How to Access a Safe, Self-Managed Medical Abortion

As I said here, the right to a safe abortion⁠ (abortion: A procedure to intentionally end a pregnancy before a birth. Miscarriage is also sometimes called "spontaneous abortion," even though it is usually not intended.) and to family planning is a human right. If you or someone you know wants to have an abortion for any reason, the  desire⁠ (desire: A feeling of wanting something. In the context of sex or sexuality, desire can be a feeling of a physical and psychological want for any kind of sex or way of being sexual.)  to make that choice should be enough. No one should ever be asked to justify why they want to access an abortion. It should be a given that if someone wants to terminate their pregnancy⁠ (pregnancy: The state of carrying a developing embryo or fetus within the uterus. Medically, someone is considered to be pregnant when an egg has been fertilized by sperm, cells divide, and the fertilized egg is implanted within the lining of the uterus.) for any reason, that is reason enough.

Research shows that self-managed abortions with pills are a safe option for people who choose to have an abortion outside of clinics and other medical settings.

The World Health Organization explains, “Abortions are safe if they are done with a method recommended by WHO that is appropriate to the pregnancy duration and if the person providing or supporting the abortion is trained. Such abortions can be done using tablets (medical abortion) or a simple outpatient procedure. Unsafe abortion occurs when a pregnancy is terminated either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both."

Thanks to the advent of medical abortion, we can now learn how to access and administer safe abortion for ourselves. This guide provides accurate information and resources about how to access and use safe abortion methods. Because medical abortions — unlike surgical abortion — are safe to use at home and with limited supervision, they are considered safe so long as the person having the medical abortion has access to accurate information and has access to trained assistance if they should need it.

Medical Abortion

If you want to have an abortion, a medical abortion is one option. (If you have access to and are interested in looking into the option of surgical abortion, this piece is a good starting place for that information.) "Medical abortion" means taking medications, usually either a regimen of mifepristone and misoprostol, or misoprostol on its own, to end a pregnancy. Medical providers and abortion clinics can provide medical abortions, or they can be attained through telemedicine, which are remote medical services, like Women on Web, Aid Access, or Plan C. Those services provide access to mifepristone⁠ (mifepristone: One of two drugs currently used for medication (or medical) abortion.) , misoprostol⁠ (misoprostol: One of two drugs currently used for medication (or medical) abortion.) , and pregnancy tests.

If you have access to mifepristone and misoprostol, using them together the most effective option, but mifepristone is generally more restricted than misoprostol because it is only used for abortions, not for other things. The combined mifepristone and misoprostol regimen is between 95-99 percent effective, whereas misoprostol used alone during the first trimester of a pregnancy is about 75-85 percent effective for inducing an abortion. Since misoprostol is used as an anti-ulcer medication sold under many different names (such as Cytotec (200µg Misoprostol), Cyprostol, Misotrol), not just an abortion medication, it can sometimes be purchased at pharmacies and online. According to Women on Waves, “Sometimes it is sold over the counter without a prescription. Sometimes a prescription is necessary.” In situations where mifepristone is not available, misoprostol can be used safely and effectively by itself.

First: Find out if you’re pregnant

If you aren’t pregnant, you obviously don’t need an abortion, so the first thing you’ll need to do is find out⁠ (out: Short for ‘out of the closet’. When someone’s LGBTQ+ identity is known to other people.) if you are.

There are two ways to do this: at home with a home pregnancy test (HPT), or in a medical office. All pregnancy tests look for human chorionic gonadotropin (hCG), a hormone that appears soon after a person becomes pregnant, so in that way, it doesn’t usually matter if you test at home or in a medical setting. If you can confirm your pregnancy with a medical professional, though, that’s often ideal, since they can counsel you about the options for the pregnancy, test for STIs you may be at risk for, and also potentially help you access contraception⁠ (contraception: Devices, medications or behaviors used to intentionally aim to prevent pregnancy, including the condom, the cervical barrier, the implant, the patch, the pill, the rhythm method, the ring, the shot, the IUD, spermicide and withdrawal.) for the future, too. If you can’t or don't want to confirm your pregnancy with a medical professional for any reason, an HPT is fine, too.

If you want more information about pregnancy tests, this guide here at Scarleteen can fill you in on all things pregnancy test⁠ (pregnancy test: What we tell you to take when you ask us if you're pregnant. A test that can be done at home or by a healthcare provider to determine pregnancy. Usually a urine test, a pregnancy test measures for a specific hormone, hCG, only produced with pregnancy.) -related.

If your test confirms you’re pregnant, the next thing you’ll want to do is to accurately estimate out how far along you are in the pregnancy, to use medical abortion in the safest way. Medical abortions should be used as early in a pregnancy as possible, ideally before 9 weeks or 63 days from the last period⁠ (period: The fluid – or flow – which contains blood, from the shedding of the uterine lining usually at the end of each menstrual cycle. Sometimes periods may be less fluid and more globby; this is the state that is often mistaken for blood clotting.) . Earlier use is safer, less painful, and more effective.

