Drug-induced Abortion After the First Trimester

This is Issue 10 of the On Women’s Health Series.

Executive Summary

• The claim that later drug-induced abortions are “safe and effective” is false. Nearly all studies document higher rates of complications and deaths following mifepristone and misoprostol used later in pregnancy compared to the first trimester, with outcomes even worse following misoprostol used alone.

• The Food and Drug Administration’s removal of mifepristone’s in-person dispensing requirement makes it easier for women to obtain mifepristone past the FDA’s gestational cutoff at 10 weeks. These later drug-induced abortions often occur outside of a medical facility, increasing the odds that complications will be more severe if emergency care is not readily available.

• For these reasons and more, any promotion of, or failure to warn against, later abortion drug use outside of standard medical care should be recognized as callous attempts to prioritize ending unborn life over the health and safety of women.

Introduction

Increasingly extreme recommendations have followed the U.S. Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade and allowed legislative abortion limitations in many U.S. states. Abortion advocates have engaged in much handwringing since then, arguing that women who “need” an abortion will not be able to “access” this “necessary” procedure. This has been followed by recommendations for women to pursue abortion procedures outside of published protocols and outside the standard medical system.

A 2022 article in The Atlantic appeared to be promoting the use of mifepristone and misoprostol abortion beyond the FDA’s 10-week gestational age limit:

“The FDA label is lagging behind what the science says,” Heidi Moseson, a researcher at Ibis Reproductive Health who has studied the issue internationally, told me. And in practice, women are using these pills even later in pregnancy. In      countries where abortion is or until recently had been illegal, such as Mexico, Argentina, Ecuador, and Chile, activists have for years helped women self-manage medication abortions in the second trimester up to 24 weeks. Different stages in pregnancy just require different doses of the drugs.

The safety of this recommendation was disproven by a story later in the article:

The girl had taken abortion pills she’d bought online to end her 15-week pregnancy five days earlier. Now she was in pain, with an umbilical cord protruding from her vagina. She was one of the patients who needed a surgical abortion to complete her second-trimester medication abortion. The procedure was entirely routine at that hospital, and she went home with antibiotics within 24 hours. Without this care, though, it could have turned into “a serious infection that could absolutely be life-threatening.”^[1]

Similarly, a 2023 article in Vox stated: “[O]utside the US, medication abortion after 10 weeks is not uncommon. But the process comes with more severe side effects and slightly higher risk of complications, experts say, and can be frightening for patients who have to go through it alone and without guidance — a more common scenario as more people self-manage their abortions, and as stories of bans and prosecutions have patients unsure who they can trust.” Despite acknowledging that patients may need to obtain emergency medical care, the author then attempted to spread fear, writing, “Prosecutors have used laws against mishandling human remains and other crimes to prosecute people suspected of self-managing abortions.” The article concluded by similarly quoting the above-mentioned Heidi Moseson: “‘There are real instances when people need care quickly to save their lives and the confusion around these laws and the real legal repercussions have a very harmful chilling effect,’ Moseson said.”^[2]

Finally, a heartbreaking story relayed by The Washington Post in 2024 demonstrated the poor advice women are sometimes given:

“Hi, this is the hotline doctor … Can I help you?” The voice Prine heard was quiet and scared — belonging to a 15-year-old with an area code in a state with an abortion ban who had taken pills and passed a fetus larger than she’d expected. Unable to flush the fetus down the toilet, the girl asked about throwing it away.  … Prine cradled the phone in both hands and leaned in, trying to channel every ounce of reassurance and understanding she could muster through the phone line. “There’s nothing in there that’s traceable back to you,” she said. “As long as you don’t tell anybody.”

With that deceptive advice, this terrifying experience became the young woman’s horrible secret.

The article described several other traumatic experiences following later use of abortion drugs. For example:

Alone in her bathroom, Briana had no idea what to do. The Aid Access doctors had told her to expect nausea, vomiting, chills, blood clots and a fetus at least the size of an orange, emails show. They said nothing about an umbilical cord. “Do I pull the cord out?” Briana wondered, frantically trying to remember what the doctors had done when she gave birth. “Do I just wait to try to push it out?” … Briana said she sat there with her umbilical cord hanging loose for at least 15 minutes before the placenta finally dropped into the toilet. … Briana stayed in the bathroom that night for more than an hour. She knew she shouldn’t look at the fetus, she said, but she couldn’t help it. In the toilet bowl, she could make out a head. She remembered thinking that the legs looked long. “I felt like a monster,” she said, reflecting back on that moment.^[3]

Despite these distressing experiences, some pro-abortion medical sources seem to be promoting later drug-induced abortions and downplaying their risks.

Pro-abortion medical sources promoting later drug-induced abortion

American College of Obstetricians and Gynecologists

In their 2013 (reaffirmed 2017) Practice Bulletin: Second Trimester Abortion, the American College of Obstetricians and Gynecologists (ACOG) began with the statement, “Second-trimester abortion is an important component of comprehensive women’s health care…” They led their discussion on medical abortion by stating, “Second trimester abortion also can be safely accomplished through medical induction or medical abortion.” But they then noted, “Compared with D&E, termination by induction with misoprostol is less cost-effective, is associated with a greater risk of complications, such as incomplete abortion, and may be prolonged.” They further note that “Modern medical abortion methods include the use of one or more of the following: prostaglandin analogues, mifepristone, osmotic cervical dilators, Foley catheters, and oxytocin. … Mifepristone followed in 24-48 hours by misoprostol is the most effective regimen for second trimester medical abortion, with up to 91% efficacy within 24 hours of initiation of misoprostol.”^[4] When this statistic is examined another way, ACOG recognizes that nearly one in ten women will have an unsuccessful or incomplete abortion when these drugs are used in the second trimester, necessitating further interventions.

ACOG reassured readers regarding the risks to women by repeating a debunked claim that the risk of maternal death associated with childbirth is approximately fourteen times higher than that with abortion.^[5] Their review of the literature documented postabortion hemorrhage requiring transfusion in 0.7% of second trimester medical abortions, retained pregnancy tissue in at least 8%, cervical laceration in 3.3% of second trimester abortions (including both D&E and drug-induced), uterine rupture in 0.28% with prior c-section and 0.04% without, and infection in 0.1-4%. Later ACOG notes that second trimester drug-induced abortion involving misoprostol regimens is associated with complications in up to 29% of cases, the most common of these being retained placenta (21%). They note that complications can be minimized by pre-abortion screening including ultrasound confirmation of gestational age, localizing the placenta and assessing hemoglobin and blood type.^[6] ACOG further reports that approximately 10.2% of the million plus yearly U.S. abortions occur in the second trimester and beyond, so these complication numbers are not inconsequential.

