Abortions are performed using two broad approaches: medication and procedural (sometimes called surgical). Which method is used depends primarily on how far along the pregnancy is, your health history, and your preference. In the first trimester, most abortions in the United States are now medication abortions, which use a combination of two pills taken over one to two days. For pregnancies further along, or when medication is not suitable, procedural methods involving gentle suction or instruments are used. Both approaches have been studied extensively, and legal abortion of any type carries very low complication rates.
Medication Abortion in the First Trimester
Medication abortion uses two drugs in sequence. First, you take mifepristone, a pill that blocks progesterone, the hormone needed to sustain an early pregnancy. Then, typically 24 to 48 hours later, you take misoprostol, which causes the uterus to contract and expel the pregnancy tissue. The experience is similar to a heavy, crampy period, though the intensity varies from person to person. Most of the process happens at home.
The standard regimen is 200 mg of mifepristone by mouth followed by 800 micrograms of misoprostol, placed either in the cheek (buccal) or vaginally. This two-drug combination has strong evidence of effectiveness up to 63 days of gestation, with success rates ranging from about 95% to 98%.1PubMed Central. Uses of Misoprostol in Obstetrics and Gynecology A large study using the buccal misoprostol regimen found an overall success rate of about 98%.2PubMed Central. Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days Failure due to an ongoing pregnancy occurs in roughly 1% of cases.
Timing matters. Research shows that giving both drugs at the same time instead of spacing them apart lowers the success rate. One trial found that concurrent administration had a significantly lower success rate compared with a 48-hour interval between the two medications.3Journal of Clinical Medicine. Early Pregnancy Termination with Mifepristone and Misoprostol: Concurrent vs. 48-Hour Interval Administration in a Randomized Controlled Trial That spacing gives mifepristone enough time to do its job before misoprostol triggers contractions. A follow-up visit, usually one to two weeks later, confirms that the abortion is complete.
When Mifepristone Is Not Available
In some settings, mifepristone is difficult to obtain due to cost, regulation, or supply chain issues. Misoprostol can be used on its own. It is less effective than the two-drug combination, but it still works well. A study of more than 600 people using misoprostol alone found that about 98% had a complete abortion without needing a procedural intervention.4PubMed Central. Medication Abortion Safety and Effectiveness With Misoprostol Alone An updated systematic review confirmed that misoprostol-only regimens are a safe and effective fallback when mifepristone is unavailable.5PubMed. Effectiveness and safety of misoprostol-only for first-trimester medication abortion: An updated systematic review and meta-analysis Across a pooled analysis of thousands of women using misoprostol alone, hospitalizations and transfusions occurred in well under 1% of cases, and no deaths or ectopic pregnancies were reported.6PubMed Central. Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review
Telehealth and Self-Managed Medication Abortion
The ability to receive abortion pills by mail, prescribed through a video or phone visit rather than an in-person appointment, expanded rapidly during the COVID-19 pandemic and has been studied since. A trial comparing telehealth-prescribed, mailed medication abortion with the traditional in-person route (with ultrasound) found no meaningful difference in effectiveness: roughly 94% in the mail group and 93% in the in-person group, meeting the standard for being considered equivalent. Serious adverse events, including hospitalization, transfusion, and emergency surgery, were uncommon and occurred at similar rates in both groups.7JAMA. Comparison of No-Test Telehealth and In-Person Medication Abortion Earlier data from COVID-era telehealth programs similarly supported the feasibility, safety, and effectiveness of mailed medications.8JAMA Network Open. Safety and Efficacy of Telehealth Medication Abortions in the US During the COVID-19 Pandemic
Self-managed medication abortion, where someone obtains and uses the pills without direct clinical supervision, has also been studied. A population-based study found that about 96% of people who used medications obtained through an online telemedicine service reported ending their pregnancy without surgical intervention, and only about 1% reported treatment for a serious adverse event.9PubMed Central. Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study The World Health Organization considers self-managed medication abortion safe and effective up to 12 weeks of gestation when people have access to accurate information and a health-system referral if needed.10PubMed Central. Self-Managed Medication Abortion: History, Evidence, Models of Care, and Policy Considerations
First-Trimester Procedural Abortion
If you prefer a procedural approach, or if medication abortion is not appropriate, a suction aspiration (sometimes called vacuum aspiration) is the most common first-trimester procedural method. It is a brief outpatient procedure, often lasting less than 15 minutes. The cervix is gently dilated, and a thin tube connected to a suction device empties the uterus. Two types of suction devices exist: manual vacuum aspiration (MVA), which uses a handheld syringe, and electric vacuum aspiration (EVA), which uses a machine.
