This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

Introduction

• In countries where mifepristone is approved, pregnant people have improved access to medical abortion; however, abortion rates do not increase.

• Pregnant people who can choose their method of abortion have higher satisfaction rates.

• Recommendations:

  • Clients who are eligible for medical abortion should be counselled on the availability of both medical and surgical options.

Pre-Procedure Care

• In the absence of readily available ultrasound, gestational age can be estimated using last menstrual period (LMP), clinical history, and physical examination, in clients who are certain of the date of their LMP. Ultrasound is needed when uncertainty remains.

• The probability of ectopic pregnancy among clients requesting abortion is consistently lower than in the general population.

• Recommendations:

  • When communicating with a client who has an unintended pregnancy, health care providers should use appropriate nonjudgemental and nondirective language, preferably with additional written or online material, and should ensure a confidential environment.

  • Health care providers uncomfortable with abortion counselling or provision must promptly refer the client to another health care provider/facility or provide information on where she may be able to access abortion care.

  • Clients seeking an abortion should have the capacity to provide voluntary informed consent. Health care providers should counsel clients on the proposed intervention and alternatives, outcomes, and risks.

  • Providers should use a reliable method to confirm that a pregnancy is at appropriate gestational age for effective and safe medical abortion.

  • Clients should be informed that medical abortion carries a small increased risk of additional intervention compared with surgical abortion.

Medical Abortion Regimens

• There is limited evidence regarding teratogenicity of mifepristone, but overall the risk appears to be low.

• Misoprostol is a known teratogen when used in the first trimester of a pregnancy.

• The risk of teratogenicity is high with the use of methotrexate.

• Oral mifepristone 200 mg and buccal misoprostol 800 µg is 95% to 98% effective up to 49 days after LMP. The risk of ongoing pregnancy is less than 1%.

• Oral mifepristone 200 mg and buccal, vaginal, or sublingual misoprostol 800 µg is 87% to 98% effective up to 63 days after LMP. The risk of ongoing pregnancy is less than 3.5%.

• Intramuscular/oral methotrexate and vaginal/buccal misoprostol is 84% to 97% effective up to 63 days after LMP. The risk of ongoing pregnancy is 0.4% to 4.3%.

• Recommendations:

  • Only evidence-based regimens should be used to perform medical abortion.

  • Mifepristone 200 mg oral and misoprostol 800 µg buccal/vaginal/sublingual is the regimen of choice for medical abortion up to 70 days among eligible clients.

Providing Medical Abortion

• There is no evidence to support or refute the routine administration of Rh immunoglobulin to Rh negative clients who undergo medical abortion before 49 days LMP.

• There is no strong evidence supporting routine antibiotic prophylaxis for medical abortion.

• Medical abortion is associated with bleeding, which is often heavier than a menstrual period, and with potentially severe cramping.

• Prophylactic ibuprofen administration does not provide superior pain control compared with as-needed dosing in clients undergoing medical abortion.

• Recommendations:

  • Rh immunoglobulin is recommended to Rh negative clients undergoing medical abortion beyond 49 days from LMP and may be offered before 49 days.

  • Clients who have risk factors for ectopic pregnancy and/or clinical symptoms, such as abdominal pain and vaginal bleeding, should have an ultrasound and be adequately followed.

  • Clients who have a pregnancy of unknown location and request medical abortion should receive abortion care without delay provided that they have no clinical symptoms of ectopic pregnancy (EP). If the transvaginal ultrasound demonstrates an empty uterus and the bhCG is > 2000 IU/L, the client should be evaluated for an EP and appropriate counselling, investigations, and follow-up should be arranged.

  • All clients with a pregnancy of unknown location, and clients who have not had a pre-abortion ultrasound, must have serial bhCG levels until ectopic pregnancy has been excluded and/or the abortion is complete.

Post-Abortion Care

• Follow-up rates are similar for both remote and in-clinic visits.

• When both clients and their clinician believe successful expulsion has taken place, based on history alone, complete abortion is likely.

• Either ultrasound and/or serial bhCG measurements provide definitive evidence of pregnancy termination.

• A fall of bhCG levels of 80% or more from pre-treatment to first follow-up at 7 to 14 days is indicative of a completed medical abortion.

• If ultrasound is used to assess completion of a medical abortion, endometrial thickness alone is not predictive of the need for subsequent surgical intervention.

• Retained products of conception requiring aspiration are more common in medical compared with surgical abortion.

• A second dose of misoprostol may lead to completion of a medical abortion when there is a retained gestational sac or an ongoing pregnancy.

• Severe complications following medical abortion are rare.

• Ovulation may occur as soon as 8 days after starting the medical abortion procedure.

• Insertion of an IUD at the follow-up visit after medical abortion is associated with higher insertion rates and equivalent expulsion rates compared with delayed insertion.

• Recommendations:

  • All clients undergoing medical abortion should have a follow-up assessment to confirm completion of the abortion.

  • A reliable method of follow-up should be used. This can be done in clinic or remotely using ultrasound and/or serial bhCG measurements combined with clinical history.

  • A fall of bhCG levels of less than 80% from pre-treatment to the first follow-up at 7 to 14 days requires further investigation/ management/follow-up/referral.

  • Providers should inform clients about symptoms and signs of complications and give them clear information on emergency care.

  • Clients with ongoing pregnancy at first follow-up after the start of a medical abortion with mifepristone/misoprostol should be offered repeat misoprostol or surgical evacuation.

