For centuries, women everywhere in the world have felt entitled to terminate unwanted or mistimed pregnancies, and used whatever means were known and available to them to do so. The development of modern medical technology has now made it possible for women to terminate a pregnancy surgically without jeopardising their lives and their health.

An alternative to surgical abortion, a combination of two drugs (“abortion pills”) which induce abortion was first licensed in France in 1988. One of the two drugs, Mifepristone, is now (2005) licensed in 35 countries. More than 22 million women in China and about four million in the rest of the world have used the method to terminate a pregnancy, and have found it safe and effective [1].

The second drug, Misoprostol, is registered for the prevention of gastric ulcers induced by the use of non-steroidal anti-inflammatory drugs in over 80 countries [2]. Thus, misoprostol is available in countries where mifepristone is not yet registered.

In many countries, including those with legal restrictions or limited access to abortion, one or both of these drugs are available across the counter in pharmacies. Recent studies have shown that many women, especially in countries where access to abortion services is limited, need more information about the abortion pills.  This fact sheet, presented in a question-and-answer format, answers in simple terms questions that women usually ask about ‘abortion pills’. It aims to inform women about drugs that can safely and effectively be used to bring about an abortion, so as to enable them to make informed decisions about termination of pregnancy. In countries where abortion is legally available, it is safest if women use these drugs under the guidance of a health provider, if possible.

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Medical abortion is the termination of pregnancy through the use of a drug or a combination of drugs.

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EC pills consist of a progesterone-like hormone in much higher doses than in oral contraceptive pills. They are for use by a woman if:

It is advisable to take EC pills as soon as possible after unprotected sexual intercourse. The sooner they are taken, the more effective they are. If not taken within 120 hours, then EC is not likely to prevent pregnancy. EC pills are less effective in preventing pregnancy and have more side effects than most forms of regular contraception. After use the EC pills do not protect against further acts of  unprotected intercourse.They are therefore not considered suitable for routine use.

(For more information on emergency contraception, refer to http://www.cecinfo.org/ )

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  Mifepristone and misoprostol

The most commonly used combination of drugs for medical abortion is

Mifepristone causes the thinning of the uterine lining and softening of the cervix and combined with misoprostol causes strong contractions in the uterus. Together, the drugs cause the products of pregnancy to be expelled. The result is very much like a spontaneous abortion or miscarriage [3].

Mifepristone is commonly available as “Mifiprex”, “Mifegyne” or “Mifegest”. It is sold under several other brand names in India and China. Misoprostol is commonly available under the names Cytotec, Oxaprost or Cytoprost.  

In some settings, the prostaglandin misoprostol alone is used for medical abortion. This is often because mifepristone is not available or not affordable. When misoprostol alone is used, it causes uterine contractions, softening of the cervix and the products of pregnancy are expelled. But without mifepristone pre-treatment, a higher dose of misoprostol is needed. The abortion process can take longer and be more painful, with more side effects [3]. The likelihood of a complete abortion is also somewhat lower than in combination with mifepristone. But misoprostol remains a safer option than other dangerous and invasive methods of abortion that women resort to when safe abortion services are not available.

In countries where mifepristone is not available, methotrexate has been used in combination with misoprostol. However, methotrexate is not recommended by the World Health Organization (WHO) for inducing abortion, because of concerns that it may increase the risk of fetal malformation in a continuing pregnancy [4]. It also involves a more prolonged abortion process.

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Medical abortion can be used from very early in pregnancy up to 24 weeks counting from the first day of the last menstrual period (LMP) [4]. However, the dosage and regimens change at 9 weeks, for 9 - 13 weeks and for 13 - 24 weeks of pregnancy [5].