For background, ACOG has demonstrated pro-abortion ideology for decades. In their 2014 Committee Opinion: Increasing Access to Abortion, they stated, “Safe, legal abortion is a necessary component of women’s health care … The American College of Obstetricians and Gynecologists calls for advocacy to oppose and overturn restrictions, improve access, and mainstream abortion as an integral component of women’s health care.”^[7] In their 2014 Committee Opinion: Abortion Training and Education, they recommended ob/gyn residencies require “opt-out” abortion training, which stigmatizes young doctors who do not want to perform abortions.^[8] In their 2007 Committee Opinion: The Limits of Conscientious Refusal in Reproductive Medicine (Reaffirmed in 2019), they stated, “Physicians and other health care providers have the  duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request.”^[9] In other words, they expect their pro-life members to violate their own consciences by referring for abortion. In fact, ACOG has never filed an amicus in support of any legislative limitation on the performance of abortion.^[10] Notably, for a variety of practical and personal reasons, no more than one in five obstetricians are willing to provide elective abortions.^[11] ACOG does not represent the positions of all of its members, only its leadership’s pro-abortion ideology.^[12]

Society of Family Planning

In 2023, the Society of Family Planning (SFP) created clinical recommendations to be used for drug-induced abortions performed between 14 and 24 weeks of gestation, based on a review of the literature between 2008 and 2022. They concluded by recommending a regimen of mifepristone 200 mg orally followed in 24 to 48 hours by misoprostol 400 mcg every three hours vaginally, sublingually, or buccally until the abortion was completed. When that regimen was not available, they advised that simultaneous mifepristone and misoprostol or misoprostol alone were also appropriate methods of performing second trimester drug-induced abortions.^[13]

SFP notes that there are many variables and confounders that cause comparisons amongst studies to be challenging, including gestational duration (and availability of ultrasound), additional interventions (such as osmotic dilators, mechanical dilation, or amniotomy), routine aspiration after fetal delivery, and fetal demise status (living, natural demise, or induced demise). They remark that non-standardized definitions also limit interpretation of the literature. For example, “procedure length” usually but not always begins after the misoprostol dose (which may begin simultaneously or up to 48 hours after mifepristone); “success” may mean complete abortion without the need for procedural intervention, or it may mean fetal and placental expulsion within a predefined time period (usually 24 or 48 hours). Conversely, no consistent definition of “failure” exists. It may include delivery beyond a specified time period, or it may indicate a procedure was needed “to remove the fetus, placenta, or both.” They examined regimens including mifepristone, misoprostol, gemeprost (similar to misoprostol but not available in the United States) and oxytocin, or some combination of these drugs.^[14]

They noted that later drug-induced abortions typically occur in a medical facility (ambulatory center or hospital) because this allows more options for management of pain control and expedient treatment of common problems. They do state a medical facility may not be necessary for all patients, but this is a retrospective recommendation, as there is no way to predict which women will experience complications. SFP also recommend that if a pre-abortion ultrasound raises concerns for abnormal placentation, a woman “should be referred to a tertiary care center where adjacent emergency services such as blood bank, surgical services, or interventional radiology are immediately available.” SFP reported the risk of uterine rupture was 0.47% with prior c-section and 0.08% without, but the risk rose dramatically to 2.5% with two or more prior c-sections. The researchers implied that this risk may be similar after other uterine surgeries such as myomectomy.^[15]

SFP also sponsored a 2023 systematic review (SR) examining “no test” drug-induced abortion, specifically omitting ultrasound. They reported the overall efficacy was 96.4% through 63 days of gestation, 95.2% through 70 days of gestation and 83.8% through 84 days of gestation, demonstrating what nearly all studies show, that failures increase with increasing gestational age. The overall rate of surgical evacuation was 4.4%, need for additional misoprostol 2.2%, blood transfusion 0.5%, and ectopic pregnancy 0.06%. They justified “no test” abortion due to their concerns regarding ease of abortion access: “With legal restrictions on abortion, more patients will find themselves without access to abortion with considerable, unfeasible travel distances and expenses to the nearest abortion clinic.” They concluded, “No-test protocols can be used to provide safe abortion care without a pretreatment ultrasonogram and, thus, with no in-person requirement for the vast majority of patients. There is ample evidence regarding the safety and acceptability of remote or telemedicine follow-up for medication abortion.”^[16] Although this SR only addressed first trimester drug-induced abortions, it is not implausible that “no test” recommendations will eventually be expanded to include second trimester drug-induced abortions. At a minimum, failure to provide ultrasound documentation of gestational age in the first trimester will result in some women taking the abortion drugs in the second trimester or greater, due to error or intentional misuse.

For background, the Society of Family Planning has also demonstrated pro-abortion ideology. It has published a “position statement” that says: “Abortion care is an essential and critical component of comprehensive healthcare … The Society of Family Planning supports expansive, inclusive protections for abortion care for all people. The Society opposes legislation, laws, initiatives, and regulations that limit abortion care … No exception to an abortion restriction can adequately mitigate its harm.”^[17]

World Health Organization

The World Health Organization (WHO) published 2025 guidelines on drug-induced abortion at greater than 12 weeks. They suggested “the use of 200 mg mifepristone administered orally, followed 1–2 days later by repeat doses of 400 mcg misoprostol administered vaginally, sublingually or buccally every 3 hours.” They also gave recommendations for using misoprostol alone with “repeat doses of 400 mcg misoprostol administered vaginally, sublingually or buccally every 3 hours.” When used in the second trimester, they recommended (defined as a “strong recommendation”) that generalist medical practitioners and specialist medical practitioners manage the patients, but when a provider with that training was unavailable, they suggested (defined as a “weak recommendation”) that the medical management could also be performed by traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives and associate/advanced associate clinicians. They also said use should occur “where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.” WHO stated that abortion is “a safe and non-complex health-care intervention that can be effectively managed using medication or a surgical procedure in a variety of settings.”^[18]

WHO guidelines and studies must be interpreted with caution. The WHO has a well-known pro-abortion agenda, and it operates under the assumption that many women with unintended pregnancies will obtain abortions, and if “safer” methods like mifepristone and misoprostol are not readily available, then women will resort to unsterile instrumentation or non-medically trained abortionists.^[19] They stated when they issued  their 2022 guidelines on abortion, “Being able to obtain safe abortion is a crucial part of health care,” and recommended “removing medically unnecessary policy barriers to safe abortion, such as criminalization, mandatory waiting times, the requirement that approval must be given by other people (e.g., partners or family members) or institutions, and limits on when during pregnancy an abortion can take place.”^[20]

National Abortion Federation

Similarly, the National Abortion Federation (NAF) made the following 2024 Policy Statement: “Medication abortion is a safe and effective method for termination of pregnancies beyond the first trimester when performed by trained clinicians in medical offices, freestanding clinics, ambulatory surgery centers, and hospitals. Induced fetal demise may be particularly important at later gestational ages.” In their discussion they remarked that “Evidence-based regimens for later medication abortion are difficult to compare. Mifepristone increases the efficacy and decreases the total time and doses needed for misoprostol to cause pregnancy expulsion. Misoprostol dosing can be repeated until expulsion with no limit on the number of doses.”^[21] As its name implies, NAF’s mission is to support abortion providers. They strongly oppose abortion restrictions and advocate for unrestricted access to abortion.

To summarize, the previously quoted four pro-abortion medical organizations, despite providing a nuanced discussion within their guidelines, are unanimous in opposing legislative limitations on later abortion procedures, resorting to the refrain that abortion is “safe” even when performed with abortion drugs in the second trimester. While superficially reassuring, this contrasts with the experiences of women documented earlier. A deeper dive is in order, examining the best quality studies from the peer-reviewed literature, to see how “safe” this procedure really is for women.

