The literature review identified 27 articles/papers which are highly diverse in terms of methodological approaches, data collection techniques, design, inclusion criteria, and sample methods.m Most studies were carried out between 2005 and 2011. Earlier production is scarce, except for the case of Brazil where over half a dozen articles were published in the early and mid 1990s. Brazil was the first country to report the use of misoprostol for self-induced clandestine abortions, and most research addresses women hospitalized for postabortion care[12, 34–38].
Few studies focus exclusively on medical abortion, while the rest address medical abortion within a wide variety of issues related to the abortion event such as reasons for seeking an abortion, the decision making process, or attitudes towards abortion and include women who used medical abortion as well as women who resorted to other means of pregnancy termination. In these cases, we only selected the information which could shed light on the experience of undergoing a medical abortion.
Studies differ in the time elapsed between the abortion and the moment data was collected. Some only included women who had had an abortion in the previous six months or in the previous two years, while others encompass much longer periods of time, up to 20 years.
Selected studies can be classified in the following categories according to the study population and sample used as shown on Additional file2: Table S2.
Studies include both qualitative and quantitative approaches that applied different data collection techniques: 1) in-depth interviews focused on the narrative of the abortion experience; 2) review of medical records and surveys of women hospitalized for postabortion care to describe socio-demographic characteristics, previous use of contraception, abortion method used and incidence of complications (these studies do not analyze in depth the experience around self-inducing the abortion); and 3) literature reviews.
Despite the diverse approaches, all articles address critical aspects of the medical abortion experience. The following section summarizes the main dimensions present in the evidence reviewed which include: knowledge and information about medical abortion; choice of method; obtaining the medication; the medical abortion process: the physical and the psychological experience.
Knowledge and information about medical abortion
Women usually learn about MA when they have an unintended pregnancy. Previous knowledge is scarce and superficial, often limited to knowing about the existence of “abortion pills” that sometimes are confused with emergency contraception[17, 30, 39–41].
Deciding to have an abortion and doing so is not a linear process, particularly in legally restricted settings, not only because women might face ambivalence and personal, familial and social conflict, but also because they might take several different “small actions” which do not follow a sequential or organized pattern[42]. Faced with an unwanted pregnancy, women start searching for solutions that might eventually lead to a MA. Many find out about MA only after unsuccessfully trying other supposedly abortifacient methods such as herbal infusions and hormonal injectables[17, 18, 25, 26, 30, 39, 43].
Clandestinity implies that information about MA is not openly and publicly available but that it rather flows through hidden informal or “underground” channels. Female relatives, friends, neighbors and the sexual partner, are the ones who provide information or help to identify sources of information such as women who had abortions in the past or who have been close to women in a similar situation, women’s health organizations, health professionals, pharmacies and Internet sites[11, 24, 35, 36, 39, 43, 44].
Women who reach harm reduction services often find out about MA through the counseling provided[25]. In some cases men lead the search for information resorting to other men who can provide advice[12, 45, 46] while women adopt a more passive stance[47].
Information about MA is mostly spread by word of mouth and it is therefore highly diverse and fragmented, particularly when it comes from laypeople, but pharmacy staff and health professionals also provide highly heterogeneous information that in some cases differs significantly from scientific standards[19–21, 23, 30, 39, 44, 48].
Complete and correct information about how to use and what to expect from MA, including dosage, routes of administration, mechanism of action, effectiveness, contraindications and side effects is crucial in determining the outcome of the process and the woman’s experience. Women who receive accurate and complete information on how the medical abortion process will develop and what is and what is not normal have more positive experiences. In this sense, counseling by a health care professional or a qualified counselor is vital for the whole abortion process[4, 13, 25, 39].
Choice of method
As with most abortion matters within legally restricted settings, the experience of undergoing a medical abortion is primarily determined by social class. Lower income women do not have an array of safe methods to choose from according to their needs and preferences[39, 49], but they do perceive that using medication is safer than introducing objects or other traditional unsafe methods[12, 24]. Preference for MA is also expressed based on fear of unsafe medical procedures or because they associate it more with a menstrual regulation process. However, cost and accessibility are key factors for deciding for a MA, more than personal preferences or a balance of its advantages and disadvantages. Women make pragmatic decisions regarding the abortion method based on their possibilities that are not necessarily “real choices”[17, 18]. In the absence of financial constraints some would prefer a surgical abortion performed by a physician or a medically supervised procedure[35, 39, 49].
Women value the safety and effectiveness of MA as well as the privacy that it allows and the possibility of having their partner, a friend or a person of their choice nearby during the process. Women perceive MA as less painful, easier, safer, more practical, less expensive, more natural and less traumatic than other methods. The fact that it is self-induced and that it avoids surgery is also pointed out as an advantage[11, 17, 18, 24, 35, 44].