A systematic review found no meaningful difference between MVA and EVA in complete abortion rates or patient satisfaction.11PubMed. Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review At very early gestational ages (less than about seven weeks), MVA was associated with less blood loss and less severe pain, while EVA had a slightly shorter operating time. A separate controlled study found that major complication rates were low and similar for both devices, around 2% for each.12Obstetrics & Gynecology. Manual Versus Electric Vacuum Aspiration for Early First-Trimester Abortion: A Controlled Study of Complication Rates Incomplete abortion occurred in fewer than about 2.5% of cases across methods in a randomized trial comparing both vacuum devices with the older sharp curettage technique.13PubMed Central. Safety and efficacy of manual vacuum suction compared with conventional dilatation and sharp curettage and electric vacuum aspiration in surgical treatment of miscarriage: a randomized controlled trial Severe complications were not observed in any group in that trial.
Pain Management During Procedural Abortion
Pain control for first-trimester procedures usually involves a local anesthetic injected into the cervix, called a paracervical block. Evidence suggests that a higher volume of lidocaine and deeper injections improve pain relief.14Clinical Obstetrics and Gynecology. Analgesia/Pain Management in First Trimester Surgical Abortion Adding intravenous sedation, typically a combination of fentanyl and midazolam, reduces pain further. In one study, patients who chose intravenous sedation reported pain scores about a point lower on a 10-point scale compared with local anesthesia alone.15PubMed. Pain management of first-trimester surgical abortion: effects of selection of local anesthesia with and without lorazepam or intravenous sedation Oral benzodiazepines like lorazepam, sometimes offered for anxiety, did not actually reduce pain in that study and left more people dissatisfied with their pain control. Deep sedation or general anesthesia is reserved for more complex procedures or people with significant medical conditions.
Second-Trimester Procedural Methods
After about 12 to 14 weeks, abortions require different approaches because the pregnancy is larger. Dilation and evacuation (D&E) is the most common procedural method in the second trimester across much of the developed world. The cervix needs to be opened wider than in a first-trimester procedure, and this is done gradually using osmotic dilators, small rods inserted into the cervix that absorb moisture and expand over hours.16Cochrane Database of Systematic Reviews. Cervical preparation for second-trimester surgical abortion Some are made from dried seaweed (laminaria), while synthetic options expand more quickly, within about six hours rather than 12 to 24.17PubMed. Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation Prostaglandin medications can also be used to soften and dilate the cervix. A single set of dilators placed the day before is usually enough for D&E before 20 weeks.
The procedure itself uses a combination of suction and specialized instruments to remove the pregnancy tissue. It is typically done under sedation or general anesthesia and takes longer than a first-trimester aspiration, but it is still completed in one session. Cervical preparation reduces the risk of cervical tears and uterine perforation, both of which are rare but more concerning at later gestational ages.
Second-Trimester Labor Induction
The alternative to D&E in the second trimester is labor induction, where medications cause the uterus to contract and expel the pregnancy much as it would during a miscarriage or delivery. The most effective protocol combines mifepristone with repeated doses of misoprostol. In a review of nearly 400 consecutive cases between 12 and 20 weeks, roughly 98% of women aborted within 24 hours and over 99% within 36 hours.18PubMed. Induction of second trimester abortion (12-20 weeks) with mifepristone and misoprostol: a review of 386 consecutive cases The median time from starting misoprostol to completion was under seven hours.
Adding mifepristone before misoprostol roughly halves the time needed. A randomized trial found that people who received mifepristone first completed the process at a median of 10 hours, compared with 18 hours for those who received misoprostol alone.19Obstetrics & Gynecology. Mifepristone in Second-Trimester Medical Abortion: A Randomized Controlled Trial The ideal spacing between the two drugs matters here too. A trial comparing simultaneous dosing with a 24-hour interval found that the spaced regimen led to faster completion and fewer doses of misoprostol needed, though by 48 hours both regimens worked equally well.20Obstetrics & Gynecology. Simultaneous Administration Compared With a 24-Hour Mifepristone–Misoprostol Interval in Second-Trimester Abortion
Abortions After 20 Weeks
Later abortions, performed after about 20 weeks, are uncommon and almost always involve either serious fetal anomalies or maternal health complications. These procedures may involve an additional step: inducing fetal asystole (stopping the fetal heartbeat) before the procedure begins. This is typically done by injecting a medication, most often digoxin or potassium chloride, through the abdomen or cervix.21PubMed Central. Drugs used to induce fetal demise prior to abortion: a systematic review
There is no strong evidence that routine induction of fetal asystole is necessary before previable abortions. However, at gestational ages near or past viability, clinical recommendations advise it to prevent the rare but serious possibility of a fetus being expelled with signs of life.22American Journal of Obstetrics and Gynecology. Induction of fetal asystole before abortion: clinical recommendations The procedure is performed by an experienced provider, often with ultrasound guidance.