To find out about how far along you are, use the Women on Web pregnancy calculator. If you have irregular or missing periods, the most reliable way to figure out how far along the pregnancy is is by asking a medical professional.

Next: Before any medical abortion

• Make sure you read through the whole process of the procedure, so that you know what to expect in advance. If you can, find someone who can be with you or within easy reach who knows you are having an abortion, supports you, and who also knows what to expect. Ideally, that person also could help you get yourself to medical care, if needed.

• You can take naproxen sodium (Aleve is one brand name) or ibuprofen (Advil is one brand name) as the instructions on the bottle suggest for you. Using over-the-counter analgesics like these before taking misoprostol is helpful for reducing pain or discomfort from the contractions that occur during a medical abortion. If you’re worried about nausea or diarrhea, which are common symptoms during a medical abortion, you can also take Immodium or Lomotil.

• Make sure you have a box of heavy flow menstrual⁠ (menstrual: Having to do with menstruation.) pads, or 5-6 washable pads. You’ll need to use menstrual pads to absorb flow from the abortion, never tampons or a menstrual cup⁠ (menstrual cup: A small device inserted into the vaginal canal to catch menstrual flow. Can be reusable or single-use depending on the brand.  ) .

• Have the information for a hospital or medical clinic — no more than 60 minutes away, if possible — handy.

• Have a plan and a means of transportation in case you need to go to the hospital. This can be the phone number of a taxi and money to pay for the taxi, or having someone who can drive you to medical care.

Learn about and be aware of the following warning signs:

• Completely soaking two to three large pads every hour for two or more consecutive hours.
• Bleeding that causes dizziness or you can’t see very clearly and feel very weak.
• Fever for more than 24 hours or getting a high fever (higher than 100.4 F/ 38 C).
• Severe abdominal pain or chills.
• Bad smelling vaginal discharge⁠ (discharge: In the context of sex and sexual health, any number of fluids which come from the genitals. Plenty of genital discharge is healthy, while some discharges can be symptoms of illness.) .
• Bleeding starts and then stops for two or more weeks and then it starts again very heavily.

If any of these things occur, it is important to go to an emergency room, urgent care, or other source of immediate medical attention, as these can be signs of an infection⁠ (infection: When harmful microbes, or germs, or harmful levels of microbes/germs, enter the body and multiply, causing illness. The common cold, flu viruses, sexually transmitted infections, chickenpox, impetigo, rabies and diphtheria are some kinds of infections.) or a failed abortion. Women Help Women states that you do not need to share with medical staff that you had an abortion if you do not want to or feel safe doing so, and can say instead that you are experiencing a miscarriage⁠ (miscarriage: When a pregnancy ends before birth all by itself, often without anyone having done anything to make that happen.) .

What to expect with a medical abortion

There are two methods that you can use for a medical abortion, mifepristone and misoprostol or misoprostol alone.

Mifepristone is a medication that blocks progesterone⁠ (progesterone: A steroid hormone in people's bodies, which is also included synthetically in hormonal birth control methods.) —the hormone bodies need to maintain a pregnancy—so that the embryonic cells stop developing and a pregnancy cannot continue. Misoprostol is a medication that starts contractions that will empty the contents of the uterus⁠ (uterus: An internal, muscular reproductive organ in the pelvis. During pregnancy, this is where a fetus will develop. The lining of a person’s uterus is also the thing that sheds every menstrual cycle in what we call a period.) .

If you have access to both mifepristone and misoprostol, it’s best to use both, because that way is safest and most effective. But in some cases, misoprostol may be available to you when mifepristone is not, in which case you can have an abortion with just misoprostol.

Before you begin taking the pills to start the abortion you’ll want to prepare yourself physically, emotionally and medically. This means getting as physically and emotionally comfortable and being in a space where you can feel as relaxed and safe as possible. Having an emergency plan ready as well as the pain and nausea medications and pads previously mentioned will also likely make you feel more comfortable and confident.

When you’re ready, you'll take the pills according according to the guidelines based on how far along you are.