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It is advisable for a woman not to use the mifepristone/misoprostol regimen for medical abortion if she has any one of the following health conditions [6]:

•	Her health provider suspects or has confirmed that she has an ectopic pregnancy (see BOX 2).
•	She has an allergy to mifepristone .
•	She has an allergy to misoprostol .
•	She has a disease or condition affecting blood's ability to clot.
•	She is taking drugs for thinning the blood.
•	She is taking certain steroid drugs. If she is taking drugs orally or as injections for treating chronic arthritis, asthma and other allergic conditions, she should check to see if these are (or contain) corticosteroids. If in doubt, her health provider may be consulted.
•	She suffers from chronic failure of adrenal glands. Adrenal glands are small, triangular glands located on top of the kidneys and produce a variety of hormones including adrenaline, essential to help the body cope with stress.
•	She has inherited porphyries, which is an uncommon disorder of certain enzymes responsible for the formation of the iron-containing pigments in proteins.

None of the above conditions, apart from allergy to misoprostol, applies to the use of misoprostol alone.

If a woman has an IUD in place in the uterus, this should be removed prior to use of medical abortion with mifepristone/misoprostol combination or with misoprostol alone.

Women with mild to moderate anaemia (haemoglobin levels between 9 and 12 gm/dl) can use medical abortion. However, it may be beneficial for women with mild to moderate anaemia to take iron pills when using medical or surgical abortion.

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An ectopic pregnancy is a condition where a fertilized egg settles and grows in any location other than the inner lining of the uterus. The vast majority of ectopic pregnancies occur in the fallopian tube (95%); however, they can occur in other locations, such as the ovary, cervix or abdominal cavity [7].

Ectopic pregnancy can be asymptomatic in the initial stages. Symptoms of an ectopic pregnancy can often be vague, and include vaginal bleeding, abdominal or pelvic pain (usually stronger on one side), shoulder pain, weakness or dizziness. These symptoms can also occur in other conditions such as ovarian cysts, miscarriages, or even in normal pregnancy.

Occasionally, the doctor may feel a tender mass during the pelvic examination. If an ectopic pregnancy is suspected, beta hCG blood tests, and ultrasound can be used to help confirm the diagnosis [7].

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There is some evidence that mifepristone is excreted into breastmilk but little evidence regarding any effect on the adrenal function of the infant. The evidence that is available suggests that the amounts of mifepristone ingested by the infant are unlikely to cause harm [8].

Small amounts of misoprostol enter breastmilk soon after administration, but it is not known whether this could have any effect on the infant. As misoprostol levels decline rapidly, it has been recommended that misoprostol should be taken immediately after a feed and the next feed given after four hours in case of oral administration of misoprostol and somewhat later after vaginal administration [9].

 However, if a woman is worried that the drugs may be excreted in the breastmilk, she may discard her milk for 24 hours following the use of mifepristone/misoprostol or misoprostol alone.

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There is no reason why HIV positive women cannot use medical abortion. HIV positive women may be at higher risk of reproductive tract infections from retained products of conception, but this may occur with medical or surgical abortion.

They may also be at risk for anaemia, especially if they have malaria or are taking certain antiretrovirals (ARVs) and iron pills may be prescribed. The small proportion of women who develop heavy bleeding need to be treated promptly to avoid serious consequences [10].

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There is no medical reason why medical abortion may be unsuitable for adolescents. Medical abortion is more painful for anyone who has never been pregnant, and this may mean that young nulliparous women may need more pain medication than women who have previously given birth.

The availability of medical abortion can be especially helpful for unmarried adolescents and other young women who do not have access to safe surgical abortions in many countries.

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A woman may be aware that she has an infection of the reproductive tract (RTI) because she is undergoing treatment for it. Or, she may suspect she has an RTI because of the symptoms she is experiencing, such as foul-smelling white or yellow/green discharge, itching or sores in the genital area, or frequent urination with pricking pain. Treatment should not be delayed as untreated infection can have serious health consequences, including infertility.

During a woman’s first clinic visit for medical abortion, the health provider is required to take a detailed history and give a thorough physical examination, including pelvic examination. If an RTI is suspected, a laboratory test may be prescribed to confirm if the woman has a reproductive tract infection.

If a woman has an RTI, then she will be treated for the infection alongside use of medical abortion. The same is true when surgical abortion is carried out. There is no reason to wait for RTI treatment to be completed before either medical or surgical abortion.