Early drug-induced abortion

In order to evaluate second trimester drug-induced abortion, one must begin by understanding early drug-induced abortion. Current FDA guidelines allow a drug-induced abortion to be induced with two drugs until 10 weeks gestational age. Mifepristone (Mifeprex or RU486) blocks progesterone receptors to cut off hormonal support for the pregnancy, resulting in disruption of the placental implantation site and embryonic or fetal death. Misoprostol (Cytotec) is consumed 24-48 hours later to induce contractions to expel the dead embryo or fetus and placental tissue.^[22]

Women often choose this method under the assumption that it is safer and more natural, yet complications occur two to four times more frequently from drug-induced than surgical abortions.^[23] The average woman bleeds for 9-16 days, and 8% will bleed for a month or more. Approximately 1 in 25 women will require emergency room evaluation,^[24] nearly 1% will have ongoing viable pregnancies (the drugs will fail to kill the fetus), and surgery for incomplete abortion will be required in 3.4-7.9% of cases.^[25] The side effects of cramping, vaginal bleeding, nausea, weakness, fever, chills, vomiting, headache, diarrhea, and dizziness occur in large percentages of  women.^[26] It has been extensively documented that the abortion drug complications reported to the FDA consist of only a small percentage of the total complications due to incomplete reporting^[27] and frequent misattribution of induced abortion complications to miscarriages,^[28] and since 2016, the FDA has required no abortion drug complication reporting unless it resulted in the woman’s death.^[29] The Guttmacher Institute reported that 63% of abortions in the U.S. were induced by these drugs in 2023.^[30]

In their 2020 Practice Bulletin: Medication Abortion up to 70 days of Gestation, ACOG recommends mifepristone and misoprostol as “a safe and effective method of providing abortion.” They also reassure readers that “[m]edication abortion can be provided safely and effectively by telemedicine.”^[31]

Some abortion providers have extended their provision of these drugs to more advanced gestational ages, with Planned Parenthood, Aid Access, and Women on Web advertising that they are willing to provide the drugs beyond the FDA’s recommendations.^[32]

In December 2021, the FDA removed its Risk Evaluation and Mitigation Strategy (REMS) in-person dispensing requirements.^[33] As we have previously shown in our paper Immediate Physical Complications of Induced Abortion,^[34] this change allows “mifepristone provision without sonogram or physical exam to document gestational age or intrauterine pregnancy, or without labs to rule out anemia or sexually transmitted infections, or documentation of Rh status and provision of Rhogam, if indicated, to prevent isoimmunization. This change allows telemedicine prescribing, internet ordering and mail order provision of these potentially dangerous drugs.^[35] This unsupervised use “will undoubtedly increase the risk of failures and adverse events after chemical abortions. Additionally, it may encourage coercion of hesitant women by unwilling partners, incestuous abusers and sex traffickers into unwanted abortions.”^[36]

Yet, despite the poor experiences of many women, some abortion advocates have promoted expanding the gestational ages at which abortion drugs may be used. An editorial in The Lancet explains the reason for this promotion: “Strategies to increase access to abortion later in pregnancy are especially crucial in settings where laws and other barriers prevent people from accessing abortion care in a timely manner.”^[37] The priority seems to be ending unborn life over the health and safety of women who encounter unintended or problematic pregnancies.

Later abortion procedures

In 2022, UpToDate, a well-respected and evidence-based clinical resource, discussed surgical and medical options for abortion after the first trimester, noting that “second trimester abortion is associated with more morbidity and mortality and, for some patients, more social or emotional challenges than first trimester abortion.” They noted that “determining gestational age is a critical part of providing appropriate care.”^[38] The National Abortion Federation (NAF) affirms this, stating that “gestational age must be verified by ultrasonography … prior to termination of a pregnancy … more than 14 weeks from LMP.”^[39] As noted earlier, current FDA protocols do not require ultrasound to confirm gestational age before abortion drugs are provided (though they do limit drug-induced abortion to 10 weeks of gestation).

Surgical termination after the first trimester is usually performed by dilation and evacuation (D&E) and drug-induced abortion is performed with mifepristone and misoprostol, or sometimes misoprostol alone. UpToDate notes that the advantages of D&E are “decreased procedure duration and predictable timing, decreased cost and [use when] medical conditions … required controlled timing of the procedure,” but the significant disadvantage is “risk of uterine perforation which may require (emergency abdominal) surgery.” The only advantage they note for abortion drugs is the “desire for an intact fetus” (which may occur if an abortion is being performed for a child with life-limiting fetal anomalies when the parents desire an autopsy or burial of their child), but the significant disadvantages are many: “increased experience of the procedure, unpredictability of the timing of delivery, risk of hemorrhage and risk of retained placenta necessitating surgical removal.”^[40]

UpToDate also notes that second trimester drug-induced abortion most commonly occurs in hospitals but may also be performed in appropriate clinics and ambulatory surgery centers, although they “must have appropriate staff, equipment and medication to perform the procedure and manage complications and to provide analgesia and anesthesia.” Additionally, the National Abortion Federation’s Policy Statement on drug-induced abortion after the first trimester states, “Medication abortion is a safe and effective method for termination of pregnancies beyond the first trimester when performed by trained clinicians in medical offices, freestanding clinics, ambulatory surgery centers, and hospitals … Gestational age must be verified by ultrasonography … A trained clinician must be available from initiation of induction until post-abortion discharge. Access to surgical management or appropriate referral must be available if surgical intervention is required.”^[41]

What does the scientific evidence tell us about the safety of later abortion procedures?

Later surgical abortion

Dilation and evacuation (D&E) is the most common surgical method after the early second trimester, accounting for about 95% of these abortions.^[42] If complications occur, additional surgery may be needed to correct damages resulting from the procedure or remove retained tissue.^[43] Severe complications could lead to death.^[44]

Risks of complications and death from later surgical abortions increase with gestational age. A D&E is nearly three times more likely to result in death when it is performed at greater than 16 weeks compared to 13-15 weeks of gestation.^[45] Beyond 21 weeks, at the gestational age where many infants may survive delivery, the risk of death from D&E is higher than the risk of death from childbirth.^[46] The CDC reports that the risk of mortality increases by 38% for each week beyond eight weeks, with a 15-fold increase early in the second trimester, a 30-fold increase in the mid-second trimester, and a 76-fold increase in the late second trimester.^[47] Another CDC study documented more than twice the risk of death from a D&E beyond 18 weeks of gestation compared with an earlier D&E.^[48]

D&E complication rates from high-volume abortion providers usually range from 4-7%,^[49] but resident physicians in training have much higher rates. One study found 11% major complications (including death, prolonged hospitalization, transfusion, exploratory surgery, stroke, heart attack, pulmonary embolus, and deep venous thrombosis), and 24% readmission rates from inexperienced physicians.^[50] The  University of California, San Francisco (UCSF) reported 13% complications and10% hemorrhage when a late miscarriage was treated with a D&E.A D&E abortion on a living fetus resulted in 10% complications and 7% hemorrhage.^[51] Two other studies documented hemorrhage in more than half of the women using standard D&E procedures, although hemorrhage was inconsistently defined.^[52]

Later drug-induced abortion

In very late abortions, D&E becomes more difficult due to the difficulty in eviscerating and disarticulating the larger fetus, so abortion providers may choose to perform a medication induction abortion. Labor may be induced with medications (prostaglandins such as misoprostol, with or without mifepristone, intravenous Pitocin). Historically, saline, urea, or prostaglandin intraamniotic infusion were also used but resulted in many complications. Infection, hemorrhage, or retained tissue sometimes required surgical completion.^[53]

The birth of a live baby is rarely acknowledged but likely occurs frequently. One European study documented that more than half of abnormal fetuses survived induction when aborted between 20-24 weeks.^[54] A large Canadian study found that 11% survived induction when aborted between 15-29 weeks.^[55] Although methods are available to kill the fetus before labor induction,^[56] a recent survey of abortion providers discovered that 69%  do not routinely induce fetal demise after 18 weeks of gestation.^[57]

What do studies of later drug-induced abortions show about safety and complications?