  • Clients with ongoing pregnancy 14 to 21 days after the start of a medical abortion with mifepristone/misoprostol should be offered surgical evacuation.

  • Surgical abortion is recommended for clients with ongoing pregnancy after methotrexate/misoprostol for attempted medical abortion.

  • If a client wishes to start a hormonal method of contraception, it should be started as soon as possible after taking misoprostol.

  • If a client wishes to start using an intrauterine device, it should be inserted at the follow-up visit after medical abortion, once completion of the abortion is confirmed.

Overview

• This study analyzed the distribution, practice, and experiences of rural and urban abortion providers in BC, with a focus on the decreased availability of rural abortion services in recent years.

• All data was gathered using the British Columbia Abortion Providers Survey (BCAPS).

Key Findings

• Medical abortions represented only 15% of all abortions in BC.

• Abortion services are offered at 21/97 (22%) of all hospitals in BC (rural and urban); Only one-quarter (17/67) of rural hospitals offer abortion services.

• The three largest urban centres in BC reported 90% of all abortions, although only 57% of reproductive age women reside in the associated health authority regions.

• Due to the absence of abortion clinics in rural areas of BC, surgical abortion in rural areas is available only within hospitals.

  • Abortion providers in rural areas are more likely than their urban counterparts to perform abortions in a hospital operating room, and to use general anaesthesia. This occurs despite relevant guidelines suggesting that local anaesthesia with or without conscious sedation is preferred to general anaesthesia for procedural abortions.

• Rural providers report more stigma and operational barriers within professional relationships and at their hospitals when compared to urban providers.

  • This may suggest frustration and early burn-out as etiologies for the decrease in rural abortion providers.

  • Rural abortions are provided predominantly in hospital operating room settings, which physicians identified as a factor in both limitation to services and contributing to their experience of conflict, harassment, and stigma

• With declining rural access to surgical abortion, increasing access to medical abortion could be an available alternative.

  • Health system benefits include the cost-effectiveness of decreasing the need for surgical abortions (by increasing access to medical abortions).

  • Urban hospital-based abortions are primarily provided in non-operating room settings similar to those for other outpatient procedures; this approach has been shown to increase cost-effectiveness for surgical abortion management without general anesthesia, and reduce post-operative complications in ambulatory settings.

Overview

• This book details The Turnaway Study conducted in the United States (US) between 2008-2010, including the stories of 10 women who were interviewed for the study.

• The Turnaway Study investigated what happens to the women who get the abortions they want, and the women clinics turn away; documenting the emotional, health, and socioeconomic outcomes for those who received a wanted abortion and for those who were denied one. The study also sought to answer the questions of “does abortion hurt women?” and “what are the harms from not being able to access a wanted abortion?” 

• Over a thousand women seeking abortions at 30 facilities across the US were recruited for the study, including those who received an abortion early in pregnancy, those who received an abortion just before the gestational cut-off, and those who were a little too late and were turned away. The researchers interviewed each woman every 6 months over five years to learn how receiving versus being denied an abortion affected their mental and physical health, life aspirations, and the well-being of their families.

Key Findings

• Women make thoughtful, well-considered decisions about whether to have an abortion.

• There is no evidence that abortion hurts women.

• For every outcome that was analyzed, women who received an abortion were either the same or, more frequently, better off than women who were denied an abortion in terms of physical health, employment, financial situations, and life aspirations. 

• Women who received an abortion also had better mental health initially, and eventually the same reported mental health as before seeking an abortion. These women had a greater chance of having a wanted pregnancy and being in a stable romantic relationship years later, and the children they already had were better off by several measures of health and development. 

• The vast majority (70%) of those turned away carried their pregnancies to term. Two women in the study died from childbirth-related causes; many others experienced complications from delivery.

• Over the following five years, women who were denied abortions experienced increased head and joint pain, hypertension, and poorer self-rated overall health. These women also experienced economic hardships not experienced by women who received their wanted abortions.

• In the short term, women experienced increased anxiety and loss of life satisfaction after being denied an abortion, and those facing intimate partner violence found it difficult to extricate themselves after the birth.

Overview

• Barriers to accessing sexual and reproductive health (SRH) services disproportionately impact Indigenous women and 2SLGBTQIA+ people. Barriers include an absence of services (especially in rural, remote, and northern areas), travel costs, logistical challenges, and a lack of culturally safe, stigma-free care.

• The significant inequities in SRH service access are rooted in historical and ongoing forms of colonialism that target Indigenous reproduction, including forced and coercive abortion, contraception, and sterilization by medical providers.

• This article presents qualitative findings investigating Indigenous experiences of accessing abortion services in Canada, highlighting participant recommendations for improving safety and accessibility of abortion services.

• The researchers applied an Indigenous methodology to engage with 15 Indigenous people across Canada utilizing in the form of conversational interviews. Participants spanned across nine provinces and territories, and identified with Anishinaabe, Cree, Dene, Haudenosaunee, Inuit, Metis, and/or Mi’kmaq Nations.

Key Findings

• Participant recommendations demonstrate that Indigenous people who have experienced an abortion carry practical solutions for removing barriers and improving access to abortion services in Canada.

• Five cross-cutting recommendations emerged:

  • Location, comfort, and having autonomy to choose where the abortion takes place;

  • Holistic post-abortion supports;

  • Accessibility, availability, and awareness of non-biased and non-judgemental information;

  • Companionship, advocacy, and logistical help before and during the abortion from a support person;

  • Cultural safety and the incorporation of local practices and knowledge.