Medical abortion

From Wikipedia, the free encyclopedia
Jump to navigation Jump to search

Medical abortion
Background
Abortion type Medical
First use United States 1979 (carboprost),
West Germany 1981 (sulprostone),
Japan 1984 (gemeprost),
France 1988 (mifepristone),
United States 1988 (misoprostol)
Gestation 3–24+ weeks
Usage
Medical abortions as a percentage of all abortions
France 64% (2016)
Sweden 92% (2016)
UK: Eng. & Wales 62% (2016)
UK: Scotland 83% (2016)
United States 30% (2014)
Infobox references

A medical abortion, also known as medication abortion, occurs when pills are used to bring about an abortion. The recommended regimen consists of a combination of medications, starting with mifepristone followed after at least a day by misoprostol.[1] Mifepristone followed by misoprostol for abortion is considered both safe and effective throughout a range of gestational ages.[2] When mifepristone is not available, misoprostol may be used.

Medical uses[edit]

Medical abortion is used in people who want to use medications to end a pregnancy.

Through 12 weeks gestation[edit]

For medical abortion prior to 12 weeks gestation, the World Heath Organization recommends mifepristone 200 mg by mouth followed 1-2 days later by misoprostol 800 mcg inside the cheek, vaginally, or under the tongue; misoprostol may be repeated to maximize success.[3] The success rate of mifepristone followed by misoprostol through 10 weeks pregnancy is 96.6%.[4] In another review of people up to 9 weeks gestation, mifepristone followed by various routs of misoprostol was associated with a successful abortion rate of over 95%; 1.1% experienced ongoing pregnancy.[5] Those who took misoprostol less than 24 hours after mifepristone had higher failures rates compared to women who waited 1-2 days. The National Abortion Federation (NAF) recommends a mifepristone and misoprostol combination regimen.[6] This is an option for people with gestations through 70 days. Mifepristone 200 mg is taken and followed by misoprostol 800 mcg buccally, vaginally, or sublingually 24 to 48 hours later. The early first-trimester medical abortion regimen (200 mg of oral mifepristone, followed 24–48 hours later by 800 mcg of buccal misoprostol) currently used by Planned Parenthood clinics in the United States since April 2006 is 98.3% effective through 59 days' gestation.[7]

If mifepristone is not available, the WHO recommends misoprostol 800 mcg inside the cheek, under the tongue, or in the vagina.[8] The success rate of misoprostol alone for first trimester abortion is 78%.[9]

Though not a first line choice, a methotrexate/misoprostol combination regimen is appropriate. Methotrexate is given either orally or intramuscularly, followed by vaginal misoprostol 3–5 days later.[10] This is an appropriate option for gestations through 63 days. Per the WHO, a methotrexate-misoprostol regimen can also be used;[11] but is not recommended as methotrexate may be teratogenic to the fetus in cases of incomplete abortion. However, this combination is considered more effective than misoprostol alone.[12]

After 12 weeks gestation[edit]

WHO recommends mifepristone 200 mg by mouth (orally) followed 1-2 days later by misoprostol 400 mcg under the tongue, inside the cheek, or in the vagina.[3] Misoprostol may be repeated doses every 3 hours until successful abortion is achieved, the mean time to abortion after starting misoprostol is 6-8 hours, and approximately 94% will abort within 24 hours after starting misoprostol.[13] When mifepristone is not available, misoprostol may still be used though the mean time to abortion after starting misoprostol will be extended compared to regimens using mifepristone followed by misoprostol.

Contraindications[edit]

Contraindications to mifepristone are inherited porphyria, chronic adrenal failure, and ectopic pregnancy.[14][15] Some consider an intrauterine device in place to be a contraindication as well.[15] A previous allergic reaction mifepristone or misoprostol is also a contraindication.[14]

Many studies excluded women with severe medical problems such as heart and liver disease or severe anemia.[16] Caution is required in a range of circumstances including:[14]

Adverse effects[edit]

Symptoms that require immediate medical attention:[17]

  • Heavy bleeding (enough blood to soak through two sanitary pads in 2 hours)
  • Abdominal pain, nausea, vomiting, diarrhea, fever for more than 24 hours after taking mifepristone
  • Fever of 38 °C (100.4 °F) or higher for more than 4 hours

Most women will have cramping and bleeding heavier than a menstrual period.[18] Nausea, vomiting, diarrhea, headache, dizziness, and fever/chills are also common. Misoprostol taken vaginally tends to have fewer gastrointestinal side effects. Nonsteroidal antiinflammatory medications such as ibuprofen reduce pain with medication abortion.

