Second Trimester Taboo

Abortion Pills are More Important Than Ever, and Safe Far Later Than Most People Know

By Cecilia Nowell

Illustrations by Zhenya Oliinyk

Illustration of fetus growing inside a womb

In a small Texas courtroom last spring, Erik Baptist, senior counsel for the conservative group Alliance Defending Freedom, insisted that the Food and Drug Administration had been reckless when it approved the abortion pill mifepristone for use before seven weeks of pregnancy in 2000, and then, in 2016, for up to 10 weeks.

The judge agreed, suspending the FDA’s approval of mifepristone, one of two pills used in the typical protocol for medication abortions in the U.S. The case made its way to the Supreme Court, which is expected to rule this summer on whether to uphold the suspension or otherwise restrict the use of mifepristone.

But in reality, the FDA’s regulations on mifepristone have always been conservative.

“Medications can be used safely throughout pregnancy,” said Caitlin Gerdts, vice president for research at Ibis Reproductive Health.

 Just as abortion by pill becomes more popular, and more necessary, it’s also become extremely sensitive to talk about its use later in pregnancy. Prominent organizations promoting medication abortions, like Plan C, generally say that medication abortions work best up to 13 weeks, or the start of the second trimester. That 12- or 13-week caveat hovers in nearly every progressive account championing medication abortion (this magazine included), in part because the process does get more challenging, more like an actual birth, the later it happens. And in the rare case of complications, an emergency room visit in certain jurisdictions could now lead to prosecution.

“Especially in a context where abortion is legally restricted, even later in pregnancy, the risks really are legal ones,” Gerdts said. In 2022, she helped develop the World Health Organization’s newest abortion care guidelines. Those guidelines describe how to use abortion pills up to and beyond 24 weeks of pregnancy — referencing studies conducted in 23 different countries. Doctors across the world — including some in the U.S. and the majority of providers in Northern Europe — have been prescribing abortion pills well into the second trimester since the early 2000s.

“Even later in pregnancy, the risks really are legal ones.”

Since the Supreme Court overturned Roe v. Wade in 2022, a thickening web of restrictions is causing people to seek abortions later in their pregnancies. In 2022, less than one percent of Americans lived more than 200 miles from an abortion clinic. Today, it’s more than 14 percent. Since the court’s ruling, the distance that the average American must travel to access an abortion has more than tripled. It’s no surprise, then, that Americans have increasingly turned to pills to terminate pregnancies. They can be ordered online and self-administered. And despite a raft of restrictions specifically targeting abortion pills, they can still evade state lines. So it’s vital to understand that abortion pills are remarkably safe — including far later into pregnancy than they’ve typically been used in the United States.

Dr. Gabrielle Goodrick was offering abortion care at her clinic, Camelback Family Planning in Phoenix, Arizona, when the FDA first approved mifepristone in 2000. She remembers desperately waiting as the FDA took nearly five years to review the data on the medication. 

“I got so impatient we started using methotrexate with misoprostol, which people were doing a lot,” she said, referencing a rheumatoid arthritis medication sometimes used in abortion care that’s been available in the U.S. since the 1970s, and misoprostol, which is available as an ulcer medication and generally used in combination with mifepristone. “I just couldn’t wait any longer. Patients were desperate for that. They really wanted a non-surgical option.” The day the FDA approved mifepristone, she applied to start prescribing it.

Illustration of tool in uterus

After she met Scandinavian midwives who provided second trimester medication abortions at a conference in Europe, Goodrick became one of only a few doctors in the United States offering “induction abortions” that use medicines to induce labor and delivery (of the placenta and fetus) in the second or third trimester. She’s offered that care “off-label” — using the pills outside their FDA-approved use, which is perfectly legal — since 2017. 

“The body just expels the pregnancy naturally. It’s incredible,” Goodrick told me. “That medicine makes the uterus just cramp down. These are magical medicines.” 

Here are the basics: Before 12 weeks of pregnancy, the WHO recommends a combination of mifepristone and misoprostol (or misoprostol alone if no mifepristone is available) similar to what the FDA has approved before 10 weeks in the U.S. First, patients are instructed to swallow one 200mg pill of mifepristone — then, 24 to 48 hours later, 800 mcg of misoprostol (usually taken as four small pills absorbed under the tongue, in the cheek, or in the vagina). After 12 weeks, the WHO guidelines only vary slightly. Instead of taking 800 mcg of misoprostol, patients should take repeat doses of 400 mcg every three hours until the pregnancy is expelled (which usually happens one to two days after they’ve taken the mifepristone). The WHO classifies mifepristone and misoprostol as “core” medications that can be provided without specialized training and should be available in every health system.