Main disadvantages identified by women are that MA is painful and takes time to complete. Other negatively evaluated aspects have to do with side effects, prolonged bleeding, the possibility that it might not be effective, and the fact that some women eventually need to seek medical care at a hospital where they might be sanctioned for having an illegal abortion and even reported to the police[11, 17, 18].
Obtaining the medication
In most cases women have to procure the medication by themselves, except those who access MA through an institution or a health professional that provides misoprostol. Risk reduction services offer information on medical abortion as a way to avoid higher risk methods but women must obtain the drug on their own. Some women feel highly frustrated when they learn that abortions are not practised nor is misoprostol provided by such services[25].
In many Latin American countries pharmacies are widely used as a source of medical advice, especially by lower income populations, and women have traditionally resorted to pharmacies in search for drugs to bring on menstruation when they have a delayed menstrual period[13, 21]. Misoprostol is purchased at retail pharmacies either as the entire package or by the pill, usually without prescription despite the fact that government regulations require sale under prescription[11, 20–22, 34]. Pharmacy staff often recommend misoprostol for pregnancy termination but their knowledge about dosage, route of administration, side effects complications and effectiveness is often poor in quality[20, 21]. They usually advise to seek medical care once bleeding starts[22].
Different levels of difficulty exist in obtaining misoprostol related to the local regulation of the drug and the level of government control over pharmacy sales. Stricter control makes access more difficult, pushing women to the black market where prices are higher[25, 48, 50].
In settings where misoprostol is sold only under prescription women display a variety of strategies to either obtain a prescription or to buy the drug without one. These include paying for a prescription, claiming that the drug is not for ObGyn purposes either by obtaining and presenting a prescription from a non-ObGyn specialist, or asking a man or an older woman to buy the drug for them arguing that is for their own use[22].
Internet is extensively used to search for information on MA and to a lesser extent to buy misoprostol. The quality and authenticity of misoprostol sold on the Internet by individuals with lucrative purposes is questionable since it is sometimes not provided in its original packaging and can be fake[19, 50, 51]. The studies reviewed do not report use of telemedicine websites or hotlines for obtaining MA medication among Latin American women.n
Prices vary widely, and depend on where the medication is purchased[16, 39, 40]. Even if medical abortion is considerably less expensive than surgical methods, it is still unaffordable for poor women and adolescents who do not have ready access to cash. Women implement different strategies to gather the money to buy the medication: borrowing money from friends and relatives, asking for a salary advance, working overtime, selling valuable objects[25, 39, 49]. One study even refers to women travelling or contacting people in neighboring countries to obtain the medication[39].
Sometimes women who bought the whole package and have pills left after completing the abortion either offer them or sell them to other women in need of misoprostol as a way of female solidarity or cost-recovery[22, 39].
Obtaining the drug implies not just having the money but entering the circuit of irregular sale of misoprostol. Internet is the main source of this kind of information.
Accessing the drug will depend on the woman’s economic capacity, social network, personal skills, and support from others. Male partners who are involved in the abortion decision usually have an active role in obtaining the medication, particularly in contributing economically and searching for where to buy it[12, 25, 46].
The medical abortion process: the physical experience
Like the majority of abortions, most medical abortions take place within the first 12 weeks of pregnancy[11, 12, 32, 39, 40]. Women generally understand that earlier abortions are safer, but sometimes the abortion is delayed because time is spent seeking information, trying ineffective methods, searching for the medication and raising the money to buy it[30, 39]. Second and even third trimester self-induced home abortions with misoprostol have been reported[11, 34]. These situations can be extremely risky.
For most women, getting ready for a medical abortion means preparing for something unknown, an unexperienced event that can trigger unexpected consequences[39, 49]. They must decide when and where to do it, if someone will be with them at that moment and who they want that person to be. If they have children they must arrange for someone to look after them and organize the domestic chores[17, 18, 39].
Women appreciate the privacy that medical abortion allows them. In some circumstances they conceal the abortion from other people. There are testimonies of women who went through a MA without altering their daily lives and surrounded by relatives, or even their partner, who were unaware of their condition. In other cases, hiding the abortion from other household members is difficult and problematic[17, 26, 44].
Women often prefer to use the pills during the night as they perceive it to be safer, with few chances of being interrupted, and they are usually at home while others are resting[12, 17, 39]. The night might also feel like a more private and protected time for doing something illegal[39].
It is not uncommon for women to use misoprostol together with other methods, mostly ineffective ones like teas and other infusions, and injections bought in pharmacies[12, 51, 52].
Few of the women who obtain the medication outside clinical settings can specify the name of the medication they used for pregnancy termination[17, 39, 40, 44, 49, 53] and cannot precise if they were antibiotics, analgesics or tranquilizers[17].
The information that women receive outside clinical settings about how to use misoprostol is highly diverse, consequently, women use misoprostol in a variety of ways[24, 35, 51] with doses ranging between 4 and 16 tablets, and much higher doses in extreme cases[11, 35, 54, 55]. However the median dose is usually 800 mcg, the adequate dosage for early abortion[34, 35, 37]. Intervals between doses also vary widely[24].