In the following review of the literature, note that the focus is on applicable systematic reviews, meta-analyses, and randomized control trials from the peer-reviewed literature, although occasionally other studies of high impact are included.

A. Drug-induced abortions compared to surgical abortions

Because the options for later abortions include both abortion drugs and D&E, ideally studies would compare these two methods to allow a direct comparison of safety for a woman seeking a later abortion.^[58] Yet, few high-quality studies make this comparison. Only one randomized controlled trial (RCT) of abortions between 13-20 weeks gestational age by Kelly and colleagues compares the options of D&E (Surgical Termination of Pregnancy or STOP, n=62) to mifepristone 200 mg orally followed in 36-48 hours by misoprostol 800 mcg vaginally, then 400 mcg vaginally or orally (Medication Termination of Pregnancy or MTOP, n=60). Drug-induced abortions required a subsequent surgical procedure to remove retained pregnancy tissue in 10% of cases. Loss to follow-up occurred in 40%. Only half of the women found the drug-induced abortion procedure “acceptable” (53%) and half (53%) reported the experience was “worse than expected.”^[59]

Apparently, it is difficult to find women willing to participate in randomized controlled trials, because most women would prefer a faster surgical abortion.^[60] An RCT by Grimes was stopped after one year because of slow enrollment, with only 18 women willing to participate. Of the women who completed the study, 44% of the women receiving abortion drugs required surgical completion.^[61]

Studies are limited in other ways, as some have less rigorous study designs, often retrospective or non-randomized. The specific dosage and route of delivery of mifepristone and misoprostol may differ between studies. Others may differ in other variables such as use of laminaria for cervical ripening, injections to induce fetal death, and other factors. Because the FDA limits mifepristone abortions to 10 weeks gestational age, most later drug-induced abortions in the U.S. have not been performed with mifepristone and misoprostol, limiting the data on mifepristone in the U.S. So, international studies must be consulted in order to find more data specific to later mifepristone and misoprostol abortions.

An Ethiopian quasi-experimental study, which allowed women to choose their intervention, studied 219 women who chose mifepristone and misoprostol abortion and 60 who chose surgical abortion between 13 and 20 weeks of gestation. This study found that: “The composite complication rate is not significantly different among medical and surgical abortion patients (15% versus 10%) … Nine patients (4.1%) in the medical arm required additional intervention to complete the abortion.”^[62]

Another small, retrospective study compared 81 mifepristone and misoprostol abortions and 75 D&E abortions between 14 and 24 weeks of gestation, finding that there were only 7% complications in the medical abortion group and 1% in the surgical abortion group.^[63]

Some studies have looked at misoprostol or other prostaglandins alone compared to D&E, documenting even more complications than from mifepristone and misoprostol abortions, affecting approximately one in four women. A 2011 retrospective chart review compared D&E (n=94) with prostaglandin induction abortions—usually misoprostol but some used dinoprostone—(n=126) between 13 and 24 weeks in Pennsylvania. Complications were common in both groups, with a rate of 15% in the D&E group vs. 28% in the drug-induced group. Retained placental tissue requiring surgery (or repeat surgery) occurred in 2% of D&E patients vs. 22% drug-induced patients, and cervical injury occurred in 5% of D&E patients vs 0% of drug-induced patients. Notably, the D&Es were performed by an “experienced provider under continuous ultrasound guidance.”^[64] A 2017 U.S. retrospective cohort study compared D&E (n=343) to misoprostol induction abortions (n=122) between 14 and 24 weeks, documenting complications in 7% vs. 23%, and serious complications in 1.5% vs. 3.3%.^[65]

B. Late first trimester – early second trimester drug-induced abortions

A 2019 Systematic Review (SR) by Kapp and colleagues concluded that medical abortion, as compared with surgical abortion, was effective in the late first trimester between 9 and 12 weeks (94.6% versus 97.9% complete abortion, therefore 5.4% vs. 2.1% incomplete abortion). It concluded that: “A combined regimen of mifepristone and misoprostol was significantly more effective than misoprostol alone (90.4% versus 81.6% complete abortion).” It follows that there the rates of incomplete abortion were 9.6% vs. 18.4%, respectively. They go on to observe, “Complete abortion rates for all regimens investigated ranged from 78.6% to 94.6%. Success rates were higher with repeat dosing of misoprostol both in combination regimens and alone, and with vaginal compared with oral administration for repeat dosing.”^[66]

A 2015 Chinese RCT studied women who used mifepristone orally followed by oral misoprostol (n=417) or vaginal misoprostol (n=208) between 8 and 16 weeks. The complete abortion rate, the study concluded, was “significantly higher” in the vaginal misoprostol group (98.1%) than in the oral group (94%) The incomplete abortion rates were therefore 1.9% vs. 6%, respectively.^[67]

A 2010 RCT by Dalenda and colleagues in Tunisia compared mifepristone 200 mg followed in 48 hours by misoprostol 400 mcg orally (n=73) vs. 800 mcg vaginally (n=49) for abortions 9 to 12 weeks of gestation. Surgical curettage was required in 19.1% vs. 22.4%, respectively.^[68]

A 2010 Chinese RCT of 100 abortions compared mifepristone 200 mg orally followed by 600 mcg vaginal misoprostol, then 400 mcg miso every six hours x 2 doses, one or two days later, between 13 and 16 weeks of gestation. They reported similar time to delivery intervals (7 vs. 6.8 hours) and failures of 6% in the first group and none in the second group. Although they reported only 12% and 4% emergency surgical curettages, they documented that postabortion curettage is performed routinely in China after placental expulsion, and the pathologic examination of this tissue removed surgically showed retained pregnancy tissue, respectively, in 46.2% and 29.8% of the women. ^[69]

A 1999 Chinese RCT studied 2,007 women obtaining medical abortions at 10-16 weeks of gestation. Group I (n=511) took mifepristone 75 mg orally per day for two days, and 48 hours later misoprostol 0.6 mg orally every 3-4 hours three times; group II (n=491) took mifepristone 100 mg orally per day for two days followed by the same dose of misoprostol 48 hours later; group III (n=519) took the same dose of mifepristone as group I and 48 hours later had misoprostol given vaginally every 12 hours three times; group IV (n=486) took the same dose of mifepristone as  group II and 48 hours later had the same dose of misoprostol vaginally as in group III. “The successful abortion rate from group I to group IV were 88.6%, 89.4%, 90.9% and 94.0% respectively,” the report concluded. Thus, incomplete abortions occurred in 11.4%, 10.6%, 9.1%. and 6% of cases, respectively.^[70]

A 2023 prospective observational cohort study performed by Moseson and colleagues recruited 264 callers between 9 and 22-weeks of gestation seeking advice about self-managed mifepristone and misoprostol abortions (n=149) or misoprostol only abortions (n=115) in Argentina, Nigeria, and Southeast Asia. Only three women were between 17 and 22 weeks of gestation, so the results mainly reflected abortion between 9 and 16 weeks. They documented that surgical intervention was required in 10.6% of cases overall (5.8% at nine weeks, 3.1% at 10 weeks, 9.1% at 11 weeks, 7.7% at 12 weeks, 31.3% at 13-14 weeks, and 9.1% at 15-16 weeks of gestation). Nearly a quarter (23.5%) of these women sought additional health care during the abortion.^[71]