These guidelines draw on more than four decades of research. Biochemist Étienne-Émile Baulieu first synthesized mifepristone in 1980, while working for the French pharmaceutical company Roussel-Uclaf. The company arranged clinical trials of the medication — which it named RU-486 — and found that it successfully terminated 95.4 percent of pregnancies if taken within seven weeks, and 92.8 percent if taken before nine weeks. China and France approved the medication within a week of each other in 1988, both restricting its use to before seven weeks.

A U.S.-based nonprofit, the Population Council, submitted a new drug application for mifepristone to the FDA in 1996, along with its own studies in the U.S. from 1994 and 1995, which reported lower effectiveness than other countries were seeing, although the council added that providers in the U.S. might be less well-versed in the appropriate protocols for administering abortion pills. With those results in hand, the FDA limited use of mifepristone in the U.S. to the first seven weeks of pregnancy when it approved the medication in 2000. But Goodrick said that in the five years after the Population Council’s study, researchers in the U.S. and Europe had already refined the procedure. They’d determined that 200mg of mifepristone was more effective than the 600mg dose the FDA recommended, for example. “They had approved it based on data and studies that were old,” said Goodrick. “It was outdated the moment it was approved.” She and many other doctors she knew of began using it outside the FDA’s limits.

“These are magical medicines.”

By that time, much of Europe had approved mifepristone for use in the first and second trimester. In 2011, when researchers from the Netherlands, Sweden, and the United Kingdom reviewed the existing studies evaluating the effectiveness of medication abortion in the second trimester, there were 40 randomized controlled trials (and dozens of other studies) for them to reference. When the WHO updated its guidelines to a safe abortion in 2012 it included recommendations for using abortion pills after 12 weeks of pregnancy. It’s updated those guidelines twice since then, as evidence has grown on the most effective doses and timing of medications.

Despite the evidence emerging elsewhere in the world, U.S. doctors remained reticent to use medications later in pregnancy. Dilation and Evacuation — the process of dilating the cervix and then emptying the uterus with suction or surgical instruments — had been in use in the United States since the 1970s and remained the most common way to terminate pregnancies in the second and third trimesters. There were reasons to prefer D&E over induction: It was less costly, quicker, and didn’t require patients to interact with the fetus (though of course some patients, especially those terminating wanted pregnancies, might long to hold and grieve their child). In the late 2000s many studies had found that D&Es resulted in fewer complications, but today research suggests that inductions are equally safe. 

Goodrick believes inductions could expand access to care — most providers with training in labor and delivery could offer them. But she suspects that’s part of why they’re less common. “It doesn’t fit into the classic abortion clinic. How do you have all of these people laboring? Where do you have room? It doesn’t really fit in the model of how clinics practice and hospitals practice,” she said. With a D&E, you can schedule the procedure in an operating room and know exactly when it will be over. Goodrick said her dream is to have “an overnight clinic where a nurse can stay late, just like a labor and delivery [ward]”; providers would be prepared to sit with patients, giving doses of misoprostol until they expel their pregnancies, as she’s seen it done in Scandinavia. In a review of all of the induction abortions she oversaw from October 2017 to November 2021, Goodrick and her colleagues found that 63.5 percent of patients had a complete abortion with medication alone. More would have, she said, if they’d been able to continue laboring after the clinic closed at 4 p.m. — but if staff couldn’t stay late, they’d transition to a procedural abortion. 

A foetus in a bubble with waves around it

Medication abortion can be painful at any gestation. Even early in pregnancy, some patients compare it to the worst cramps they’ve ever had. But those words above — laboring, delivering — do indicate that later in pregnancy, it’s more and more like a birth. “The contractions build and build and build, and then you have pressure,” said Goodrick. In a 2017 study, researchers from Scotland interviewed women about their “embodied experiences of second trimester medical abortion” and found that many had not “anticipated how closely the process might resemble experiences of childbearing” and said that the experience of “passing the fetus was distressing and painful” for many. To make her patients more comfortable, Goodrick’s clinic offers conscious sedation. “They really have little memory of it, even if it takes all day. And no discomfort,” she said.

Although the majority of studies on second trimester medication abortion in the U.S., Asia, and Northern Europe have happened in clinics, according to the Royal College of Obstetricians and Gynecologists “there is no evidence indicating that out-of-facility medical abortion is unsafe.” But it is an area where there is still little research.