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Women choose medical abortion because of its following features [11], [12]:

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Pregnancy can be confirmed with a pregnancy test. There are two types of pregnancy tests, blood and urine tests. Both tests look for a special hormone, human chorionic gonodotrophine (hCG) that is only present in the blood and urine when a woman is pregnant. The urine test may be performed at home using a pregnancy test kit, available from pharmacies, while the blood test can only be performed by a laboratory (See BOX 3).

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The blood test for pregnancy is known as a beta hCG test. This measures the exact amount of hCG in the blood. This test is carried out in a clinical laboratory, on being prescribed by a health provider. The blood test can tell whether a woman is pregnant within just one or two days after she has missed her menstrual period [15].

A pelvic exam by a midwife or doctor can confirm pregnancy only around six weeks after a woman’s last menstrual period. She does not have to wait till then to confirm pregnancy. If a woman does not want to be pregnant, she may prefer to have a pregnancy test as soon as she has missed her period, and make arrangements to have an abortion.

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Women opting for medical abortion need to know how many weeks pregnant they are. This is because although dosage of mifepristone remains the same, the dosage and number of doses of misoprostol change at different stages of pregnancy.

The following methods are usually used for finding out the duration of pregnancy:

Ultrasonography may be used if:

With ultrasonography the size of the gestational sac and later in pregnancy, the length of the fetus can be measured. 

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Medical abortion for pregnancy ≤ 9 weeks	Surgical abortion using vacuum aspiration for pregnancy ≤ 9 weeks
Can be used from 4 weeks LMP.	May not be available before 7 weeks LMP.
Resembles a natural miscarriage.	Involves inserting a tube into the uterus to aspirate the contents.
Abortion usually happens at home.  If misoprostol  is given in the health facility , abortion  happens there.	Abortion happens in a health facility.
Abortion process lasts more than one day.	Procedure is completed within 10–15 minutes.
Takes at least two clinic visits.	Takes one to two clinic visits.
May be painful for 2-3 hours or more after using misoprostol.	May be painful during aspiration and afterwards when the uterus contracts.
Severe complications are rare.	Severe complications are rare.
Longer period of bleeding up to several weeks, although amount of blood lost is the same as with surgical abortion.	Shorter period of bleeding, as most blood is aspirated during the procedure.
Anaesthesia is not needed. Pain medication should be available.	Pain medication, light sedation and local anaesthesia should be provided , .
Most effective for pregnancy of less than 7 weeks.	Most effective in pregnancies of more than 7 weeks.
Woman may see blood clots and the products of conception.	Woman does not see products of conception.

[16]

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  The following regimens are recommended for medical abortion from 4-9 weeks of pregnancy: 

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The dosage of mifepristone/misoprostol varies for pregnancies of 9-13 weeks and 13-24 weeks.

The use of medical abortion after 9 weeks of pregnancy needs to be under medical supervision in a hospital or clinic setting because of increased risk of complications.

The following regimens have been recommended for medical abortion from 9–13 weeks and 13–24 weeks of pregnancy [5]:

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Misoprostol alone is sometimes used for medical abortion in pregnancies above 9 weeks duration in places where mifepristone is not available, but there is not yet enough information on the safest and most effective regimen.

Caution is needed in the use of misoprostol alone for pregnancies above 9 weeks. The dosages of misoprostol must be reduced as the duration of pregnancy increases because the uterus becomes very sensitive to prostaglandin. There is a risk of rupture of the uterus, especially after 16 weeks of pregnancy and in women who have a scar from a previous caesarean section [2].

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Efficacy of medical abortion may be measured by rates of ongoing pregnancy. In pregnancies up to 9 weeks, only about 1% of women who use the mifepristone/vaginal misoprostol regimen for medical abortion have a continuing pregnancy, and in about 3-5%, abortion is incomplete [18]. Rates of complete abortion are lower when the mifepristone/oral misoprostol (400 microgram) regimen is used in pregnancies of up to 7 weeks. In one study the complete abortion rate was 84 % when mifepristone was followed by 400 micrograms of oral misoprostol, as compared to 96% with mifepristone and 800 micrograms of vaginal misoprostol [19].