C. Drug-induced abortions throughout the second trimester

A 2011 Cochrane review by Wildschut and colleagues examined 40 RCTs comparing various medical induction regimens, including mifepristone and misoprostol, for varying gestational ages after three months of gestation. Studies examining the need for surgery were limited, comprising less than 300 mifepristone and misoprostol abortions, but nonetheless documented that over 12% of these women required surgery due to retained tissue or hemorrhage.^[72]

A 2020 Systematic Review and Meta-Analysis (SR/MA) by Whitehouse and colleagues of 43 studies of drug-induced abortion between 8 and 28 weeks of gestation concluded that mifepristone 200 mg 1 to 2 days before misoprostol 400 mcg vaginally every 3 hours at ≥ 12 weeks of gestation received the most support from the literature. Direct comparisons of buccal misoprostol to sublingual or vaginal routes after mifepristone were limited, as was evidence on how to best manage women with prior uterine incisions. Serious adverse events occurred in 1.7% of cases, including need for hospitalization, transfusion, further surgery (not including aspiration for retained pregnancy tissue), or death. Unfortunately, they reported the relative risk of outcomes between the compared studies, but not the absolute risk of complications. For example, they reported that giving mifepristone and misoprostol simultaneously caused three times more ongoing pregnancies than giving misoprostol more than 24 hours after mifepristone (Risk Ratio=3.13) but did not report the incidence of ongoing pregnancies in each group. The curious reader is required to consult the referenced studies to determine this important information.^[73]

A 2024 Swedish RCT by Rydelius and colleagues studied women who had mifepristone and misoprostol abortions between 12 and 22 weeks. All received 200 mg mifepristone in the clinic, followed in 24-48 hours by 800 mcg misoprostol at home two hours before hospital admission (“priming at home” group, n=220) vs. in the hospital (n=215). The study stopped prematurely due to slow enrollment. Nevertheless, the researchers documented complications in 22% of the abortions, including hemorrhage during hospitalization (both 7%), hemorrhage after discharge (both 6%), infection (4% vs. 6%), surgical removal of the placenta (6% vs. 9%), and retained placenta after discharge (5% vs. 3%). Serious adverse events (SAE) occurred in 3% of cases.^[74]

A 2025 RCT by Rajaraman and colleagues studied mifepristone abortions in Indian women between 13-20 weeks, most of which were induced for fetal anomalies. Two pretreatment mifepristone regimens were used. Single dose mifepristone 200 (n=27) and double dose mifepristone 200 x 2 doses 24 hours apart, were both followed in 36 to 48 hours by misoprostol 600 mcg vaginally and then 400 mcg orally every four hours (n=27). Although the researchers reported that the “success rate of abortion was 100% in both groups”, they noted that 48.1% in the single dose group and 22.2% in the double-dose group required evacuation.^[75]

A 2022 RCT by Sharma and colleagues studied Indian abortions performed for fetal anomalies 13-20 weeks randomized to group 1 (n=30), involving mifepristone 200 mg, then 48 hours later vaginal misoprostol 400 mcg every 4 hours, versus group 2 (n=30), involving the same medical regimen along with a mechanical method (transcervical Foley catheter). Only 63% of group 1 had a complete abortion within 12 hours compared with 100% of group 2. Failed induction occurred in 7% of group 1 requiring an additional induction agent (oxytocin) and this group also had 7% post-abortion complications vs. 3% in group 2.^[76]

A 2021 RCT by Allanson and colleagues studied mifepristone and misoprostol vs. misoprostol alone when fetal death occurred between 14 and 28 weeks of gestation. Australian women were randomized to mifepristone 200 mg orally followed by misoprostol 400 mcg vaginally every 6 hours at < 24 weeks or 200 mcg vaginally every 4 hours if ≥24 weeks (n=32), or placebo plus the same misoprostol regimen (n=34). Median delivery time was faster for mife/miso (6.8 hours vs. 10.5 hours). Retained placenta occurred in 29% vs. 30.3% of cases, manual placental removal in 22.6% vs. 30.3%, hemorrhage > 500 cc in 19.4% vs. 15.2%, blood transfusion in 3.2% vs. none, and readmission in 6.5% vs. 9.1%.^[77]

A 2016 RCT by Abbas and colleagues examined Vietnamese drug-induced abortions between 13 and 22 weeks of gestation of 200 mg mifepristone orally followed in 24 hours (n=252) by 400 mg buccal misoprostol every three hours vs. those who received simultaneous administration of both drugs (n=252). Complete abortion within 24 hours occurred in 94.4% and 85%, respectively. The trial allowed up to 48 hours to complete the abortion. 2.8% in each group required oxytocin but surgical completion was required in only 0.003% and 0.007%.^[78]

A 2014 RCT by Chaudhuri and colleagues studied Indian women from 13 to 20 weeks randomized to receive 200 mg mifepristone orally, followed 24 hours (n=47) or 48 hours (n=48) later by misoprostol 800 mcg, then 400 mcg every 3 hours. Successful abortions occurred in 95.8% and 93.6% of cases, respectively. Mean induction-to-abortion interval was 8.6 hours vs. 8.7 hours. Surgical evacuation was required in 6.4% of cases in the 24-hour group but none in the 48-hour group.^[79]

A 2014 RCT by Dickinson and colleagues studied drug-induced abortions between 14 and 24 weeks, in which all women received 200 mg mifepristone orally followed 24–48 hours later by 800 mcg vaginal misoprostol. The “[w]omen were then randomized to receive additional 400-mcg misoprostol doses orally every 3 hours [n=100], vaginally every 4 hours [n=100], or sublingually every 3 hours [n=102].” At 12 hours, 37% remained undelivered in the oral group, 20.5% in the vaginal group, and 21% in the sublingual group. The misoprostol was repeated and after 24 hours, 11%, 3.9%, and 4% of women, respectively, remained undelivered. Placental retention necessitating further intervention was noted in 18%, 18% and 19.6% of cases, respectively. Transfusion was required in 1.7% of cases and 5% experienced more than a liter of blood loss. One woman experienced a ruptured uterus.^[80]

A 2010 RCT by Brouns and colleagues studied Dutch drug-induced abortions between 14 and 24 weeks, randomized to mifepristone 200 mg orally followed by either 200 (n=86) or 400 mcg (n=90) followed by misoprostol vaginally 36–48 hours later every 4 hours. Complete expulsion occurred in 66% of the 200 mg misoprostol group vs. 73% in 400 mcg group. Surgical evacuation was required, respectively, in 27% and 34% of cases. Notably, 18.6% and 22.8% of the women delivered live fetuses.^[81]

A 2000 RCT by Ngai and colleagues of Chinese drug-induced abortions between 14 and 20 weeks studied mifepristone 200 mg orally followed by misoprostol 400 mcg orally every 3 hours (n=70) or misoprostol 200 mg vaginally every 3 hours (n=69). Complete abortion occurred within 24 hours in 81.4% of women who received oral misoprostol vs. 75.4% of women who received vaginal misoprostol. Surgical evacuation for incomplete abortion was required, respectively, in 18.6% and 24.6% of cases.^[82]

In a 1997 RCT of Hong Kong women with pregnancies at 14 to 20 weeks of gestation, the participants were given mifepristone 200 mg orally followed in 36-48 hours by misoprostol 200 mcg vaginally (n=49) or orally (n=49) every three hours. The vaginal misoprostol group had shorter median induction intervals (9 vs. 13 hours) and higher complete abortion rates at 24 hours (89.8% vs. 69.4%). Women still pregnant were given a repeat course and if undelivered at 48 hours gemeprost was added and this caused all women to successfully abort. However, surgical evacuation to remove retained placenta was required for 26.5% of women in the vaginal group and 40.8% in the oral group.^[83]