Although medical abortion is associated with more bleeding than surgical abortion, overall bleeding for the two methods is minimal and not clinically different. In a large-scale prospective trial published in 1992 of more than 16,000 women undergoing medical abortion using mifepristone with varying doses of gemeprost or sulprostone, only 0.1% had hemorrhage requiring a blood transfusion. It is often advised to contact a health care provider if there is bleeding to such degree that more than two pads are soaked per hour for two consecutive hours.

Management of bleeding[edit]

Vaginal bleeding generally diminishes gradually over about two weeks after a medical abortion, but in individual cases spotting can last up to 45 days.[14] If the woman is well, neither prolonged bleeding nor the presence of tissue in the uterus (as detected by obstetric ultrasonography) is an indication for surgical intervention (that is, vacuum aspiration or dilation and curettage). Remaining products of conception will be expelled during subsequent vaginal bleeding. Still, surgical intervention may be carried out on the woman's request, if the bleeding is heavy or prolonged, or causes anemia, or if there is evidence of endometritis.

Complications[edit]

Complications following medical abortion with mifepristone and misprostol under 10 weeks pregnancy are rare; according to two large reviews, bleeding requiring a blood transfusion occurred in 0.03-0.6% of women and serious infection in 0.01-0.5%.[4][5]

Between January 2005 and June 2008 rates of serious infection after medical abortion at Planned Parenthood affiliate centers declined by 93% after a change from vaginal to buccal administration of misoprostol combined with the routine preventative use of doxycycline antibiotics.[7]

A few rare cases of deaths from clostridial toxic shock syndrome have occurred following medical abortions.[19]

Pharmacology[edit]

Mifepristone blocks the hormone progesterone,[20][21] causing the lining of the uterus to thin and preventing the embryo from staying implanted and growing. Methotrexate, which is sometimes used instead of mifepristone, stops the cytotrophoblastic tissue from growing and becoming a functional placenta.[22] Misoprostol, a different kind of medication, causes the uterus to contract and expel the embryo through the vagina.[23]

Frequency[edit]

Medical abortions as a percentage of all abortions
Country Percentage
Italy 17% in 2015[24]
Spain 19% in 2015[25]
Belgium 22% in 2011[26]
Netherlands 22% in 2015[27]
Germany 23% in 2016[28]
United States 30% in 2014[29]
England and Wales 62% in 2016[30]
France 64% in 2016[31]
Iceland 67% in 2015[32]
Denmark 70% in 2015[32]
Portugal 71% in 2015[33]
Switzerland 72% in 2016[34]
Scotland 83% in 2016[35]
Norway 87% in 2016[36]
Sweden 92% in 2016[37]
Finland 96% in 2015[38]

A Guttmacher Institute survey of abortion providers estimated that early medical abortions accounted for 31% of all nonhospital abortions and 45% of nonhospital abortions before 9 weeks' gestation in the United States in 2014.[29][39]

At Planned Parenthood clinics in the United States, medical abortions accounted for 32% of first trimester abortions in 2008,[40] 35% of all abortions in 2010 and 43% of all abortions in 2014.[41]

History[edit]

Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone (also known as RU-486)[42] in the 1980s.[43][44][45] Mifepristone was initially approved in China and France (need date); in 2000, the United States Food and Drug Association approved mifepristone followed by misoprostol for abortion through 49 days.[46] In 2016, the United States FDA updated mifepristone's label to support usage through 70 days gestation.[47]

Society and culture[edit]

The legal and political setting should support people's access to evidence-based medically approved care, including medical abortion.[48][49]

Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used to induce second-trimester abortions in Canada, most of Europe, China and India;[45] in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.[50]

"Reversal" controversy[edit]