Efficacy depends on the length of pregnancy: the more advanced the pregnancy, the lower the complete abortion rate and the higher the rate of ongoing pregnancy. For example, in one large study on use of medical abortion during 9-13 weeks of pregnancy (with the dosages mentioned under Q.13), 96% of the women experienced complete abortion [20]. About 5% may have an ongoing pregnancy with medical abortion at 13-20 weeks of pregnancy [18].

The success rate with misoprostol alone is lower and more variable. Efficacy rates range from 10–15% ongoing pregnancies for pregnancies up to 9 weeks duration [21]. Evidence is not yet unavailable on efficacy rates for pregnancies above 9 weeks duration.

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When a mifepristone/misoprostol regimen is used for medical abortion in pregnancy up to 9 weeks, in a few instances (2-3% of women), a woman may abort after taking the mifepristone and before using misoprostol. Of the rest, about 90% will have a complete abortion within 4-6 hours of using misoprostol [5].

After nine weeks of pregnancy, the more advanced the pregnancy, the longer it takes to have a complete abortion [18] [20]. In one study, the time taken for complete abortion was about six hours for women with previous deliveries and about 8 hours for women with no previous deliveries. More than 70% of the women went home the same day [22].

There is a lot of variability in the reported time needed for abortion with misoprostol alone up to 9 weeks of pregnancy, depending on the duration of pregnancy, dosage and route of administration. One study reported that 72% and 86% of women aborted within 24 hours of one and two doses respectively of 800 micrograms of vaginal misoprostol [23].

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Studies show that two clinic visits are adequate to ensure safe use of mifepristone/misoprostol for pregnancies up to 9 weeks, and three clinic visits are needed for pregnancies of more than 9 weeks’ duration.

When mifepristone/misoprostol combination is used

Up to 9 weeks of pregnancy

The health provider

If the woman opts to take the misoprostol at home, then the provider

•	gives her the 800 microgram dose of misoprostol (4 pills of 200 micrograms each) to be inserted vaginally, or 400 microgram dose of misoprostol (2 pills of 200 micrograms each) to be taken orally at home, 24-48 hours after mifepristone.
•	gives a pain-killer to help cope with the cramps and pain that the woman will experience once she has taken misoprostol.

Second visit (if the woman opts to take misoprostol in the clinic)

This visit should be between 24 and 48 hours after the first visit [4]. During this visit, misoprostol is inserted vaginally (in pregnancies up to nine weeks) or taken orally (in pregnancies up to seven weeks).

In many settings, the woman is kept under observation in the clinic for 4-6 hours. During this time, more than 90 per cent of women will have expelled the products of conception [5].

If abortion does not occur within the observation period, the woman may be permitted to go home to abort.

In a few places, misoprostol may be administered by a provider and the woman can leave immediately. In this case, the woman needs to know that abortion may occur before she reaches home.

All women are asked to return 14 days after they took mifepristone. This is to check if abortion is complete and that all products of conception have been expelled.

During this visit, the health provider:

Pregnancies of more than 9 weeks duration 

In this case, the only difference is that there are at least three clinic visits. The woman returns to the clinic24-48 hours days after her first visit, when she took mifepristone. Misoprostol is administered by a health provider in a clinic setting. 

During this visit, misoprostol is inserted vaginally, followed by several additional doses of the drug vaginally and/or orally until abortion takes place. The woman is kept under observation until several hours after she expels the products of conception.

This is followed by a follow-up visit, as described above.  

When misoprostol alone is used

In pregnancies of less than 9 weeks duration, the dosage regimen consists of repeated doses of vaginal or  sublingually misoprostol till abortion occurs. This may mean staying in the health facility for at least a day, or administering repeat doses of misoprostol at home, depending on the setting.

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In pregnancies of up to 9 weeks, there is no reason why home use of mifepristone and misoprostol should be unsafe, provided the woman has accurate information about who can and cannot take the drug, the dosage for different regimens, side effects and complications, and has access to medical care if needed. Home use of mifepristone/misoprostol is not recommended after 9 weeks of pregnancy, when it is important to use medical abortion under the supervision of a competent medical professional.