Women use misoprostol vaginally, orally or a combination of both routes[24, 35–37] and seem to prefer oral rather than vaginal administration[13]. Some women dislike or are uncomfortable with the vaginal administration of tablets, or are not sure they can insert them correctly by themselves. Several authors relate oral preference to the idea of menstrual regulation, while vaginal insertion is culturally more linked to abortion[12, 17].
After inserting or taking the pills women wait for something to happen. When possible, they stay home and rest. Others continue with their daily routines. In some cases expulsion or heavy bleeding took them by surprise while they were at school or at work[17, 49].
Bleeding usually starts few hours after the first dose and is most abundant at 6 to 12 hours after insertion[44] but can also take much longer[24, 35]. Bleeding can last between 1 and 60 days[24]. Several studies report testimonies of heavy bleeding, or bleeding more abundant than what women had expected[30, 40]. Often women are unable to determine whether their symptoms are normal or abnormal or whether a complete abortion has occurred[30].
Common side effects include chills, diarrhea, nausea, headache, dizziness and fever. These are usually well tolerated[17, 40]. Most women experience pain of different intensity and duration[24, 40, 44]. Generally the most severe pain takes place the first day after inserting/taking the pills, particularly after 5 to 7 hours, and later diminishes[44]. Some women report unbearable sustained pain for several hours[17, 25, 26]. Those who have medical supervision are recommended to take pain relief medication[17].
Some women start and finish the MA process at home. Others do not wait enough to complete the abortion alone and seek medical assistance in health care institutions where a surgical uterine evacuation procedure is usually performed. Some women seek medical care shortly after bleeding starts, either because they are afraid that something bad will happen to them, or because they were told to do so by the person who instructed them on how to use the medication[12, 20, 22, 30, 35, 36, 44, 45].
As information on MA becomes more widespread and women gain more experience they make better use of misoprostol[11, 35]. Evidence collected from hospitalized postabortion women shows that prevalence of severe complications is lower among women who used misoprostol than among those who used other methods[29, 34, 35].
In some cases attempts to terminate pregnancy with misoprostol are not successful and pregnancy continues. Women who access medical services that perform abortions can resort to a surgical abortion[17, 18, 26]. But women who lack this alternative are left with no options. The possibility of having a surgical procedure depends on their economic capacity. These are critical situations marked by anxiety and distress, particularly when women are aware of the possible teratogenic effects of the medication[39].
The psychological experience
Having a medical abortion means a direct and vivid physical experience which triggers strong emotions, fantasies and fears. Few of the articles reviewed refer to the psychological aspects of the MA experience, which are closely related to the physical experience, the information the woman has received, and the availability or lack of medical and emotional support[17, 18, 39, 45, 49].
Some women relate MA to a menstrual regulation process or something akin to getting their period, which reduces emotional distress and helps them to cope with the process[11, 17, 18, 44]. On the other hand, many women go through a MA feeling that it is an unknown process of which they have no full control[39]. Common feelings are fear of the negative reactions in the body, and concern linked to pain and bleeding. Women are very anxious about heavy vaginal bleeding and fear they can bleed to death or suffer long lasting health complications including infertility[25, 43, 51]. Women who have legal medical abortions in a medically controlled setting are less concerned about bleeding[56].
Testimonies also reflect uncertainty and anxiety about how long the process will last, when they will be able to return to their daily life and whether or not certain activities are safe to do (working, swimming, bathing, physical activity, sex)[17].
Women who have medical supervision and/or receive detailed information from a qualified source and know what to expect in terms of bleeding, pain and side effects report more positive experiences with less anxiety and fear, feel more in control and tend to remain calm[29]. In addition, previous experience with pregnancy and delivery seems to contribute to a better management of the situation[17].
Many women, but particularly those who undergo the process with no counseling or supervision, have emotionally draining experiences marked by fear of negative consequences, anxiety and concern. These are mostly elicited by the clandestine context and the lack of medical back-up in moments when women feel extremely vulnerable and out of control of the situation[39, 45]. Some women refrain from seeking medical care out of fear that they will be mistreated, penalized or given medication to retain the pregnancy[43].
Affective support and company are vital during the MA process, particularly for adolescents who are more vulnerable than older women in the same situation[25, 26]. Women are usually accompanied by their partner, female relatives (mother, sister) or female friends who help to minimize discomfort or simply stay by them[17, 25, 39, 49]. Having the support of their close ones gives women not only the possibility of sharing doubts and fears, and not feeling alone -which is reassuring and helps them to remain calm- but also implies the possibility of accessing economic resources or having someone who will take care of their children if they have any[25, 39]. Women who go through the process alone or conceal the abortion from other household members usually have emotionally difficult situations[17, 25, 47].
