Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries

J Obstet Gynaecol Can. 2020 Dec;42(12):1532-1542.e2. doi: 10.1016/j.jogc.2020.04.006. Epub 2020 Apr 27.


Objective: Abortion-related complications remain one of the leading causes of maternal morbidity and mortality worldwide. Nearly half of all abortions are unsafe, and the vast majority of these occur in low- and middle-income countries. The use of mifepristone with misoprostol for medical abortion has been proposed and implemented to improve abortion safety.

Data sources: A systematic review of the literature was conducted in PubMed, Embase, Cochrane, and CINAHL.

Study selection: Criteria for study inclusion were first-trimester abortion, use of mifepristone with misoprostol, and low- or middle-income country status as designated by the World Health Organization.

Data extraction: Results for effectiveness, safety, acceptability, and qualitative information were assessed.

Data synthesis: The literature search resulted in 181 eligible articles, 52 of which met our criteria for inclusion. A total of 34 publications reported effectiveness data on 25 385 medical abortions. The average effectiveness rate with mifepristone 200 mg and misoprostol 800 µg was 95% up to 63 days gestation. A sensitivity analysis was performed to assume that all women lost to follow-up failed treatment, and the recalculated effectiveness rate remained high at 93%. The average continuing pregnancy rate was 0.6%. A total of 22 publications reported safety and acceptability data on 17 381 medical abortions. Only 0.8% abortions required presentation to hospital, and 87% of patients found the side effects of treatment acceptable. Overall, 95% of women were satisfied with their medical abortion, 94% would choose the method again, and 94% would recommend this method to a friend. A total of 16 publications reported qualitative results and the majority supported positive patient experiences with medical abortion.

Conclusions: Mifepristone and misoprostol is highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.

Keywords: abortion, induced; acceptability; effectiveness, treatment; mifepristone; pregnancy trimester, first; safety.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Abortifacient Agents / adverse effects
  • Abortifacient Agents / therapeutic use*
  • Abortifacient Agents, Nonsteroidal / adverse effects*
  • Abortion, Induced*
  • Developing Countries
  • Female
  • Humans
  • Mifepristone / adverse effects
  • Mifepristone / therapeutic use*
  • Misoprostol / adverse effects
  • Misoprostol / therapeutic use*
  • Patient Acceptance of Health Care*
  • Pregnancy
  • Treatment Outcome


  • Abortifacient Agents
  • Abortifacient Agents, Nonsteroidal
  • Misoprostol
  • Mifepristone