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Women who use medical abortion will experience menstrual-like cramps, pain in the abdomen and bleeding. For most women, uterine cramps and vaginal bleeding start between one hour and seven hours after they take misoprostol. But some 5% of women will start to have cramps already after they take mifepristone.

Vaginal bleeding is heavier than menstruation while abortion is occurring and the products of conception are being expelled. This heavy bleeding lasts only for a short duration, about 1-4 hours. Light bleeding and spotting will continue for 9-13 days. In rare cases, women may experience light bleeding for up to 45 days after the abortion occurs [4]. The amount of bleeding depends on the duration of pregnancy and the drug used.

Many women compare the process to a spontaneous miscarriage. Women may also notice passing blood clots, tissue or products of conception [24].

Women may experience other side effects such as diarrhoea, nausea, vomiting, headache, dizziness, back pain and tiredness. These side effects occur after misoprostol administration but last only for about 2-4 hours. Several studies show that nausea, vomiting and diarrhoea with vaginally administered misoprostol are fewer as compared to taking misoprostol orally [24].

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Bleeding

Nausea, vomiting and diarrhoea

It is important to consult the health provider if you are taking any other prescription or non-prescription drugs or herbal medicines or preparations when seeking medical abortion. These drugs or preparations may interfere with the action of mifepristone [25].

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Heavy or excessive bleeding

If abortion is incomplete, there is a risk of heavy bleeding. Some health providers treat heavy bleeding with a drug called Methergin before performing a surgical abortion. Approximately 1% of women using medical abortion up to 9 weeks of pregnancy require this [11].

In rare instances, the woman may experience excessive uterine bleeding. Such heavy bleeding usually occurs 1-3 weeks after taking the medications (apart from the bleeding after taking misoprostol).

A woman will know that bleeding is too heavy if

About 1 in 1000 women experience bleeding that is so heavy that they need a blood transfusion [16].

A woman should contact her health provider without delay if she has such heavy bleeding. In the meanwhile, she should drink a lot of fluids so that she does not lose essential minerals from her body.

Chills and a mild rise in temperature usually occur immediately after misoprostol has been taken. These are side effects of the medication, not signs of infection, and usually last only for about 2 hours [11].

Less than 1% of women have been shown to develop infection after medical abortion [26]. Infection may be suspected if

The woman needs medical help if she develops these symptoms [11]. She may be treated as an outpatient and sent home, or may need to be admitted to hospital as an inpatient for treatment, depending on the severity of the infection and the need for observation and further tests.

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Four deaths following medical abortion in the United States and one in Canada, which occurred between 2001 and 2005, were the subject of recent articles and letters in the medical and mainstream media. These were associated with infection from an anaerobic bacterium called Clostridium sordellii; they were not attributed to the medical abortion drugs. In March 2006, two additional deaths were reported in the United States following medical abortion. One of these deaths has features consistent with Clostridium sordellii; the other appears not to have been related to the abortion at all.

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A woman may suspect that the pregnancy is ongoing if

When taken under medical supervision, a woman is always asked to return for a follow-up visit within 14 days from the day she took mifepristone. The health provider will confirm whether abortion has occurred and whether further treatment is needed. If there is reason to suspect that pregnancy is ongoing, or that abortion is incomplete, a beta hCG blood test may be done and/or an ultrasound exam.

It is important that she consults a health provider. If pregnancy is ongoing, the health provider may give a further dose of misoprostol. If the woman wishes to have the pregnancy terminated right away, her health provider should arrange for a surgical abortion as soon as possible.

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In the vast majority of pregnancies carried to term after use of mifepristone/misoprostol or misoprostol alone, the infant born will be normal.

However, a small number of studies to examine the risk of birth defects have concluded that there may be a slightly higher risk of birth defects in infants born after use of misoprostol. The majority of these defects pertain to the central nervous system and lower and upper limbs [21]. Mifepristone does not cause birth defects [4].