A 2011 large Finnish register-based cohort study of 18,248 drug-induced abortions by Mentula and colleagues studied second trimester mifepristone 200 mg orally followed by 400 mcg misoprostol vaginally at 12 to 24 weeks (n=2,005) compared to first trimester mifepristone 200 mg orally followed by 400 to 800 mcg misoprostol vaginally every 3 to 4 hours at < 12 weeks (n=17,099). In the second trimester, 38.5% required surgery for retained pregnancy tissue vs. 7.9% in the first trimester, 14.4% experienced hemorrhage vs. 17.2%, and 4% experienced infection vs. 1.9%. This study was particularly informative because it utilized records-linkage data to document all abortions with minimal loss to follow-up. All abortions in Finland are paid for by single payer insurance and can be linked to all subsequent complications also paid by insurance, so that all abortions and their outcomes are known.^[84]

A 2024 retrospective case series described a protocol of 359 Arizona mifepristone and misoprostol abortions between 18 and 24 weeks of gestation. Feticide was performed with a vaginal digoxin injection, followed by mifepristone 200 mg orally, then misoprostol 600 mcg was given vaginally about 18 hours later, followed by 400 mcg buccally or vaginally every two hours.  More than one in three (36.5%) women underwent procedural evacuation, usually for removal of the undelivered placenta. One woman experienced a uterine rupture requiring a hysterectomy and one experienced internal hemorrhage (broad ligament tear) requiring surgery.^[85]

D. Comparison of mifepristone plus misoprostol with misoprostol alone

A 2024 Indian RCT by Saharan and colleagues compared misoprostol 800 mcg followed by 400 mcg vaginally every four hours (n=50) vs. mifepristone 200 mg orally, followed in 24 hours by the same vaginal misoprostol regimen (n=50) from 12 to 20 weeks of gestation. The induction termination interval of 10.21 hours was shorter in the mifepristone-misoprostol group compared to the 18-hour interval in the misoprostol-only group. The complete expulsion rate within 24 hours was 92% vs. 72%. Intervention was needed to complete the termination in 10% vs. 30% of cases.^[86]

Similarly, a 2023 RCT by Nayak and colleagues compared mifepristone 200 mg orally followed in 48 hours by misoprostol 400 mcg vaginally every 3 hours (n=50) vs. the same dose of misoprostol alone (n=50) in Indian women being delivered between 13-24 weeks, mostly due to congenital anomalies or intrauterine fetal demise. Complete abortion occurred in 92% of mifepristone and misoprostol abortions vs. 72% with misoprostol alone, with incomplete abortion occurring in 8% and 26% of cases, respectively, and failed abortion in 2% of the misoprostol-only group. Induction time averaged 11.6 hours vs. 15.6 hours.^[87]

A 2011 RCT by Ngoc and colleagues compared mifepristone 200 mcg plus misoprostol 400 mcg buccally every three hours (n=130) to placebo plus the same dose of misoprostol (n=130) in Vietnamese women between 14 to 21 weeks of gestation. In the mifepristone and misoprostol group, 79.8% completed the abortion within 15 hours, compared with 36.9% in the misoprostol-alone group. If fetal delivery did not occur within 15 hours, the induction was considered a failure and uterine evacuation was performed, occurring in 13.9% vs. 60.8% of cases. Additional interventions were required to deliver the placenta in 14% vs. 3% of cases, respectively. ^[88]

A 2015 RCT by Dabash and colleagues compared 200 mg mifepristone orally followed by 400 mcg buccal misoprostol every 3 hours (n=60) vs. placebo followed by the same dose of misoprostol (n=60) in Tunisian women between 14 and 21 weeks. Complete uterine evacuation occurred at 48 hours in 91.7% of the mifepristone and misoprostol group vs. 71.7% in the misoprostol alone group. Mean time to complete abortion was 10.4 hours vs. 20.6 hours. Interventions for placental removal were required in 11.7% of each group.^[89]

A 2007 RCT by Kapp and colleagues studied Boston drug-induced abortions between 18 to 23 weeks randomized to mifepristone 200 mg (n=32) vs. placebo (n=32) following digoxin amnioinfusion, then buccal misoprostol 400 mcg followed by 200 mcg every six hours. Median procedure time was shorter for mifepristone and misoprostol, with 10 hours for mifepristone and misoprostol vs. 18 hours for misoprostol alone. Placental retention occurred in 3.1% vs. 6.3% of cases, and completed inductions within 24 hours in 97% vs. 72% of cases.^[90]

A 1995 RCT by El-Refaey and Templeton studied drug-induced abortions in the United Kingdom between 13 and 20 weeks. Mifepristone 600 mg was given orally followed in 36-48 hours by misoprostol 600 mcg vaginally, then 400 mcg orally (n=35) or vaginally (n=34) every three hours. Abortion was achieved in 97% of each group without resort to other prostaglandin agents. The mean induction abortion times were 6.0 and 6.7 hours. Retained placenta occurred in 8.7% of the abortions.^[91]

A 2013 RCT by Tanha and colleagues evaluated two methods of misoprostol alone for second trimester abortions, 400 mcg every six hours sublingually (n=67) or vaginally (n=67). Surgical evacuation of retained tissue was required in 29.8% and 38.8% of cases, respectively.^[92]

A 2019 systematic review by Cleeve and colleagues analyzed the safety of mifepristone and misoprostol vs. misoprostol alone regimens at 14-28 weeks of gestation, reviewing 16 randomized controlled trials and evaluating their use with intrauterine fetal death. The authors concluded, “Certainty of evidence related to mifepristone-misoprostol regimens and safety and acceptability is very low.”^[93] This candid remark ought to give abortion advocates pause when they confidently assert the “safety” of the use of these drugs in second trimester abortions.

E. Late second trimester extending into third trimester drug-induced abortions

A 2024 RCT by Meyer and colleagues studied Israeli drug-induced abortions, 90% of which were induced for fetal anomalies, between 17 and 28 weeks. Mifepristone 200 mg orally was followed in 24 (n=40) or 12 (n=40) hours with misoprostol 400 mcg vaginally, then repeated sublingually every three hours. Median induction time was 9.5 hours and 12.5 hours, median total abortion time was 33.0 hours and 24.5 hours. At 12 hours from misoprostol administration, 62.5% and 45.0% of the abortions were completed, and at 24 hours, 90.0% and 75.0% had complete abortions. Surgical curettage or manual placental removal were required in 15% and 25% of cases, and postpartum hemorrhage occurred in 12.5% and 10% of cases.^[94]

A California retrospective study examined abortions after 24 weeks of gestation with mifepristone and misoprostol (n=257) compared to misoprostol alone (n=172). Mifepristone 200 mg was given orally but no specific protocol was utilized for misoprostol. Intervention (described as assisted delivery or D&E) was required in 3% of the mifepristone and misoprostol group and 6% of the misoprostol alone group, with 2% and 1%, respectively, requiring transfer to a hospital. One woman who received mifepristone and misoprostol died of a pulmonary embolus. All received feticidal injections with digoxin, laminaria to prepare the cervix, and amniotomy (rupture of membranes) prior to beginning the abortion.^[95]

Conclusions

The claim that later drug-induced abortions are “safe and effective” is false. “Safe” and “effective” remain undefined in most abortion studies, but close examination reveals that complications are common.