How Safe Is Abortion Compared With Childbirth
Legal abortion is one of the safest procedures in medicine. A widely cited comparative analysis found that the mortality rate from legal induced abortion was 0.6 deaths per 100,000 procedures, while the pregnancy-associated mortality rate among women who delivered live births was 8.8 deaths per 100,000, making childbirth roughly 14 times riskier.23PubMed. The comparative safety of legal induced abortion and childbirth in the United States A more recent analysis covering 2018 through 2021 found the gap had widened: depending on how pregnancy-related deaths were defined, the ratio of pregnancy-related mortality to abortion-related mortality ranged from about 44 to 70.24JAMA Network Open. Pregnancy- and Abortion-Related Mortality in the US, 2018-2021 Some critics have argued that the data underlying these comparisons are biased, but an investigation of that claim found the opposite: abortion deaths appear to be more completely counted than childbirth deaths, meaning the statistics, if anything, slightly overestimate the risk of abortion relative to childbirth.25JAMA. Mortality From Abortion and Childbirth: Are the Statistics Biased?
What Complications Can Occur
Although serious complications from legal abortion are rare, they do happen, and it helps to know what to watch for. The main complications include:
- Heavy bleeding: Some bleeding is normal after any abortion, but excessive bleeding requiring medical attention occurs in a small minority of cases.
- Incomplete abortion: Sometimes pregnancy tissue is not fully expelled or removed. This can usually be resolved with a follow-up dose of misoprostol or a brief aspiration procedure.
- Infection: Endometritis (infection of the uterine lining) can develop but is typically treatable with antibiotics.
- Uterine perforation: A rare complication of procedural abortion, reported at rates between 0.05% and 1.9%, where an instrument passes through the uterine wall.26International Journal of Surgery Case Reports. Uterine perforation and bowel incarceration following a second trimester abortion Most perforations heal without intervention, but rarely they can involve nearby organs and require surgery.
Retained products of conception (RPOC) deserve particular attention because they are the complication most likely to require follow-up care. Ultrasound is the standard tool for diagnosis. Management options range from watchful waiting to a repeat dose of misoprostol to a minor surgical procedure.27PubMed Central. Retained Products of Conception (RPOC): Diagnosis, Complication & Management In one retrospective study of expectant management, about three-quarters of patients with RPOC resolved on their own without any intervention, though those with heavy initial bleeding or increased blood flow to the retained tissue on ultrasound were more likely to need additional treatment.28European Journal of Obstetrics & Gynecology and Reproductive Biology. Expectant management of retained products of conception following abortion: A retrospective cohort study
Ruling Out Ectopic Pregnancy
Before any abortion, clinicians need to confirm that the pregnancy is in the uterus and not in a fallopian tube (ectopic pregnancy), because an ectopic pregnancy will not respond to abortion medications and can become life-threatening if untreated. Ultrasound is the primary tool. If a scan shows an empty uterus when a pregnancy is expected, blood levels of hCG (the hormone produced during pregnancy) are tracked over a couple of days. A normal early pregnancy shows hCG rising by at least about 53% in two days, while a failing pregnancy drops by at least 21% to 35%.29Obstetrics & Gynecology. Suspected Ectopic Pregnancy A rise or fall slower than expected suggests ectopic pregnancy and prompts further evaluation. In one retrospective study of women undergoing very early medical abortion, ectopic pregnancy was identified in less than 1% of cases.30PubMed. Detection of ectopic pregnancy and serum beta hCG levels in women undergoing very early medical abortion: a retrospective cohort study
Rh Testing and Changing Guidelines
If you have Rh-negative blood and are carrying an Rh-positive pregnancy, there is a theoretical risk that fetal blood cells could enter your bloodstream during an abortion and cause your immune system to produce antibodies that could attack future pregnancies. For decades, standard practice was to give Rh-negative patients an injection of anti-D immunoglobulin (commonly known by the brand name RhoGAM) after any abortion, regardless of gestational age. That guidance is now shifting. The World Health Organization’s guidelines from 2022 onward recommend against anti-D for abortions in the first trimester, based on the very small volume of fetal blood that can cross during early pregnancy.31PubMed Central. Rhesus testing and anti‐D prophylaxis in RhD‐negative women undergoing first‐trimester abortion—Systematic Review and Opinion The American College of Obstetricians and Gynecologists has also issued updated guidance for losses and abortions before 12 weeks.32PubMed. ACOG Clinical Practice Update: Rh D Immune Globulin Administration After Abortion or Pregnancy Loss at Less Than 12 Weeks of Gestation For second-trimester abortions, anti-D is still generally recommended.