Some pro-life groups claim that the abortifacient effect of mifepristone can be reversed by administering progesterone to the patient.[51][52] At this time there is no scientifically rigorous evidence that the effects of mifepristone can actually be reversed this way.[53] Even so, several states in USA require providers of non-surgical abortion who use mifepristone to tell patients that reversal is an option.[54] For the first time, a small (forty participant subjects) but rigorous, properly-controlled, double-blind academic clinical trial of the reversal regimen using progesterone is underway, at the University of California at Davis.[55][56]

Cost[edit]

In the United States in 2009, the typical price charged for a medical abortion up to 9 weeks' gestation was $490, four percent higher than the $470 typical price charged for a surgical abortion at 10 weeks' gestation.[57] In the United States in 2008, 57% of women who had abortions paid for them out of pocket.[58]

In April 2013, the Australian government commenced an evaluation process to decide whether to list mifepristone (RU486) and misoprostol on the country's Pharmaceutical Benefits Scheme (PBS). If the listing is approved by the Health Minister Tanya Plibersek and the federal government, the drugs will become more accessible due to a dramatic reduction in retail price—the cost would be reduced from between AU$300 and AU$800, to AU$12 (subsidised rate for concession card holders) or AU$35.[59]

On 30 June 2013, the Australian Minister for Health, the Hon Tanya Plibersek MP, announced that the Australian Government had approved the listing of mifepristone and misoprostol on the PBS for medical terminations early in pregnancies consistent with the recommendation of the Pharmaceutical Benefits Advisory Committee (PBAC). These listings on the PBS occurred on 1 August 2013.

References[edit]