As Heather Corinna writes about the experience in their guide on abortion:

From a few days to a week after the first dose [of the mifepristone and/or misoprostol], the embryo⁠ (embryo: During a pregnancy, the term for the developing cells of an organism until around eight-nine weeks after an ovum was fertilized. After this time, the organism would then be called a fetus.) and other products of conception⁠ (conception: The onset of pregnancy, marked by implantation of the blastocyst into the endometrium (the lining of the uterus).) will pass out through the vagina⁠ (vagina: The internal passage leading from the opening of the vulva to the cervix of the uterus.) . The experience will be very similar to miscarriage: there will be heavy cramping and bleeding, and what is expelled may contain large blood clots and/or the small, grayish-looking gestational sac created by the blastocyst⁠ (blastocyst: A stage of very early fetal development. If cell development continues and a blastocyst implants in the uterus, it will become an embryo and create a pregnancy.) ...The embryo is so small at the time medical abortion can be performed that it is unlikely to be able to be seen. Cramps and bleeding are usually stronger and more intense than during a menstrual period⁠ (menstrual period: The shedding of the uterine lining as part of the menstrual cycle. This often appears as a bloody liquid, but sometimes is more solid, and is made of numerous components, of which blood is only one.) . Side effects can include nausea, headaches, vomiting or bowel problems as well as continued spotting for a week or two, sometimes more.”

The smell and color of flow from a medical abortion should be similar to your normal period. Having fever, chills, nausea, vomiting, and diarrhea during the first 24 hours are common side effects and are not dangerous. You can take Immodium to help relieve stomach pain as the bottle recommends. For the fever and chills, ibuprofen should do the trick.

INSTRUCTIONS FOR USING THE PILLS

If the first day of your last period was less than 12 weeks ago (84 days):

These are the instructions for taking the mifepristone and misoprostol pills from Women on Web:

First you should swallow one tablet of Mifepristone.

24 hours later, put 4 tablets of Misoprostol under your tongue and keep them there for 30 minutes, until the tablets are dissolved. You can swallow your saliva. After 30 minutes you can spit out any remains of the tablets.

We strongly advise you to use Misoprostol under your tongue. This way, no remains of the pills can be found in the event that you need to go to a hospital. There are no blood tests that can show that you have taken Misoprostol, so there will be no way to prove that you tried to do an abortion.

• On the Euki app
• At IWHC
• At Women on Web
• At Women Help Women
• In the World Health Organization Safe Abortion guide (page 44-45)

If you have less bleeding than expected and you have doubts the abortion started, 3 hours after using Misoprostol, put 2 tablets of Misoprostol under your tongue, keep them there for 30 minutes, until the tablets are dissolved. After 30 minutes, you can spit out any remains of the tablets.

If you still did not start bleeding and you have more misoprostol tablets, you can continue taking 2 more tablets of Misoprostol under your tongue, keep them there for 30 minutes, until the tablets are dissolved. After 30 minutes, you can spit out any remains of the tablets.

You can repeat this up to maximum 5 doses of misoprostol in total.

If you do NOT have access to mifepristone and you decide to use misoprostol alone to have an abortion, you can follow these instructions from the International Women’s Health Coalition:

Step 1: Place four 200-mcg tablets (or their equivalent) in the mouth under the tongue or in the cheek pouch. Hold tablets in the mouth for 20-30 minutes to allow them to dissolve, and then swallow the remaining fragments.

During this process, you may experience bleeding that is somewhat heavier than for a period. That is normal. You should have a supply of thick sanitary napkins on hand.

Bleeding and uterine contractions (cramping) may begin as quickly as 30 minutes following this first step. If bleeding and contractions do not start within 3 hours, see Step 2 (below).

Bleeding itself does not mean that an abortion has occurred. Close inspection of the sanitary pad⁠ (sanitary pad: An absorbent reusable or disposable lining made of cotton or similar materials that is worn in one’s underwear to absorb menstrual flow.) or other receptacle can reveal whether the pregnancy has been terminated. This will be difficult to detect in the very early stages of pregnancy, however, because the embryonic tissue is indistinguishable from the normal clotting of menstrual blood. For example, six weeks into pregnancy (that is, six weeks from the first day of the last menstrual period), the embryonic sac is only about the size of a short grain of rice. By the eighth week it is more visible, about the size of a kidney bean. For terminations from 10-12 weeks, the fetus⁠ (fetus: In humans, the stage of prenatal development after an embryo, usually from about the eighth-ninth week after fertilization.) is 30 mm to 8 cm in length (1+ to 3+ inches) and it will be very clear when it has passed.

If it is not clear that the pregnancy has been terminated within three hours of taking the first dose—for example, if the embryonic sac is not visible on the sanitary pad, or if cramping continues without diminishing—go to Step 2.

Step 2: Place four more 200-mcg tablets under the tongue or in the cheek pouch and hold them there for 20-30 minutes until they dissolve.

Step 3: If the pregnancy has not been terminated three hours after using the second set of pills and bleeding, take four more 200 mcg tablets of misoprostol.

The majority of pregnancies up to 12 weeks duration are terminated within hours of the first administration of misoprostol. Generally, more than three-quarters of women experience an abortion within the first 24 hours, although it sometimes takes longer. If unsuccessful, the entire process may be repeated.

