Self-Management

This resource is for health professionals. If you’re seeking personal health information about abortion with pills, go here: www.ipas.org/abortionwithpills

Last reviewed: November 29, 2022

Key Information:

• Individuals can safely and effectively self-manage medical abortion with either mifepristone and misoprostol, or misoprostol-only when they have accurate information, quality-assured medicines, and access to health services, if needed.

Quality of evidence: High

What is medical abortion self – management?

Self-management of medical abortion is the process by which an individual procures abortion medications (mifepristone and misoprostol, or misoprostol-only) and performs the component parts of their own abortion with or without support of a healthcare provider (World Health Organization [WHO], 2022b). While some individuals will prefer to manage all of the component parts of medical abortion outside of the health care system, others may choose to interact with trained health workers via traditional or innovative service delivery mechanisms as needed; importantly it is the individual who decides which aspects of care they will self-manage, and when and where to seek support (WHO, 2022a; WHO, 2022b). Barriers to clinical access, such as cost or inaccessibility of services, are the most commonly reported reason for self-managed abortion (Aiken, Starling, & Gomperts, 2021). While self-managed abortion has the potential to dramatically increase access to safe abortion, particularly in settings where access is limited (Jayaweera et al., 2021), individuals choose abortion self-management for many reasons. These reasons include more autonomy and control over the experience, possibility of greater comfort or privacy, and the ability to avoid stigma, discrimination, or other barriers associated with seeking care in a health facility (Aiken et al., 2018; Harries et al., 2021; Moseson et al., 2020a).

Self-managment of medical abortion

Medical abortion before 13 weeks is a process that takes place over a period of hours to days, consisting of three components: (1) determining eligibility for medical abortion; (2) administration of abortion medicines and management of the abortion process; and (3) assessment of the success of the abortion. Abundant clinical evidence documents the ability of pregnant people to safely and effectively perform each of these components. See 3.2: Recommendations for abortion before 13 weeks: Gestational dating and 3.3: Recommendations for abortion before 13 weeks: Screening for ectopic pregnancy for a summary of evidence supporting individuals’ ability to self-assess their eligibility for medical abortion; see 3.5.6: Recommendations for abortion before 13 weeks: Medical abortion: Home use of medications up to 12 weeks for a summary of evidence supporting individuals’ ability to self-administer abortion medications and manage the abortion process; and see 3.5.7: Recommendations for abortion before 13 weeks: Medical abortion: Confirmation of success for a summary of evidence supporting individuals’ ability to self-assess the success of their abortion.

Many models of medical abortion self-management exist, depending on the extent that the formal health system, health workers, or other supportive services are involved in the process (Dragoman et al., 2022). Studies assessing self-management of the entire medical abortion process are understandably lacking, given the inherent difficulties in recruiting participants who have self-sourced and self-managed their abortion (Sorhaindo & Sedgh, 2020). However, a growing body of evidence documents the safety and effectiveness of various models of supported self-managed medical abortion. An example would be telemedicine abortion, where a health worker geographically separate from the abortion seeker facilitates a medical abortion. Telemedicine health workers could assess abortion eligibility based on history, provide medications for abortion seekers to use at home, and offer follow up-can occur both within or outside of the formal health system, and may be synchronous or asynchronous (Endler et al., 2019 ; Raymond et al., 2020). Many cohort studies, including a large, prospective cohort study that compared outcomes between individuals receiving a traditional, in-person medical abortion (n=22,158) and those receiving a telemedicine abortion with no pre-abortion testing, examination or ultrasonography (n=18,435) (Aiken et al., 2021), confirm safety and effectiveness rates for telemedicine abortion that are comparable to traditional, in-clinic medical abortion (Aiken et al., 2022; Reynolds-Wright et al., 2021; Upadhyay, Koenig, & Meckstroth, 2021; Upadhyay et al., 2022). WHO recommends telemedicine as an alternative to in-person medical abortion care (WHO, 2022). In accompaniment models, trained non-clinical volunteers provide abortion seekers with evidence-based medical abortion information, guidance for obtaining medication abortion drugs and step-by-step instructions for their use, guidance assessing abortion success and warning signs of complications, and support during the abortion process when needed—these accompaniment groups work outside of the formal health care system in settings where abortion is highly restricted (Zurbriggen, Keefe-Oates, & Gerdts, 2018). Studies of abortion accompaniment have found abortion success rates for the combined mifepristone and misoprostol regimen that are comparable to in-clinic care (94%), and success rates for the misoprostol-only regimen (99%) that exceed those reported in clinical studies (Moseson et al., 2020b; Moseson et al., 2022). Two studies have documented the safety and effectiveness of misoprostol-only, self-managed abortion accessed through community-based distribution (Foster, Arnott, & Hobstetter, 2017; Foster et al., 2022). In these studies, lay or volunteer community health workers provided misoprostol and instructions for its use to individuals seeking abortion before 9 or 10 weeks gestation, based on their reported last menstrual period. In both studies, abortion success rates exceeded those seen in clinical misoprostol-only medical abortion studies (94-96%) with no serious adverse events recorded. One prospective cohort study conducted in Nigeria assessed success rates in pregnant individuals who purchased misoprostol from drug sellers to self-manage their medical abortion (Stillman et al., 2020). Despite receiving inadequate information about the drugs, what to expect, or where and when to seek additional care, 94% of the sample reported a complete abortion without surgical intervention; one participant required a blood transfusion.

Resources

Abortion with pills – Ipas (Several evidence-based resources for people about how to safely self-manage an abortion using pills at at this link.)

