Self-managed abortion: Toxic legislation, non-toxic medication

We were delighted to see information about medication abortion shared in the August 2022 issue, “Toxicity of abortifacients: A review for physicians in the post roe era” [1]. However, we are concerned about the framing and lack of contextualization in this article, which focused on the contraindications, adverse effects and toxicities of these medications, particularly when used without clinical supervision. In fact, there are robust data available, domestically and internationally, about the safety and efficacy of self-managed medication abortion. The greatest risk for those who are self-managing their own abortion outside of the formal medical system is likely legal, not medical [2]. We would like to provide some additional information about the agents used for medication abortion as well as the true risks involved in self-managed abortion care.

While the recent Supreme Court decision overturning Roe v. Wade has undeniably worsened already oppressive obstacles to abortion care, the practice of self-managed abortion has existed long before this ruling. In fact, a substantial minority (7%) of individuals have sought self-managed abortion prior to this loss of federal protection [3]. Importantly, and unlike prior to the legalization of abortion, people who seek self-managed abortion may have access to both information and quality, self-sourced medication to complete their medication abortion independently and safely [4]. The protocol for self-managed abortion with misoprostol (with and without mifepristone) is included in guidance from professional organizations such as the World Health Organization and the Society of Family Planning [5,6].

In the event that individuals use misoprostol (with or without mifepristone), there is strong evidence regarding the safety and efficacy of these agents, including their use with no or minimal clinical oversight [7,8]. Moreover, it is important not to misinterpret the Food and Drug Administration’s (FDA) overly restrictive Risk Evaluation and Mitigation Strategies (REMS) for mifepristone as an indication of medication risk, given the overwhelming body of literature supporting its safety profile [9]. Because the risk of complications with the FDA-approved regimen for medication abortion is so small, of those who present to emergency departments (ED) following use of misoprostol with or without mifepristone, most will do so for reassurance of a normal and effective medication abortion course. The list of concerns related to contraindications to these two medications is short; and, complexities, for example, CYP induction and electrolyte derangement, are such rare and minor considerations that the effect of listing these in a document on practice guidance for the ED clinician may inadvertently serve to mystify and misrepresent medication abortion. Certainly, in scenarios where these outcomes are a concern, the existing breadth of knowledge among obstetrician/gynecologists and reproductive health clinicians would be appropriate.

When individuals seek self-managed abortion and do not use misoprostol or mifepristone, there are a host of reported xenobiotics used, with herbal remedies being most commonly reported [10,11]. Although data are limited, some have been used in many communities for generations and toxic events from these ingestions are anticipated to be rare. When individuals present with use of a medication beyond the fund of knowledge of the ED clinician, support from toxicologists is available nationwide 24 h a day. Of note, despite the authors’ concern, methotrexate is not used for the termination of intrauterine pregnancies, and we are unaware of self-management with this agent as it is significantly more difficult to source than medications typically used for pregnancy termination.

The true knowledge deficit for frontline clinicians is unlikely to be the toxicity of mifepristone or misoprostol – for which obstetrician/ gynecologist consultants can provide reassurance over the impressive safety record and recommendations for rare complications – but rather for the role that clinicians may play by misunderstanding the use of mifepristone and misoprostol:

• People can safely self-manage their abortion with mifepristone and misoprostol with expansive networks to provide information and quality medication.

• Mifepristone and misoprostol are used for both management of first trimester pregnancy loss and medication abortion. It is not necessary for clinicians to interrogate patients regarding the details of how they obtained these medications and, in fact, doing so may put them at greater risk for criminalization.

• The same care is required for complications of pregnancy loss or induced abortion following use of misoprostol with or without mifepristone. ED and reproductive health clinicians are already skilled and trained in providing this care.

• People who have taken mifepristone or misoprostol need not disclose their diagnosis (pregnancy loss versus undesired pregnancy), and clinicians should not feel obligated to determine the reasons, but rather the exposures. This is a critical distinction in providing the highest quality reproductive care that avoids potential criminalization of patients and ensures we do not become agents of the carceral system.

• People who end their own pregnancies – or help those who do – may be targeted, reported, prosecuted, or jailed. This is more likely to happen if they seek care from a clinician. People of color, people struggling financially, immigrants, and people who identify as transgender, nonbinary, and gender-expansive disproportionally face this risk.

• There is no mandate to report self-managed abortion, suspected or confirmed, to law enforcement. Clinicians may face legal or professional penalties for violation of patient privacy.

The work of Drs. Mazer-Amirshahi and Ye is a critical entry point into nuanced conversations about the rapidly changing landscape of abortion care in the United States. We feel great solidarity with the authors and the emergency medicine readership in giving the much needed attention to medication abortion and self-managed abortion, but we hope all feel confident in patients’ use of mifepristone and misoprostol, regardless of their source or reason.