As for how abortion feels, more on what to expect and some extra tips to alleviate any pain and otherwise take care of yourself, Heather Corinna writes, in their guide on abortion:

Massaging your uterus – between your hips, just under your navel (belly button) – can help with cramping and can also help to prevent clotting. You’ll want to avoid tub bathing, hot tubs or swimming, and should not use tampons or menstrual cups to manage bleeding: have washable or disposable pads handy instead. You will also want to hold off on sexual⁠ (sexual: About or relating in some way to sex or sexuality.) activity until after your check-up. It’s typical to have some bleeding or spotting for a few weeks, and don’t worry if your menstrual period doesn’t show up right when you’d expect: it’s normal for it to take a cycle or two to get back on track. It’s also typical for any pregnancy symptoms you were having to last another few days or so after an abortion, so you don’t need to worry that you’re still pregnant because those symptoms didn’t pass right away.

It’s normal, after any pregnancy ends, whether it ends with childbirth or by terminating the pregnancy, for people to deal with some depression or tough feelings, which can vary in degree. Besides any emotional conflicts, pregnancy causes some pretty big hormonal changes in your body, and when a pregnancy ends, by it by birth or abortion, there’s another bunch of big hormonal changes, and that often causes mood changes, sometimes big ones. Obviously, if you have any mixed feelings about your abortion – or if you have an abortion you really didn’t want to have – you’ll likely have to deal with more sadness than usual. If you don’t feel sad or blue, that’s also normal and okay, and it doesn’t mean you’re insensitive or that there is something wrong with you. Plenty of people feel -- understandably -- very relieved and at peace after an abortion, too.

So, just be prepared to give yourself good care, physically and emotionally, and to honor whatever it is that you’re feeling.

Checking that your abortion was complete

A "complete" abortion means you have expelled all of the contents of the uterus and are no longer pregnant, which happens 95-99 percent of the time when using the combined mifepristone and misoprostol regimen, and happens about 75-85 percent of the time when using misoprostol alone. Ideally, you should schedule a follow-up visit with a medical professional to confirm, especially if you suspect your abortion was not successful. That may include a pelvic exam, ultrasound or serum test.

Signs that your abortion was successful are:

• You had cramps
• You had bleeding at least as heavy as your usual period
• You passed blood clots or tissue
• You feel the symptoms of pregnancy (nausea, tender breasts, need to urinate) going away

If you took mifepristone and misoprostol together:

According to Women on Web, an early ultrasound will tell you if the pregnancy has ended, but it is best wait for an ultrasound for 10 days after using Mifepristone, as only 23 percent of abortions are totally complete after 7 days.

If you took only misoprostol:

Because the success rate of misoprostol is lower, the World Health Organization recommends having a follow-up consultation 7-14 days after taking the medication to make sure that the abortion was complete. This can be done using a pelvic exam, an ultrasound, or serum test or a urine-based exam. The chemical testing, like a urine test and a serum test, might be positive if you take them too early (tests will show positives after a pregnancy ends, however it ends, for a while sometimes), so you should wait about three weeks before taking a urine test. If you still have symptoms of being pregnant, be attentive to your body and seek medical advice instead of waiting for the pregnancy test.

Finding Support

If you find yourself in need of support, listen to yourself and your own voice, and reach out to an organization — including Scarleteen, whose direct services are listed here — and a trusted friend or family member who will help support your choice. Remember that the choice to have an abortion is personal, responsible, and should not be questioned, and any emotions associated with the experience are valid.

For more information, check out these excellent and accurate resources online:

• Jewish Currents' guide to self-managed medical abortion is fantastic, and if you learn better with visual illustrations, it may be a better guide for you.
• Steph Herold's article about which apps are helpful and have accurate information about abortion, and which ones spread misinformation.
• Heather Corinna’s article about abortion, which includes helpful information about support, emotions, reaction, and making decisions that are sometimes difficult.
• Women on Web/Aid Access are organizations that can provide high quality mifepristone and misoprostol to people who need to have an abortion but don’t have access locally. They use the mail, drones, and even boats through Women on Waves.
• Safe2choose is an informative website providing information about safe abortions and options for medical abortions. They provide an email to contact a counsellor.
• International Women's Health Coalition has a guide for taking Misoprostol at home.
• National Network of Abortion Funds provides information about finding an abortion clinic and funding for an abortion. This site is US specific.
• Plan C is a team of researchers working to investigate and advocate for access to abortion pills through telemedicine. The have a report card that is frequently updated reviewing the products from telemedicine services.
• Ipas: An international organization focused on increasing safe abortion practices and contraceptive use to countries in Africa, Asia, and Latin America.
• World Health Organization: This organization is dedicated to public health generally, but has comprehensive information about abortion and access to abortions globally.

All illustrations by Isabella Rotman.