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After having medical abortion a woman should not engage in vaginal sex or insert anything into her vagina for about one week after the drugs have been taken [3], or until she feels ready.

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If she does not use an effective method of contraception, a woman can become pregnant before her first period. Conception can occur within 10 days to two weeks of having a medical abortion, depending on the length of her menstrual cycle [3].

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A woman can expect to have normal menstruation within about four to six weeks after medical abortion, provided she has not become pregnant again [3].

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A woman can start using contraception on the day of taking misoprostol. Suitable methods are: oral pill, hormonal injectables and implants. Barrier methods of contraception such as the condom, contraceptive jellies and foams, cervical cap and the diaphragm can be used when sexual intercourse is resumed. If a woman wants to have an intra-uterine device (IUD) inserted, she will have to wait till the abortion is complete and all products of conception have been expelled [11].

As for sterilization after medical abortion, there are no restrictions or contraindications, and the procedure may be carried out any time after the abortion, i.e. expulsion of products of conception. In practice, however, women who plan to have sterilization may prefer surgical abortion, so that both procedures can be done under the same anaesthesia.

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Medical abortion has no known long-term negative effects on a woman’s health. It may contribute positively to her well-being by removing the stress of unwanted pregnancy [11].

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Medical abortion will not affect a woman’s ability to become pregnant and have a child in future [11]. One study from China that has looked at women’s subsequent wanted pregnancies and their outcomes after one medical abortion found no adverse effects on the outcome [30]. Es más, un estudio reciente publicado en el New England Journal of Medicine, no encontró efectos adversos sobre la fertilidad o los embarazos subsiguientes. [38]

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There have been no long-term studies that have investigated this issue.

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Costs of medical abortion vary widely across countries depending on:

There may be additional costs if surgical aspiration is needed to complete the abortion and if additional visits are necessary for treating complications.   

However, the cost of mifepristone currently forms the major component of the cost of medical abortion everywhere in the world.

The retail prices of mifepristone in different countries as of 2005 were as follows [31]:

Retail Misoprostol is affordable in almost all settings, though a woman using misoprostol alone will probably need a greater number of pills. For example, 1 tablet of 200 micrograms of Misoprostol costs US$0.30 in the UK when accessed from hospitals and licensed facilities providing medical abortion, and about US$ 0.50 South Africa [31].

The actual cost to women of a medical abortion also depends on how abortion services are paid for, and whether medical abortion is covered by public financing or insurance.

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For details of the list of the countries where mifepristone is licensed and a map of countries where misoprostol is approved, log on to www.gynuity.org/pub_b.html#q6.

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Every woman should have the right to terminate an unwanted pregnancy safely. There are many reasons why a woman may want to terminate a pregnancy. Pregnancy may be the result of sexual assault or non-consensual sex; a woman may no longer want to continue with a pregnancy because her circumstances have altered since she became pregnant; social and economic circumstances may not allow her to continue the pregnancy; there may have been contraceptive failure; the woman may not have access to an effective method of contraception, or did not have information on how to prevent pregnancy.

Unfortunately, abortion is legally restricted in many countries. Because safe abortion services are not available, many women attempt to do an abortion by inserting sharp objects or herbal medicines into the uterus, or by putting pressure on the belly or by drinking herbal concoctions. In many instances, these can cause serious morbidity or even death.

In most countries where abortion is legally restricted it is unlikely that mifepristone will be registered. But misoprostol is widely available in almost all countries since it is registered for treatment of gastric ulcer.

Use of misoprostol bought over the counter from pharmacies is widespread in Latin America and the Caribbean and in a growing number of Asian countries. Experience from countries such as Brazil and Chile has shown that medical abortion is safer than the invasive alternatives that women were forced to use to induce an abortion. Although there are side effects, these can almost always be managed with simple medications [2].

Reporting to a health facility after home-use of misoprostol to complete the abortion will facilitate timely management of any potential complications. Misoprostol offers women living in countries with legal restrictions on abortion with an important alternative to abortion methods that are always dangerous.

See Women on Web as a possible alternative.

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