Nearly all studies document higher rates of complications following mifepristone and misoprostol used later in pregnancy compared to the first trimester. Complication rates reported by the higher quality studies (SR, MA, RCT) discussed above (excluding those that define success based on a set time interval) demonstrate the following:

• Retained tissue requiring procedural removal, usually surgical aspiration:
  • Rates documented in the first trimester range from 3.4% to 9.6% (3.4% (Chen et al., SR), 5.4-9.6% (Kapp et al., SR), 7.9% (Raymond et al., SR)).
  • Rates documented in second trimester range from 0% to 48.1% (0% (Sharma et al., RCT), 3.1% (Kapp et al., RCT), 6.4% (Chaudhuri et al,  RCT), 8% (Nayak et al.), 8.7% (El-Refaey et al., RCT), 10% (Kelly et al., RCT), 10% (Saharan et al., RCT), 11.7% (Dabash et al., RCT), 12% (Wildschut Cochrane Review), 15-25% (Meyer et al., RCT), 18-19.6% (Dickinson et al., RCT), 19.1% vs. 22.4% (Dalenda et al., RCT), 22.6% (Allanson et al., RCT), 18.6-24.6% (Ngai et al., RCT), 27-34% (Brouns et al.), 44% (Grimes et al, RCT), 22.2-48.1% (Rajaraman et al., RCT), 26.5-40.8% (Ho et al., RCT)).
• Retained tissue demonstrated pathologically after non-emergent curettage: 29.8-46.2% (Hou et al., RCT)
• Hemorrhage ranges from 5% to 19.4% (5% (Dickinson et al., RCT), 10-12.5% (Meyer et al., RCT), 13% (Rydelius et al., RCT), 19.4% (Allanson et al., RCT)).
• Blood transfusion ranges from 1.7% to 3.2% (1.7% (Dickinson et al., RCT), 3.2% (Allanson et al., RCT)).
• Infection ranges from 4-6% (Rydelius et al., RCT).
• Uterine rupture was rare but was documented in these studies. The risk is higher with more than one prior c-section or uterine incision when misoprostol is used.
• Delivery of a live fetus ranged from 18.6-22.8% in one study that reported this outcome (Brouns et al., RCT).
• Serious Adverse Events (SAE): hospitalization, transfusion, major surgery (not including aspiration for retained pregnancy tissue), or death ranged from 1.7% to 3% (1.7% (Whitehouse et al., SR/MA), 3% (Rydelius et al., RCT)).
• Readmission to the hospital occurred in 6.5% of cases in one study that reported this outcome (Allanson et al., RCT).
• Death was rare but was also documented in these studies.

Outcomes are often worse following misoprostol used alone without mifepristone. Notably, some pro-abortion medical organizations have begun publishing protocols for misoprostol-only regimens in case access to mifepristone should be restricted in the future.^[96]

• Retained tissue requiring surgical removal occurred in 6.3% to 38.8% of misoprostol-only abortions (6.3% (Kapp et al., RCT), 11.7% (Dabash et al., RCT), 26% (Nayak et al.), 30% (Saharan et al., RCT), 30.3% (Allanson et al., RCT), 29.8-38.8% (Tanha et al., RCT)).
• Hemorrhage occurred in 15.2% of the misoprostol-only abortions in one study that reported this outcome (Allanson et al., RCT).
• Readmission to the hospital occurred in 9.1% of the misoprostol-only abortions in one study that reported this outcome (Allanson et al., RCT).

Data deficiencies in U.S. abortion industry studies have been extensively documented, so it is possible that complications are even more common than reported.^[97] For example, 40% of abortion outcomes were unknown due to loss to follow-up in one study (Kelly et al., RCT).

The CDC reports that maternal deaths following abortion occur more commonly at higher gestational ages, although extensive data deficiencies impact CDC abortion-related mortality data, so the true rate of abortion-related deaths is unknown.^[98] They report that the risk of death is fifteen-fold higher in the early second trimester and 76-fold higher in the late second trimester, compared to an abortion performed at eight weeks of gestation.^[99]

Most clinical experts recommend that later drug-induced abortions be performed in hospitals or specially equipped clinics with pre-abortion ultrasound screening, but increasingly pro-abortion organizations imply this is not necessary for all women.

The FDA has permanently removed the in-person dispensing requirement for mifepristone to be used with misoprostol at less than 10 weeks of gestation. This allows abortion drugs to be prescribed and distributed remotely via telemedicine or online ordering and mail distribution, without any in-person interaction with the pregnant woman. Additionally, some feminist organizations are now openly distributing these drugs without any medical oversight, apparently under the impression that doing so helps women.^[100] These actions may result in failure to screen for preexisting conditions that may be more likely to result in complications, resulting in missed opportunities to prevent harm.

The missed opportunity for ultrasound may lead to failure to accurately determine gestational age or diagnose multiple pregnancy or fetal demise. Incorrect estimation of gestational age increases the likelihood that the drugs are taken at a later gestational age with higher likelihood of failure and other complications.

The missed opportunity for ultrasound may also result in a failure to detect uterine abnormalities, such as fibroids, septum, abnormal placental location or attachment. UpToDate recommends that, given concern for potential hemorrhage, a woman with placenta previa after 14 weeks should receive D&E rather than induction abortion. Particularly dangerous is “Placenta Accreta Spectrum,” where the placenta is invasive into or through the uterine wall and cannot be easily separated at the termination of the pregnancy, often resulting in catastrophic bleeding. A prior uterine scar (or multiple scars) from cesarean section or myomectomy raises the risk for uterine rupture with induction using misoprostol, but rupture has been documented even in women without a prior scar.^[101]

The missed opportunity for lab tests, especially Rh negativity screening and provision of RhoGAM if indicated, may result in future harm. Although pro-abortion medical organizations have recently begun to state that RhoGAM is not necessary in the first trimester, they continue to acknowledge its necessity in the second and third trimesters. Yet unsupervised later drug-induced abortions without provision of RhoGAM if needed will increase the risk of isoimmunization, a serious and potentially deadly complication for future unborn children.

The missed opportunity for full informed consent may lead to unwanted abortions in women due to coercion or unawareness of alternatives that would support a decision to give birth.^[102]

Thus, later “self-managed abortions” (SMA) may now occur outside of a medical facility, often in a woman’s home or college dorm bathroom. Interventions that could be performed by a provider within a facility (such as repeated doses of misoprostol, oxytocin infusion, or manual placental removal) cannot be performed by a woman at home alone. These unsupervised abortions outside of a medical facility will increase the odds that a woman experiencing a complication will have a worse outcome if emergency care is not readily available.

This risk is especially heightened for women who live in “maternity care deserts,” rural areas with few or no available reproductive health care providers or emergency facilities, including blood banking services if transfusion becomes necessary. Yet, these women are sometimes targeted by abortion advocates for telehealth abortions in order to improve “abortion access.”^[103]

The likelihood of a live-born baby is high when drug-induced abortions are performed late in the second trimester or third trimester. An unsupervised delivery will leave two patients in need of emergency care and may lead to a child’s death in his mother’s arms, a tragic and emotionally devastating situation. It may also lead to prosecution of women for contributing to their infant child’s death.