Abortion Care Videos – Ipas: Abortion Care Videos for Women (3 videos) 

References 

Aiken, A.R.A., Broussard, K., Johnson, J.M., & Padron, E. (2018). Motivations and experiences of people seeking medical abortion online in the United States. Perspectives on Sexual and Reproductive Health, 50(4), 157-163.

Aiken, A.R.A., Starling, J.E., & Gomperts, R. (2021). Factors associated with use of an online telemedicine service to access self-managed medical abortion in the US. JAMA Network Open, 4(5), e2111852.

Aiken, A., Lohr, P.A, Lord, J., Ghosh, N., & Starling, J. (2021). Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: A national cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 128(9), 1464-1474.

Aiken, A.R.A., Romanova, E.P., Morber, J.R., & Gomperts, R. (2022). Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study. Lancet Regional Health Americas, 10, 100200. Doi.10.1016/j.lana.2022.100200.

Dragoman, M., Fofie, C., Bergen, S., & Chavkin, W. (2022). Integrating self-managed medication abortion with medical care. Contraception, 108, 1-3.

Endler, M., Lavelanet, A., Cleeve, A., Ganatra, B., Gomperts, R., & Gemzell-Danielsson, K. (2019). Telemedicine for medical abortion: A systematic review. BJOG: An International Journal of Obstetrics & Gynaecology, 126, 1094-1102.

Foster, A.M., Arnott, G., & Hobstetter, M. (2017). Community-based distribution of misoprostol for early abortion: Evaluation of a program along the Thailand-Burma border. Contraception, 96, 242-247.

Foster, A.M., Messier, K., Aslam, M., & Shabir, N. (2022). Community-based distribution of misoprostol for early abortion: Outcomes from a program in Sindh, Pakistan. Contraception, 109, 49-51.

Harries, J., Daskilewicz, K., Bessenaar, T., & Gerdts, C. (2021). Understanding abortion seeking care outside of formal health care settings in Cape Town, South Africa: A qualitative study. Reproductive Health, 18, 190.

Jayaweera, R., Powell, B., Gerdts, C., Kakesa, J., Ouedraogo, R., Ramazani, U., Wado, Y.D., Wheeler, E., & Fetters, T. (2021). The potential of self-managed abortion to expand abortion access in humanitarian contexts. Frontiers in Global Women’s Health, 2:681039. Doi: 10.3389/fgwh.2021.681039

Moseson, H., Herold, S., Filippa, S., Barr-Walker, J., Baum, S.E., & Gerdts, C. (2020a). Self-managed abortion: A systematic scoping review. Best Practice & Research Clinical Obstetrics and Gynaecology, 63, 87-110.

Moseson, H., Jayaweera, R., Egwuatu, I., Grosso, B., Kristianingrum, I.A., Nmezi, S., Zurbriggen, R., Motana, R., Bercu, C., Carbone, S., & Gerdts, C. (2022). Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): A prospective, observational cohort study and non-inferiority analysis with historical controls. Lancet Global Health, 10(1), e105-e113.

Moseson,H., Jayaweera, R., Raifman, S., Keefe-Oates, B., Filippa, S., Motana, R., Egwuatu, I., Grosso, B., Kristianingrum, I., Nmezi, S., Zurbriggen, R., & Gerdts, C. (2020b). Self-managed medication abortion outcomes: Results from a prospective pilot study. Reproductive Health, 17(1), 164.

Raymond, E., Grossman, D., Mark, A., Upadhyay, U.D., Dean, G., Creinin, M.D., Coplon, L., Perritt, J., Atria, J.M., Taylor, D., & Gold, M. (2020). No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception, 101(6), 361-366.

Reynolds-Wright, J.J., Johnstone, A., McCabe, K., Evans, E., & Cameron, S. (2021). Telemedicine medical abortion at home under 12 weeks; gestation: A prospective observational cohort study during the COVID-19 pandemic. BMJ Sexual & Reproductive Health, Published online first 4 February 2021. Doi: 10.1136/bmjsrh-2020-200976.

Stillman, M., Owolabi, A., Fatusi, A.O., Akinyemi, A.I., Berry, A.L., Erinfolami, T.P., Olagunju, O.S., Vaisanen, H., & Bankole, A. (2020). Women’s self-reported experiences using misoprostol obtained from drug sellers: A prospective cohort study in Lagos state, Nigeria. BMJ Open, 10:e034670. Doi:10.1136/bmjopen-2019-034670.

Sorhaindo, A., & Sedgh, G. (2021). Scoping review of research on self-managed medication abortion in low-income and middle-income countries. BMJ Global Health, 6(5), e004763.

Upadhyay, U.D., Koenig, L.R., & Meckstroth, K.R. (2021). Safety and efficacy of telehealth medication abortions in the US during the COVID-19 pandemic. JAMA Network Open, 4(8), e2122320.

Upadhyay, U.D., Raymond, E.G., Koenig, L.R., Coplon, L., Gold, M., Kaneshiro, B., Boraas, C.M., & Winikoff, B. (2022). Outcomes and safety of history-based screening for medication abortion: A retrospective multicenter cohort study. JAMA Internal Medicine, 182(5), 482-491.

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

World Health Organization. (2022a). Abortion care guideline. Geneva: World Health Organization.

World Health Organization. (2022b). WHO recommendations on self-care interventions: Self-management of medical abortion, 2022 update. Geneva: World Health Organization.

Zurbriggen, R., Keefe-Oates, B., & Gerdts, C. (2018). Accompaniment of second-trimester abortions: The model of the feminist Socorrista network of Argentina. Contraception, 97, 108-115.