Long-Term Reproductive Effects
One of the most common concerns people have is whether an abortion will affect their ability to get pregnant later or carry a pregnancy to term. The bulk of evidence is reassuring. A comprehensive review concluded that, with the exception of cases complicated by infection, there is no evidence linking induced abortion to secondary infertility or ectopic pregnancy.33PubMed. The effect of pregnancy termination on future reproduction For first-trimester vacuum aspiration, the risk of premature delivery or low birth weight in a subsequent pregnancy was not significantly higher than it would be for a first-born child. The review did note a possible increased risk of preterm delivery after dilation and evacuation procedures, though the evidence was limited. The key takeaway is that a straightforward first-trimester abortion, without complications, does not appear to harm future fertility.
Contraception Right After an Abortion
Fertility returns quickly after an abortion, often within two weeks, so contraception is an important part of post-abortion care. Many people opt to have an intrauterine device (IUD) placed immediately after a procedural abortion, while they are still in the clinic. A major trial found that six-month IUD use rates were much higher in the group that received an IUD right away: about 92%, compared with roughly 77% among those who were told to come back later for insertion.34PubMed. Immediate versus delayed IUD insertion after uterine aspiration Expulsion rates were slightly higher with immediate insertion (about 5% versus 3%), but that difference was within the range considered acceptable.
A systematic review and meta-analysis confirmed that immediate IUD insertion after both surgical and medical abortions increases the likelihood that a person is actually using the IUD at six months or one year, without meaningfully increasing rates of infection, removal, or pain during insertion.35PubMed Central. Immediate and delayed placement of the intrauterine device after abortion: a systematic review and meta-analysis The practical reality is that many people who intend to return for a delayed insertion never make it back, so immediate placement removes that barrier.
Emotional and Psychological Outcomes
The psychological effects of abortion are among the most politically charged aspects of this topic, and the research is often more nuanced than either side of the public debate admits. A nationally representative study in the United States found that after accounting for pre-existing mental health conditions and other confounders, abortion was not a significant predictor of later anxiety, mood disorders, eating disorders, or suicidal thinking.36PubMed Central. Abortion and Mental Health: Findings From the National Comorbidity Survey-Replication The Turnaway Study, a landmark prospective study that followed women for five years after they either received or were denied an abortion, found that those denied the procedure initially had more anxiety and lower self-esteem than those who received one.37JAMA Psychiatry. Women’s Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study
That said, a large cohort study of 1.2 million pregnancies found higher rates of mental health hospitalization following induced abortions compared with other pregnancies. The associations were strongest in people who had pre-existing mental illness or were under 25 at the time, and the elevated risk diminished over the years following the procedure.38PubMed. Induced abortion and implications for long-term mental health: a cohort study of 1.2 million pregnancies Interpreting this is tricky. People seeking abortions are more likely to be experiencing difficult life circumstances that independently affect mental health, and disentangling cause from correlation in this area is genuinely hard. The most cautious reading of the evidence is that the abortion itself does not appear to cause mental illness in people who were previously well, but those with pre-existing vulnerabilities may need additional support.
How Methods Have Evolved
Modern abortion methods bear little resemblance to those used even a few decades ago. Sharp curettage, where the uterine lining was scraped with a metal instrument, was once the standard first-trimester procedure. It has been largely replaced by vacuum aspiration, which is faster, less painful, and causes less blood loss. Medical abortion with mifepristone and misoprostol became available in the 1980s and 1990s and has since become the dominant method in early pregnancy in many countries. The shift toward medication has been accelerated by telehealth delivery models, which the evidence discussed above supports as safe and effective. The World Health Organization and multiple national guidelines now endorse self-management with medications in the first trimester, a move that would have been unthinkable at the start of the century. Whether that trend continues will depend as much on law and politics as on medicine.