  1. ^ Medical management of abortion. World Health Organization,. Geneva, Switzerland. p. 24. ISBN 9241550406. OCLC 1084549520.CS1 maint: extra punctuation (link) CS1 maint: others (link)
  2. ^ Safe abortion: technical and policy guidance for health systems-2nd ed. Italy: WHO. 2012. p. 42. ISBN 9789241548434.
  3. ^ a b Medical management of abortion. World Health Organization,. Geneva, Switzerland. 2018. p. 24-25. ISBN 9241550406. OCLC 1084549520.CS1 maint: extra punctuation (link) CS1 maint: others (link)
  4. ^ a b Chen, MJ; Creinin, MD (July 2015). "Mifepristone With Buccal Misoprostol for Medical Abortion: A Systematic Review". Obstetrics and gynecology. 126 (1): 12–21. doi:10.1097/AOG.0000000000000897. PMID 26241251.
  5. ^ a b Raymond, Elizabeth. "First-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review". Contraception. 87(1): 26–37.
  6. ^ National Abortion Federation. (2018). Clinical Policy Guidelines for Abortion Care. Retrieved from https://www.prochoice.org
  7. ^ a b Fjerstad, Mary; Sivin, Irving; Lichtenberg, E. Steve; Trussell, James; Cleland, Kelly; Cullins, Vanessa (September 2009). "Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days". Contraception. 80 (3): 282–286. doi:10.1016/j.contraception.2009.03.010. PMC 3766037. PMID 19698822. The medical abortion regimen (200 mg of oral mifepristone, followed 24–48 hours later by 800 mcg of vaginal misoprostol) previously used by Planned Parenthood clinics in the United States from 2001 to March 2006 was 98.5% effective through 63 days' gestation—with an ongoing pregnancy rate of about 0.5%, and an additional 1% of patients having uterine evacuation for various reasons, including problematic bleeding, persistent gestational sac, clinician judgment or patient request.
  8. ^ Medical management of abortion. World Health Organization,. Geneva, Switzerland. 2018. p. 24-25. ISBN 9241550406. OCLC 1084549520.CS1 maint: extra punctuation (link) CS1 maint: others (link)
  9. ^ Raymond, EG; Harrison, MS; Weaver, MA (January 2019). "Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review". Obstetrics and gynecology. 133 (1): 137–147. doi:10.1097/AOG.0000000000003017. PMID 30531568.
  10. ^ National Abortion Federation. (2018). Clinical Policy Guidelines for Abortion Care. Retrieved from https://www.prochoice.org
  11. ^ "Women's Health".
  12. ^ Creinin, Mitchell D.; Danielsson, Kristina Gemzell (2009). "Medical abortion in early pregnancy". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 111–134. ISBN 978-1-4051-7696-5.
  13. ^ Borgatta, L; Kapp, N (2011). "Clinical Guidelines. Labor induction abortion in the second trimester". Contraception. 84(1): 4–18.
  14. ^ a b c d International Consensus Conference on Non-surgical (Medical) Abortion in Early First Trimester on Issues Related to Regimens and Service Delivery (2006). Frequently asked clinical questions about medical abortion (PDF). Geneva: World Health Organization. ISBN 978-92-4-159484-4.
  15. ^ a b "Medical management of first-trimester abortion Society of Family Planning Clinical Guideline". Contraception. American College of Obstetricians and Gynecologists; Society of Family Planning. 89: 148–161. 2014.
  16. ^ "Medical management of first-trimester abortion Society of Family Planning Clinical Guideline". Contraception. American College of Obstetricians and Gynecologists; Society of Family Planning. 89: 148–161. 2014.
  17. ^ "Mifepristone Prescribing Information" (PDF). FDA.
  18. ^ "Medical management of first-trimester abortion Society of Family Planning Clinical Guideline". Contraception. American College of Obstetricians and Gynecologists; Society of Family Planning. 89: 148–161. 2014.
  19. ^ Murray, S; Wooltorton, E (2005). "Septic shock after medical abortions with mifepristone (Mifeprex, RU 486) and misoprostol". CMAJ. 173: 485. doi:10.1503/cmaj.050980. PMC 1188182. PMID 16093445.
  20. ^ https://www.smithsonianmag.com/health-medicine/science-behind-abortion-pill-180963762/
  21. ^ Medical management of first trimestesr abortion, Society of Family Planning Clinical Guideline, Contraception 89(2014) 148-161
  22. ^ https://www.medicationabortions.com/methotrexate
  23. ^ https://www.medicationabortions.com/misoprostol
  24. ^ . (December 15, 2016). "Relazione Ministro Salute attuazione Legge 194/78 tutela sociale maternità e interruzione volontaria di gravidanza - dati definitivi 2014 e 2015 [Ministry of Health report implementation Act 194/78 social protection maternity and voluntary interruption of pregnancy - definitive data 2014 and 2015]". Rome: Ministero della Salute [Ministry of Health]. Table 25 - IVG and type of intervention, 2015: mifepristone + mifepristone+prostaglandin + prostaglandin = 17%.