In large portions of Latin America, Africa, and Southeast Asia, feminist community support networks guide people through first and second trimester medication abortions in their homes. In many ways, they take on the role of clinician: managing pain, telling the aborting person what is normal, and knowing when to go to a hospital for more advanced care. In one study of such self-managed second trimester abortions in Argentina, Chile, and Ecuador 76 percent of people successfully aborted with medication alone — while five percent had to try again with more medication, and 12 percent sought follow-up care in the formal health care system where they were able to access a procedural abortion. Knowing when to seek help (and what to tell doctors) was key: In Chile, about 15 percent of patients in the study needed treatment for heavy bleeding, delayed placental expulsion, high fever, hypotension, panic attack, or vomiting. (In the U.S., the majority of people going to the ER after medication abortions aren’t seeking treatment for a complication, but rather assurance that the bleeding they’re experiencing is normal — something accompaniers are trained to recognize — or that the abortion was successful.)

While accompaniment networks are not able to offer patients sedation or anesthetic, they are able to offer their presence and experience. In a 2023 study, one Ecuadorian accompanier explained: 

We end up sleeping alongside them [the aborting people], because you end up being there for more than 12 hours. So, you end up not only talking about abortion but about whether you like chocolate or not, of other things in life. That is lovely and I think we need more of that.

After the Supreme Court legalized abortion with Roe v. Wade in 1973, many feminist self-help collectives that had helped people access abortion care while it remained illegal disbanded. With the legal right to an abortion secured, it was easy for white middle-and-upper-class women to say the work was over, even as the procedure remained inaccessible for many others.

Women in Latin America, where abortion was mostly illegal, pioneered the use of misoprostol and began developing networks to accompany each other through self-managed abortions using newly available medications. Meanwhile, women in the U.S. barely knew abortion pills existed. According to a Kaiser Family Foundation poll, in 2020 only 21 percent of U.S. adults had ever heard of mifepristone or a medication abortion. After the Supreme Court overturned Roe in 2022, that started to change: A Guttmacher Institute report published this spring found that medication abortion now accounts for nearly two-thirds of abortions in the U.S. (up from half in 2020). 

Lack of awareness is one thing; criminalization is another. In the past two years, women from South Carolina to Georgia, Nebraska, and Texas have been arrested for allegedly using abortion pills to end their pregnancies. As important as it is to know that abortion pills are effective later in pregnancy, it’s just as important to remember that self-managing an abortion carries great legal risk in the U.S. People can be turned in by friends, family, or even medical staff: “They do NOT have to tell the police if someone has an abortion, but we know some choose to anyway,” cautions the group If/When/How, in their guide to talking to health care providers after an abortion or miscarriage. (You don’t have to tell anyone you’ve had an abortion. If/When/How offers a Repro Legal Helpline at 844-868-2812 or for free, confidential legal information and advice.)

Illustration foetus in an hourglass that is toppled over in a desert-like landscape

“In the United States, most of the laws are focused on isolating the pregnant person, not directly criminalizing the person having the abortion, but criminalizing the system of support that they have,” said Gerdts. That same system of support is what makes self-managing abortions later in pregnancy safe in many other parts of the world. 

Goodrick is one of the providers committing to offering care in the U.S. despite mushrooming restrictions. She knows people will continue seeking and having abortions if the Supreme Court were to enact a total ban on mifepristone. (Not something that even the conservative-dominated bench is expected to do.) “Okay, so they ban mifepristone. Well guess what? There’s an emergency contraceptive called Ella. It has the same mechanism as mifepristone. You can buy three Ella’s and give misoprostol. You don’t need mifepristone. Obviously it’s much more effective, but people will get around it. We’ll go back to methotrexate.” Used alone, misoprostol is also highly effective throughout pregnancy. 

At her clinic in Arizona, where abortion is now banned after 15 weeks of pregnancy, Goodrick and her colleagues have partnered with a California clinic that gives patients mifepristone and then sends them back to Arizona where Goodrick manages their abortions like a stillbirth. The patients still have to leave the state, but it saves them the cost of an overnight stay. “There’s no gestational limit on a stillbirth,” she said, “and there’s nothing illegal about doing it.” It’s a workaround patients shouldn’t have to navigate — but it works. 

Editors’ Note: As this issue went to press, Arizona’s Supreme Court reinstated an 1864 law banning abortion completely, throwing Goodrick’s whole practice into limbo.

Cecilia Nowell is a reporter focused on health equity stories in the Americas.