 57-63 days to home use from 64-76 days (Larsson, & Ronnberg, 2019). Women received mifepristone in the health center then returned home where 36-48 hours later they self-administered a single dose of misoprostol 800mcg vaginally, followed by up to four additional doses of 400mcg if bleeding did not occur.. Success rates were 96% and 94% in the earlier and later gestational groups, although more women in the later group had an ongoing pregnancy (one versus four). There was no difference in incomplete abortion, excessive bleeding, surgical intervention or unscheduled return visits between groups. There are no comparative or prospective data regarding home use of misoprostol as part of a combined regimen after 11 weeks gestation.

Misoprostol-only regimen

No studies have directly compared safety and effectiveness of home use of misoprostol in a misoprostol-only regimen to health facility use. However, several studies with misoprostol-only arms have allowed women to self-administer the medication at home up to nine weeks gestation without an effect on safety or medical abortion success (Blum et al., 2012; Ngoc et al., 2011). Additionally, three small prospective cohort studies of misoprostol-only abortion conducted in Cuba allowed home use of medication up to 9 (Carbonell, Valera, Velazco, Fernandez, & Sanchez, 1997; Velazco et al., 2000), or between 9-12 gestational weeks (Carbonell et al., 2001) without an effect on safety or success. Two studies that enrolled only adolescents (Carbonell et al., 2001; Velazco et al., 2000) found higher rates of nausea and vomiting than observed in studies with adult women.

References

American College of Obstetricians and Gynecologists. (2014). Practice bulletin No. 143: Medical management of first-trimester abortion. Obstetrics & Gynecology123(3), 676-692.

Blum, J., Raghavan, S., Dabash, R., Ngoc, N. T. N., Chelli, H., Hajri, S., … Winikoff, B. (2012). Comparison of misoprostol-only and combined mifepristone-misoprostol regimens for home-based early medical abortion in Tunisia and Vietnam. International Journal of Gynecology & Obstetrics, 118, 166-171.

Boersma, A. A., Meyboom-de Jong, B., & Kleiverda, G. (2011). Mifepristone followed by home administration of buccal misoprostol for medical abortion up to 70 days of amenorrhoea in a general practice in Curacao. The European Journal of Contraception and Reproductive Health Care, 16(2), 61-66.

Bracken, H., Dabash, R., Tsertsvadze, G., Posohova, S., Shah, M., Hajri, S., … Winikoff, B. (2014). A two-pill sublingual misoprostol outpatient regimen following mifepristone for medical abortion through 70 days’ LMP: A prospective comparative open-label trial. Contraception89(3), 181-186.

Carbonell, J. L. L., Velazco, A., Varela, L., Tanda, R., Sanchez, C., Barambio, S., … Mari, J. (2001). Misoprostol for abortion at 9-12 weeks’ gestation in adolescents. The European Journal of Contraception and Reproductive Health Care, 6, 39-45.

Carbonell, J. L. L., Varela, L., Velazco, A., Fernandez, C., & Sanchez, C. (1997). The use of misoprostol for abortion at ≤ 9 weeks’ gestation.  The European Journal of Contraception and Reproductive Health Care, 2(3),181-185.

Chong, E., Frye, L. J., Castle, J., Dean, G., Kuehl, L., & Winikoff, B. (2015). A prospective, non-randomized study of home use of mifepristone for medical abortion in the US. Contraception, 92(3), 215-9.

Conkling, K., Karki, C., Tuladhar, H., Bracken, H., & Winikoff, B. (2015). A prospective open-label study of home use of mifepristone for medical abortion in Nepal. International Journal of Gynecology & Obstetrics, 128(3), 220-223.

Fjerstad, M., Sivin, I., Lichtenberg, S. Trussell, J., Cleland, K., & Cullins, V. (2009). Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days. Contraception, 80(3), 282-286.

Gatter, M., Cleland, K., & Nucatola, D. L. (2015). Efficacy and safety of medical abortion using mifepristone and buccal misoprostol through 63 days. Contraception, 91(4), 269-73.

Goldstone, P., Walker, C., & Hawtin, K. (2017). Efficacy and safety of mifepristone-buccal misoprostol for early medical abortion in an Australian setting. Australian and New Zealand Journal of Obstetrics and Gynaecology, 57, 366-371.