  25. ^ . (December 30, 2016). "Interrupción Voluntaria del Embarazo; Datos definitivos correspondientes al año 2015 (Voluntary interruption of pregnancy; final data for 2015" (PDF). Madrid: Ministerio de Sanidad, Politica Social e Igualdad (Ministry of Health and Social Policy). Table G.15: 17,916 (sum of the greater of mifepristone or prostaglandin abortions by gestation period) / 94,188 (total abortions) = 19.0%.
  26. ^ Commission Nationale d'Evaluation des Interruptions de Grossesse (August 27, 2012). "Rapport Bisannuel 2010-2011". Brussels: Commission Nationale d'Evaluation des Interruptions de Grossesse. prostaglandin 0.40% + mifepristone 21.23% = 21.63% medical abortions
  27. ^ . (February 9, 2017). "Jaarrapportage 2015 van de Wet afbreking zwangerschap [Annual Report 2015 of the Discontinuation of Pregnancy Act]". Utrecht, Netherlands: Inspectie voor de Gezondheidszorg (IGZ) [Health Care Inspectorate], Ministerie van Volksgezondheid, Welzijn en Sport (VWS) [Ministry of Health, Welfare and Sport].
  28. ^ . (March 9, 2017). "Schwangerschaftsabbrüche 2016 (Abortions 2016)" (PDF). Wiesbaden: Statistisches Bundesamt (Federal Statistical Office), Germany. 20.237% Mifegyne + 3.021% Medikamentöser Abbruch = 23.257% medical abortions
  29. ^ a b Jones, Rachel K.; Jerman, Jenna (January 17, 2017). "Abortion incidence and service availability in the United States, 2014". Perspectives on Sexual and Reproductive Health. 49 (1): 17–27. doi:10.1363/psrh.12015. PMC 5487028. PMID 28094905.
    96% of all abortions performed in nonhospital facilities × 31% early medical abortions of all nonhospital abortions = 30% early medical abortions of all abortions; 97% of nonhospital medical abortions used mifepristone and misoprostol—3% used methotrexate and misoprostol, or misoprostol alone—in the United States in 2014.
  30. ^ . (May 30, 2017). "Abortion statistics, England and Wales: 2016" (PDF). London: Department of Health, United Kingdom.
    Medical abortion accounted for 72% of abortions under 10 weeks' gestation—in England and Wales in 2016.
  31. ^ Vilain, Annick (June 26, 2017). "211 900 interruptions volontaires de grossesse en 2016 (211,900 voluntary terminations of pregnancies in 2016)" (PDF). Paris: DREES (Direction de la Recherche, des Études, de l'Évaluation et des Statistiques), Ministère de la Santé (Ministry of Health), France.
  32. ^ a b Heino, Anna; Gissler, Mika (March 7, 2017). "Pohjoismaiset raskaudenkeskeytykset 2015 (Induced abortions in the Nordic countries 2015)" (PDF). Helsinki: Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland. ISSN 1798-0887. Appendix table 6. Drug-induced abortions in Nordic countries 1993–2015, %
  33. ^ . (September 20, 2016). "Relatório dos Registos das Interrupções da Gravidez - Dados de 2015 [Report of the Interruptions of Pregnancy - Data of 2015]". Lisbon: Divisão de Saúde Sexual, Reprodutiva, Infantil e Juvenil [Division of Sexual, Reproductive, Child and Juvenile Health], Direção de Serviços de Prevenção da Doença e Promoção da Saúde [Directorate of Disease Prevention and Health Promotion Services], Direção-Geral da Saúde (DGS) [Directorate-General for Health].
  34. ^ . (June 13, 2017). "Interruptions de grossesse en Suisse en 2016 (Abortions in Switzerland 2016)". Neuchâtel: Office of Federal Statistics, Switzerland.
  35. ^ . (May 30, 2017). "Termination of pregnancy statistics, year ending December 2016" (PDF). Edinburgh: Information Services Division (ISD), NHS National Services Scotland.
    Medical abortions accounted for 89% of abortions before 9 weeks' gestation in Scotland in 2016.
  36. ^ Løkeland, Mette; Mjaatvedt, Aase Gunn; Akerkar, Rupali; Pedersen, Yngve; Bøyum, Bjug; Hornæs, Mona Tornensis; Seliussen, Ingvei; Ebbing, Marta (March 8, 2017). "Rapport om svangerskapsavbrot for 2016 (Report on pregnancy terminations for 2016)" (PDF). Oslo: Divisjon for epidemiologi (Division of Epidemiology), Nasjonalt Folkehelseinstitutt (Norwegian Institute of Public Health), Norway. ISSN 1891-6392.
    Medical abortions accounted for 90% of abortions before 9 weeks' gestation in Norway in 2016.
  37. ^ Öman, Maria; Gottvall, Karin (May 10, 2017). "Statistik om aborter 2016 (Statistics on abortions in 2016)" (PDF). Stockholm: Socialstyrelsen (National Board of Health and Welfare), Sweden.
    Medical abortions accounted for 94% of abortions before 9 weeks' gestation in Sweden in 2016.
