Medication abortion: A perfect solution?

1. MEDICATION ABORTION AND ANTICIPATED CHANGES TO US ABORTION ACCESS

The United States is on the cusp of eradicating nearly 50 years of reproductive health care precedent. If the Supreme Court's official ruling aligns with its leaked draft opinion, the consequences for people seeking abortion in many parts of the United States would be severe as abortion inevitably becomes illegal in many states (indeed, over 20 states are poised to ban abortion swiftly, given the opportunity). ¹ , ²

In light of this striking presumptive change in the provision of reproductive health care, considerable attention has shifted to medication abortion. ³ , ⁴ , ⁵ , ⁶ Medication abortion is FDA‐approved for use up to 10 weeks gestation. In contrast to surgical forms of abortion (e.g., dilation and curettage/D&C), it relies upon the joint action of mifepristone and misoprostol to induce cervical dilation, uterine contractions, and ultimately the expulsion of tissue. This strategy is also used to treat patients experiencing a missed or incomplete miscarriage and is a safe alternative to surgical intervention. ⁷ , ⁸

Following roughly two decades of steadily increasing use, medication abortions accounted for over half of all US abortions as of 2020. ⁹ , ¹⁰ This reflects both temporal shifts in patient/provider preferences, and more recently, the impact of the COVID‐19 pandemic and resulting barriers to clinical/surgical care. ⁹ , ¹⁰ , ¹¹ , ¹² The pandemic also shaped the provision of medication abortion itself: while patients were historically required to present in‐person for ultrasonographic confirmation of intrauterine pregnancy and blood tests prior to treatment (as the procedure is contraindicated for certain individuals ¹³ ), telehealth medication abortion, which does not require blood testing or ultrasound examination, gained prominence during the COVID‐19 pandemic as a safe and effective alternative to in‐person care. ⁷

Medication abortion introduces a compelling layer of complexity—and indeed, a safety net for many patients—in the event that Roe v. Wade is overturned. These medications can be sent by mail and self‐administered at home, posing a significant regulatory challenge to states seeking to restrict abortion within their borders. Several states currently ban the mailing of abortion pills, ⁹ but this is difficult to enforce and would likely continue to be challenging in the future. While patients seeking an abortion should ideally have agency over their preferred treatment modality—and the numbers above suggest that many patients still opt for the surgical route, given the choice—medication abortion certainly seems like a welcome solution to an impending reproductive health crisis: a safe, effective, and covert approach to pregnancy termination.

2. MANAGEMENT, SAFETY, AND EFFICACY

Entirely self‐managed medication abortions are not currently the “norm” in the United States as the medications are only one piece of the puzzle: safe, comprehensive medication abortion also includes clinical guidance and unimpeded access to appropriate follow‐up care. Accordingly, much of what we currently know about the safety and efficacy of medication abortion in the United States comes from clinically managed procedures, where patients have some form of (in‐person or virtual) interaction with a provider. Our current estimates of efficacy/safety are, therefore, influenced by both the availability of pre‐procedure guidance (e.g., to discuss medication regimens and patients' medical histories), and postprocedure follow‐up care (to ensure the procedure was successful).

To be clear, adverse outcomes linked to medication abortion are rare. ⁸ The overall complication rate of medication abortion is approximately 2% in clinically managed procedures. ¹⁴ Serious complications, including major adverse events like hemorrhage or death, are even rarer (≤0.5%). ¹⁵ , ¹⁶ , ¹⁷ Furthermore, medication abortion's effectiveness (defined as the complete expulsion of an intrauterine pregnancy) is commonly estimated at 95% or higher, despite some heterogeneity by medication regimen and gestational age. ⁷ , ¹¹ , ¹⁶ , ¹⁷ , ¹⁸ However, adverse events may become increasingly common (and complex) in contexts where medication abortion is entirely self‐managed, that is, in the absence of any individualized patient/provider interaction.

3. MEDICATION ABORTION IN THE ABSENCE OF SUPPORTIVE CARE

A failed medication abortion (one of the more common, albeit still rare, complications) is clinically consequential. Retained products of conception can lead to infection and/or sepsis, ¹³ , ¹⁴ which has significant implications for subsequent fertility, morbidity, and even mortality. Importantly, resolution of a failed medication abortion commonly involves uterine aspiration or D&C, ¹¹ which may not be readily accessible for patients residing in restrictive states. Legal penalties may also delay treatment‐seeking and influence patient/provider interactions. While the majority of self‐managed medication abortions would be uncomplicated, a number of patients could find themselves in a very precarious situation.

How many patients? The US abortion rate is historically low, but abortion remains a common procedure; the most recent available data ¹⁰ indicates that over 600,000 abortions were reported to the CDC in 2019 (and this is almost certainly an underestimate). Assuming that, for the sake of illustration, this number remains relatively constant and 25% of these patients reside in states that ban abortion, over 150,000 people would have an unmet need for care. We cannot be sure how many would turn to self‐managed medication abortion, but research has repeatedly demonstrated that patients who want an abortion will ultimately obtain one, ¹⁹ , ²⁰ and medication abortion is certainly safer than more invasive unregulated alternatives. If half opt for self‐managed medication abortion (assuming a 5% failure rate in the context of total self‐management), the procedure will fail for nearly 4000 individuals. These patients will be at risk of further, potentially serious complications. The extent to which these patients will seek and access care remains to be seen, and these events will be extraordinarily difficult—if not impossible—to quantify. Providers in restrictive states will also be faced with the unenviable challenge of detecting these events and treating more advanced/complex complications while simultaneously wrestling with legal reporting obligations.

4. THE ROAD AHEAD: CHALLENGES FOR PATIENTS AND PROVIDERS

The availability of medication abortion is indisputably a key advance in the world of reproductive health. It will likely be a lifeline for many people in the years to come, but it is not a perfect solution to a future without safe and equitable access to abortion. Patients obtaining medication abortions in the absence of clinical support—and with a backdrop of criminal liability—will not only lack access to provider guidance but also basic and emergency follow‐up care. This is inequitable from a patient care perspective, and its also dangerously uncharted territory: treatment failure will inevitably occur for a meaningful number of patients, and some of the adverse outcomes we currently view as “rare” may become more prevalent when patients are suddenly left without personalized access to providers and essential supportive care. In short, the medication abortion of the future may not be the same procedure responsible for generating such reassuring statistics.

Moving toward an era of self‐managed medication abortion also means moving away from clinically important safeguards against adverse events. In the absence of these supports, and in light of new legal penalties for abortion, patients may delay treatment‐seeking at great personal risk. As patients begin to navigate these waters, health systems and providers in restrictive contexts should be prepared for new challenges in clinical care.

FUNDING INFORMATION

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Austin N. Medication abortion: A perfect solution? Health Serv Res. 2022;57(4):717‐719. doi: 10.1111/1475-6773.14013