Iyengar, K., Klingberg-Allvin, M., Iyengar, S. D., Paul, M., Essen, B., & Gemzell-Danielsson, K. (2016). Home use of misoprostol for early medical abortion in a low resource setting: A secondary analysis of a randomized controlled trial. Acta et Obstetricia Gynecologica Scandanavica, 95(2), 173-181.

Larsson, A., & Ronnberg, A. M. (2019). Expanding a woman’s options to include home use of misoprostol for medical abortion up until 76 days: An observational study of efficacy and safety. Acta obstetricia et gynecologica Scandinavica, 98(6), 747-752.

Lokeland, M., Iversen, O.E., Engeland, A., Okland, I., & Bjorge, L. (2014). Medical abortion with mifepristone and home administration of misoprostol up to 63 days gestation. Acta Obstetricia et Gynecologica Scandinavica93(7), 647-653.

Louie, K.S., Tsereteli, T., Chong, E., Aliyeva, F., Rzayeva, G., & Winikoff, B. (2014). Acceptability and feasibility of mifepristone medical abortion in the early first trimester in Azerbaijan. The European Journal of Contraception and Reproductive Health Care19(6), 457-464.

National Abortion Federation. (2017). Clinical policy guidelines for abortion care. Washington D. C.: National Abortion Federation.

Ngo, T. D., Park, M. H., Shakur, H., & Free, C. (2011). Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: A systematic review. Bulletin of the World Health Organization89(5), 360-370.

Ngoc, N. T., Blum, J., Raghavan, S., Nga, N. T., Dabash, R., Diop, A., & Winikoff, B. (2011). Comparing two early medical abortion regimens: Mifepristone+misoprostol vs. misoprostol alone. Contraception, 83, 410-417.

Platais, I., Tsereteli, T., Grebennikova, G., Lotarevich, T., & Winikoff, B. (2016). Prospective study of home use of mifepristone and misoprostol for medical abortion up to 10 weeks of pregnancy in Kazakhstan. International Journal of Gynecology & Obstetrics, 134(3), 268-271.

Raghavan, S., Tsereteli, T., Kamilov, A., Kurbanbekova, D., Yusupov, D., Kasimova, F., … Winikoff, B. (2013). Acceptability and feasibility of the use of 400mcg of sublingual misoprostol after mifepristone for medical abortion up to 63 days since the last menstrual period: Evidence from Uzbekistan. The European Journal of Contraception and Reproductive Health Care, 18(2), 104-111.

Royal College of Obstetricians and Gynaecologists. (2015). Best Practice Paper No. 2: Best practice in comprehensive abortion care. London: Royal College of Obstetricians and Gynaecologists Press.

Swica, Y., Chong, E., Middleton, T., Prine, L., Gold, M., Schreiber, C. A., & Winikoff, B. (2012). Acceptability of home use of mifepristone for medical abortion. Contraception88(1), 122-127.

Tan, Y. L., Singh, K., Tan, K. H., Gosavi, A., Koh, D., Abbas, D., & Winikoff, B. (2018). Acceptability and feasibility of outpatient medical abortion with mifepristone and misoprostol up to 70 days gestation in Singapore. European Journal of Obstetrics, Gynecology and Reproductive Biology, 229, 144-147.

Velazco, A., Varela, L., Tanda, R., Sanchez, S., Barambino, S., Chami, S., … Carbonell, J. L. L. (2000). MIsoprostol for abortion up to 9 weeks’ gestation in adolescents. The European Journal of Contraception and Reproductive Health Care, 5, 227-233.

Winikoff, B., Dzuba, I. G., Chong, E., Goldberg, A. B., Lichtenberg, E. S., Ball, C., & Swica, Y. (2012). Extending outpatient medical abortion services through 70 days of gestational age. Obstetrics & Gynecology120, 1070-1076.

World Health Organization. (2015). Health worker roles in providing safe abortion care and post-abortion contraception. Geneva: World Health Organization Press.

World Health Organization. (2018). Medical management of abortion. Geneva: World Health Organization Press.