  38. ^ Heino, Anna; Gissler, Mika (October 20, 2016). "Raskaudenkeskeytykset 2015 (Induced abortions 2015)" (PDF). Helsinki: Suomen virallinen tilasto (Official Statistics of Finland), Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland.
  39. ^ Jatlaoui, Tara C.; Ewing, Alexander; Mandel1, Michele G.; Simmons, Katharine B.; Suchdev, Danielle B.; Jamieson, Denise J.; Pazol, Karen (November 25, 2016). "Abortion Surveillance — United States, 2013" (PDF). MMWR Surveillance Summaries. 65 (12): 1–44. doi:10.15585/mmwr.ss6512a1. PMID 27880751.
    Medical abortions accounted for 22.2% of abortions—and 32.8% of abortions at ≤8 weeks' gestation—in the United States in 2013 that were voluntarily reported to the CDC by 43 reporting areas (excluding California, Florida, Hawaii, Illinois, Louisiana, Maryland, New Hampshire, Tennessee, and Wyoming).
  40. ^ Fjerstad, Mary; Trussell, James; Sivin, Irving; Lichtenberg, E. Steve; Cullins, Vanessa (July 9, 2009). "Rates of serious infection after changes in regimens for medical abortion". New England Journal of Medicine. 361 (2): 145–151. doi:10.1056/NEJMoa0809146. PMC 3568698. PMID 19587339.
    Allday, Erin (July 9, 2009). "Change cuts infections linked to abortion pill". San Francisco Chronicle. p. A1.
  41. ^ Mindock, Clark (October 31, 2016). "Abortion Pill Statistics: Medication Pregnancy Termination Rivals Surgery Rates In The United States". International Business Times. Retrieved April 19, 2018.
  42. ^ Rowan, Andrea (2015). "Prosecuting Women for Self-Inducing Abortion: Counterproductive and Lacking Compassion". Guttmacher Policy Review. 18 (3): 70–76. Retrieved October 12, 2015.
  43. ^ Kulier, Regina; Kapp, Nathalie; Gülmezoglu, A. Metin; Hofmeyr, G. Justus; Cheng, Linan; Campana, Aldo (November 9, 2011). "Medical methods for first trimester abortion". Cochrane Database of Systematic Reviews (11): CD002855. doi:10.1002/14651858.CD002855.pub4. PMID 22071804.
  44. ^ Creinin, Mitchell D.; Danielsson, Kristina Gemzell (2009). "Medical abortion in early pregnancy". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 111–134. ISBN 978-1-4051-7696-5.
  45. ^ a b Kapp, Nathalie; von Hertzen, Helena (2009). "Medical methods to induce abortion in the second trimester". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 978-1-4051-7696-5.
  46. ^ Creinin, Mitchell D.; Chen, Melissa J. (August 1, 2016). "Medical abortion reporting of efficacy: the MARE guidelines". Contraception. 94 (2): 97–103. doi:10.1016/j.contraception.2016.04.013. ISSN 0010-7824.
  47. ^ "Highlights of Prescribing Information, Mifeprex" (PDF). U.S. Food and Drug Administration. Retrieved October 10, 2019.
  48. ^ Medical management of abortion. WHO. 2018. p. 24. ISBN 9241550406.
  49. ^ "Human Rights and Health". World Health Organization Newsroom. September 21, 2019.
  50. ^ Hammond, Cassing; Chasen, Stephen T. (2009). "Dilation and evacuation". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 978-1-4051-7696-5.
  51. ^ "As controversial 'abortion reversal' laws increase, researcher says new data shows protocol can work". Retrieved April 23, 2018.
  52. ^ "California Board of Nursing Sanctions Unproven Abortion 'Reversal' (Updated) - Rewire". Rewire. Retrieved November 23, 2017.
  53. ^ Bhatti, KZ; Nguyen, AT; Stuart, GS (November 12, 2017). "Medical Abortion Reversal: Science and Politics Meet". American Journal of Obstetrics and Gynecology. 218 (3): 315.e1–315.e6. doi:10.1016/j.ajog.2017.11.555. PMID 29141197.
  54. ^ https://www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion
  55. ^ https://www.npr.org/sections/health-shots/2019/03/22/688783130/controversial-abortion-reversal-regimen-is-put-to-the-test
  56. ^ https://news.vice.com/en_us/article/j5wqqp/theres-no-proof-abortion-reversals-are-real-this-study-could-end-the-debate
  57. ^ Jones, Rachel K.; Kooistra, Kathryn (March 2011). "Abortion incidence and access to services in the United States, 2008" (PDF). Perspectives on Sexual and Reproductive Health. 43 (1): 41–50. doi:10.1363/4304111. PMID 21388504.
    Stein, Rob (January 11, 2011). "Decline in U.S. abortion rate stalls". The Washington Post. p. A3.
  58. ^ Jones, Rachel K.; Finer, Lawrence B.; Singh, Shusheela (May 4, 2010). "Characteristics of U.S. abortion patients, 2008" (PDF). New York: Guttmacher Institute.
    Mathews, Anna Wilde (May 4, 2010). "Most women pay for their own abortions". The Wall Street Journal.
  59. ^ Peterson, Kerry (April 30, 2013). "Abortion drugs closer to being subsidised but some states still lag". The Conversation Australia. The Conversation Media Group. Retrieved April 29, 2013.

External links[edit]