There is research showing that some women experience anxiety, depression, substance and alcohol abuse, or self-harm following abortion, sometimes leading to deaths from suicides, overdoses, and accidents. Women who obtain later abortion are at increased risk for mental health complications following their abortion.^[104] How much worse can we expect women’s mental health outcomes to be following these medically unsupervised and emotionally traumatic deliveries?

For these reasons and more, any promotion of, or failure to warn against, later mifepristone and misoprostol use, or misoprostol alone, outside of standard medical care, should be recognized as callous attempts to prioritize ending fetal life over the health and safety of women seeking abortion.

Ingrid Skop, M.D., F.A.C.O.G., is Vice President and Director of Medical Affairs for the Charlotte Lozier Institute.

[1] Sarah Zhang, “The Abortion Pill Can Be Used Later Than the FDA Says” The Atlantic, June 29, 2022. https://www.theatlantic.com/health/archive/2022/06/how-late-can-you-take-abortion-pill/661437/.

[2] Anna North, “People are using abortion medication later in their pregnancies. Here’s what that means,” Vox, June 18, 2023, https://www.vox.com/23755658/abortion-pill-second-trimester-mifepristone-misoprostol.

[3] Caroline Kitchener, “Alone in a bathroom: The fear and uncertainty of a post-Roe medication abortion,” Washington Post, April 11, 2024, https://www.washingtonpost.com/politics/interactive/2024/abortion-pill-experience-stories/.

[4] The American College of Obstetricians & Gynecologists, Second Trimester Abortion. ACOG Practice Bulletin No. 135. Obstet Gynecol 2013;121:1394-1406.

[5] Fact Check: “Abortion is 14 times Safer than Childbirth”, Charlotte Lozier Institute, https://lozierinstitute.org/fact-check-abortion-is-14-times-safer-than-childbirth/.

[6] The American College of Obstetricians & Gynecologists, Second Trimester Abortion, ACOG Practice Bulletin No. 135. Obstet Gynecol 2013;121:1394-1406.

[7] The American College of Obstetricians & Gynecologists, Increasing Access to Abortion, Committee Opinion No. 613, Obstet Gynecol 2014;124:1060–1065.

[8] The American College of Obstetricians & Gynecologists, Abortion Training and Education, Committee Opinion No. 612. Obstet Gynecol 2014;124:1055–1059.

[9] The American College of Obstetricians & Gynecologists, The Limits of Conscientious Refusal in Reproductive Medicine, Committee Opinion No. 385, Obstet Gynecol 2007:110:1203-1208.

[10] Brief for American Association of Pro-Life Obstetricians and Gynecologists and Samaritan’s Purse as Amici Curiae Supporting Plaintiff’s Motion for Preliminary Relief, p. 6. https://litigationtracker.law.georgetown.edu/wp-content/uploads/2025/10/State-of-Louisiana-et-al.-v.-Food-and-Drug-Administration-et-al_2_12_2026_AMICUS-BRIEF-AMERICAN-ASSOCIATION-OF-PRO-LIFE-OBSTETRICIANS-AND-GYNECOLOGISTS-ET-AL.pdf/.

[11] See Brittni Frederiksen, “A National Survey of OBGYNs’ Experiences After Dobbs,” KFF (Jun. 21, 2023), https://perma.cc/W432-CVJS.

[12] Brief for American Association of Pro-Life Obstetricians and Gynecologists and Samaritan’s Purse as Amici Curiae Supporting Plaintiff’s Motion for Preliminary Relief.

[13] Zwerling B, Edelman A, Jackson A, Burke A. “Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation,” American Journal of Obstetrics & Gynecology. 2023;1-21.

[14] Ibid.

[15] Ibid.

[16] Pearlman Shapiro M, Dethier D, Kahili-Heede M, Kaneshiro B. No-Test Medication Abortion: A Systematic Review. Obstet Gynecol. 2023 Jan 1;141(1):23-34.

[17] The Society of Family Planning, “Abortion is Essential Healthcare”, https://societyfp.org/wp-content/uploads/2025/07/Abortion-is-essential-healthcare.pdf.

[18] Abortion care guideline, second edition. Geneva: World Health Organization; 2024, https://www.who.int/publications/i/item/9789240104204.

[19] Skop I, “Abortion Safety: At Home and Abroad,” Issues in Law and Medicine, 2019;34(1):43-75.

[20] World Health Organization, “WHO issues new guidelines on abortion to help countries deliver lifesaving care: Access to safe abortion critical for health of women and girls,” https://www.who.int/news/item/09-03-2022-access-to-safe-abortion-critical-for-health-of-women-and-girls#:~:text=Access%20to%20safe%20abortion%20critical%20for%20health%20of%20women%20and%20girls:%20WHO&text=The%20World%20Health%20Organization%20(WHO,to%20support%20quality%20abortion%20care.

[21] National Abortion Federation, 2024 Clinical Policy Guidelines for Abortion Care, p. 43, https://nationalabortionfederation.org/wp-content/uploads/2024-CPGs-FINAL-1.pdf.

[22] Food and Drug Administration, “Information about Mifepristone for Medical Termination of Pregnancy Through Ten Weeks Gestation,” https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation.

[23] Niinimaki M, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heinkinheimo O, “Immediate Complications after Medical Compared with Surgical Termination of Pregnancy,” Obstet Gynecol 2009;114:795-804; Ireland LD, Gatter M, Chen AY, “Medical Compared with Surgical Abortion for Effective Pregnancy Termination in the First Trimester. Obstet Gynecol. 2015;126:22-28.

[24] FDA “Mifeprex label,” https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/020687Orig1s025Lbl.pdf.

[25] Raymond E, Weaver S, Winikoff B, “First Trimester Medical Abortion with Mifepristone 200 mg and Misoprostol: A Systematic Review,” Contraception, 2013;87(1):36-37; Chen MJ, Creinin MD, “Mifepristone with Buccal Misoprostol for Medical Abortion: A Systematic Review,” Obstet Gynecol. 2015;126(1):12-21; Mentula MJ, Niinimäki M, Suhonen S, Hemminki E, Gissler M, Heikinheimo O. Immediate adverse events after second trimester medical termination of pregnancy: results of a nationwide registry study. Hum Reprod. 2011 Apr;26(4):927-32.

[26] FDA “Mifeprex label,” https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/020687Orig1s025Lbl.pdf.

[27] Aultman K, Cirucci CA, Harrison DJ, Beran BD, Lockwood MD, Seiler S. Deaths and Severe Adverse Events after the use of Mifepristone as an Abortifacient from September 2000 to February 2019. Issues Law Med. 2021 Spring;36(1):3-26; Gary MM, Harrison DJ, “Analysis of Severe Adverse Events Related to the Use of Mifepristone as an Abortifacient,” Ann Pharmacother 2006;40(2):191-197; Cirucci CA, Aultman KA, Harrison DJ, “Mifepristone Adverse Events Identified by Planned Parenthood in 2009 and 2010 Compared to those in the FDA Adverse Event Reporting System and those Obtained through the Freedom of Information Act,” Health Serv Res Manag Epidemiol 2021;8:1-8.

[28] Studnicki J, Fisher JW, Longbons Cox T, Cirucci CA, Reardon DC, Skop I, Louttit C, Harrison DJ, Craver C, “Determining the Period Prevalence and Acuity of Emergency Department Visits Following Induced Abortion Mistakenly Identified as Spontaneous Abortion: An Analytic Observational Prospective Cohort Study,” Fam. Med. Prim. Care Open Access 2025, 9, doi:10.29011/2688-7460.100282.

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