Safety issues with medication abortion are extremely rare, experts emphasize

Two Georgia mothers, Amber Thurman and Candi Miller, died in 2022 because of a lack of care most likely tied to the state’s abortion ban, the nonprofit news outlet ProPublica reported this week. Both experienced complications after taking abortion medications, the reporting said — complications, doctors emphasized, that are exceedingly rare and entirely treatable.

“To read about a mom just trying to make the best decisions for herself and her family die from something completely preventable in the United States – I don’t think ‘tragedy’ is a strong enough word,” said Dr. Ghazaleh Moayedi, an obstetrician/gynecologist and founder of Pegasus Health Justice Center in Dallas.

According to the report, Thurman received abortion medication from a clinic in North Carolina shortly after abortion was banned after six weeks in her home state of Georgia, and she went to her local hospital with a severe infection days later, after her body didn’t expel all of the fetal tissue.

“There should not have been a second of waiting” for her to receive care, Moayedi told CNN. “She should have immediately been taken for a uterine aspiration,” a procedure that removes the contents of the uterus, performed for both abortion and miscarriage care.

Instead, ProPublica reported, Thurman didn’t receive surgical care to remove the fetal tissue for 20 hours. The report said it’s not clear from Thurman’s records why doctors waited so long, but noted the procedure had been criminalized just weeks before by the state’s abortion ban, after the US Supreme Court’s overturning of Roe v. Wade that summer. Thurman’s heart stopped during surgery, the outlet reported, after she’d been diagnosed at the hospital with acute severe sepsis and went into organ failure.

According to a second report, Miller didn’t seek care at a hospital at all, even — as her son told ProPublica — she was bedridden with pain for days after taking medication abortion pills. A report from the Clayton County medical examiner, obtained by CNN, cited a conversation with her husband in which he indicated that she “did not go to an ob/gyn due to the current legislations on pregnancies and abortions.”

Miller too hadn’t expelled all the fetal tissue, ProPublica reported, and she should have had a dilation and curettage, or D&C, procedure to remove it and avoid infection. Her autopsy report, obtained by CNN, showed that she died from a combination of medications, including the painkillers fentanyl and acetaminophen; the medical examiner’s report noted that she didn’t have a history of illicit drug use.

Georgia’s Department of Public Health told CNN that the reports of its maternal mortality review committee are confidential. ProPublica, which cited unnamed sources, including members of the committee, noted that those reports deemed Thurman and Miller’s deaths “preventable” and, in Miller’s case, tied to the state’s abortion law.

The reports have enflamed the political debate over access to abortion, with Vice President Kamala Harris saying this week that “this is exactly what we feared when Roe was struck down.” Harris will visit Georgia on Friday to deliver further remarks on women’s reproductive rights.

Abortion rights opponents blamed Thurman’s doctors for not providing immediate care – and blamed medication abortion itself.

But researchers who study medication abortion and doctors who prescribe it emphasized to CNN that the regimen is safe and offered guidance for what patients should do if they experience rare complications.

How does medication abortion work?

Medication abortion has been approved by the US Food and Drug Administration since 2000 and is currently cleared to end a pregnancy through 10 weeks of gestation.

Data shows that it’s now the most common way people in the US access abortion, making up about two-thirds of the approximately 1 million abortions in the formal health-care system in the US last year, according to the Guttmacher Institute, a research group that supports abortion rights.

It consists of two drugs, mifepristone and misoprostol. Mifepristone blocks the hormone progesterone, which is needed for a pregnancy to continue, and is taken first. It’s followed a day or two later by misoprostol, which causes the uterus to contract, leading to cramping and bleeding, during which the pregnancy tissue is expelled.

The process, Moayedi explained, is ”physiologically really the same” as a miscarriage.

How common are complications?

Serious adverse events with medication abortion happen less than 0.5% of the time, according to Dr. Daniel Grossman, director of the Advancing New Standards in Reproductive Health (ANSIRH) program at the University of California, San Francisco. Those adverse events can include hospitalization, blood transfusions and surgery, he said.

Retaining pregnancy tissue and requiring vacuum aspiration happens for 3% to 5% of people who have a medication abortion, Grossman noted, but it’s not considered a serious complication and is typically managed in an outpatient setting; Moayedi said retained pregnancy tissue rarely leads to infection.

Deaths after medication abortion are very rare too, Grossman noted: There were 32 reported among people using mifepristone between 2000 and 2022, a time when approximately 5.9 million women used the medicine. He said his team reviewed the causes reported to the FDA, and almost half were probably not related to the abortion.

“I have cared for thousands upon thousands of people with medication abortion,” said Moayedi, whose clinic provides “wraparound” care, seeing people before or after abortion in Texas, where abortions are illegal with rare exceptions. “I can count on my one hand — less than one hand — the number that have had an infection afterwards. So this is exceedingly rare.”

Rare particularly, Moayedi said, because women “could immediately seek help” if they experienced a problem — something she worries, as the ProPublica reporting suggests, may be less accessible in states with abortion bans.

What should patients do if they experience complications?

Signs of complications include fever, severe abdominal pain and bleeding that soaks through more than two menstrual pads an hour for two hours, Moayedi said. Grossman added that feeling very weak or having nausea, vomiting or diarrhea more than a day after taking the last pill can also be a sign of an infection.

He advises people experiencing any worrisome symptoms to try to reach the clinic or service that provided the medications, or to call the Miscarriage and Abortion Hotline at 1-833-246-2632; it’s a free hotline staffed by clinicians to answer questions and provide support.

“But if a patient is experiencing one of the symptoms mentioned above and they cannot talk with a clinician by phone,” Grossman said, “they should go to an emergency department.”

What about patients in states with abortion bans?

People experiencing these complications can — and should — legally receive care for them anywhere, even in states that have abortion bans, doctors told CNN, so they shouldn’t hesitate to go to a hospital for emergency care.

But the onus can’t be only on the patient to ensure that they get care, Moayedi emphasized; hospital systems need to ensure that they understand the laws and have plans in place that enable physicians to provide necessary treatment, she said.

Grossman also pointed out that “the same complications that occur with medication abortion can also occur with miscarriage, and the treatment is the same.”

“I would never advise a patient to lie, but I am very concerned about these reports that patients’ care is being delayed in states with abortion bans when they present with complications after an abortion — even though the law should not apply to these cases,” he said, noting that his team has heard through its research about similar delays in care for other patients. “The doctors can treat the patient presenting with bleeding or an infection without knowing whether the patient took medications or not.”

He said he advises clinicians not to ask patients whether they took medications to end their pregnancies, “since it doesn’t affect their care, and instead may just increase legal risks for the patients.”