Years ago, Victoria Gómez Betancourt found herself unexpectedly pregnant. At the time, she was working three jobs, none of which offered any health insurance or paid time off, and caring for an elderly disabled parent. She decided the best decision for her was to get an abortion.
“Logistically,” Gómez Betancourt, 39, told Rewire.News, “it became a nightmare to try and act on that decision.” Gómez Betancourt, who has written about her experience for Rewire.News, would have preferred to have had a medication abortion—which involves the use of two drugs, mifepristone and misoprostol, generally for up to 10 weeks’ gestation. But she first had to save up the money for the procedure, which meant figuring out what bills and expenses she’d have to postpone paying.
“I lost a lot of time,” she said, and as a result, had to go with a more invasive, and costly, surgical abortion. Then, what would have been a 30-minute drive to the nearest clinic offering surgical abortions turned into an all-day endeavor because Gómez Betancourt—who now works as the communications and development director at Colorado Organization for Latina Opportunity and Reproductive Rights—had to rely on public transportation to get there and back.
“I’m very grateful to have had that access to care, despite the challenges,” she said, “but access to a medication abortion would have made my life a lot easier.”
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The obstacles Gómez Betancourt faced trying to get the care she needed are all too common, and particularly so for people from marginalized communities. One way to address some of these accessibility issues, medical experts argue, is to lift burdensome restrictions the Food and Drug Administration (FDA) has placed on mifepristone and allow pharmacies to dispense it with a prescription. Currently, the medication is only available in clinics, medical offices, and hospitals that have pre-registered with the drug manufacturer. (Misoprostol, the second part of the medication abortion regimen, can be picked up at a pharmacy with a prescription.)
For example, as Gómez Betancourt explains, if she’d been able to raise the money sooner for a medication abortion, she potentially could have avoided the stressful travel and long hours spent in a clinic, walked to her nearest pharmacy to obtain the pills with a prescription, and ended the pregnancy in the privacy of her own home.
Sally Rafie is an assistant clinical professor at the University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. In April, she and other researchers published a paper in the Journal of the American Pharmacists Association, discussing the potential role pharmacists can play in expanding early abortion care. If pharmacies are able to stock mifepristone like they do misoprostol, she told Rewire.News, providers who may not want to deal with the upfront costs and hurdles necessary to carry this drug will have the opportunity to prescribe medication abortions if they so wish.
“That’s what pharmacies do,” Rafie added. “They stock medications, and they get prescriptions and dispense medications for prescriptions. That’s what the pharmacy’s purpose is out in the community.”
Rafie and her co-authors argue that mifepristone’s safety record warrants the drug should be removed from the FDA’s Risk Evaluation and Mitigation Strategy (REMS) program, which adds additional measures, such as requiring patients to sign an FDA-approved form informing them of the risks, to keep users safe. “Since mifepristone was approved by the FDA in 2000,” they write, “there have been more than 3 million American users and 19 deaths reported, yielding an estimated mortality rate of 0.0006 percent. In comparison, the risk of death among pregnant women in the United States who have a live birth is 14 times greater, at 0.009 percent.” They also point out that “the opportunity for misuse of the drug is minimal owing to the fact that each woman receives only a single dose.”
From a federal perspective, while patients have to get mifepristone from a certified provider, they don’t have to actually take it in the presence of a doctor—they can do so later in the privacy of their home. However, those certified providers, at this point, do not include pharmacists; according to the prescriber agreement form, certified providers must be able to assess pregnancy duration, diagnose ectopic pregnancy, and provide surgical intervention if needed, either personally or through a referral.
Of course, if patients were able to get abortion medication from pharmacies, state regulations around abortion would still be in place, including standard counseling, clinical assessments to determine gestational age, and pretreatment lab work. In an interview with the Associated Press last year, Dr. Paul Blumenthal of the Stanford University School of Medicine, who co-authored another paper urging the FDA to relax its regulations on mifepristone, said he didn’t think doing so would increase the number of abortions. “It will just make them safer and more accessible,” he said.
In fact, researchers argue pharmacy dispensing would actually allow for an additional safety check, since patients would have the opportunity to ask their pharmacists any questions they may have when they pick up their medication. “It’s all about evidence-based practices,” Rafie said. “Why should this medication be treated differently? We have much more dangerous medications that we dispense at the pharmacy, and this one isn’t really considered dangerous [compared with] most of the other medications we have.”
Australia and Canada are among the countries that have already shifted their regulations to allow pharmacies to dispense mifepristone. According to a study that came out in 2015, within three years of making that policy change in Australia, the number of certified prescribers and dispensers of mifepristone had well surpassed the number of dedicated facilities offering abortion care. At this point, it’s unknown how such an update in policy would affecting existing standalone abortion clinics in the United States.
Another study, published in February, found that properly trained pharmacy workers in Nepal “can safely and effectively dispense MA [medication abortion] to women with or without a prescription, based on the high level of complete abortion, absence of serious complications, attendance for follow-up care when needed, high client satisfaction with MA use and high acceptability among women of pharmacy workers as a source of MA.”
Dr. Graham Chelius is a family medicine physician who practices in Kaua’i, Hawaii. Last October, he and the American Civil Liberties Union filed a federal lawsuit against the FDA, challenging its restrictions on the abortion pill. They argue that the REMS places medically unnecessary burdens on women seeking abortion care. In this case, Chelius’ patients have to actually leave the remote island and fly 150 miles to reach the nearest abortion provider; there are none on Kaua’i.
According to new research, people who live in 27 U.S. cities have to travel more than 100 miles to access an abortion facility—in other words, tens of thousands of patients may be unable to get this important care, due, in part, to restrictive and medically unnecessary laws that make it difficult for clinics to stay open.
“Whether a patient fills her prescription at a pharmacy or is handed the pill at a clinic or medical office makes no difference,” Chelius wrote in a blog post. “If we are successful [in the lawsuit], when a patient who has decided to end her pregnancy comes to my office, I’ll be able to write her a prescription the very same day, enabling her to get the medication and end her pregnancy without unnecessary, harmful delays. What’s more, she’ll be able to do so using her preferred method, in the privacy of her home, surrounded by her loved ones.”
Moreover, allowing patients to access the complete abortion pill regimen from their local pharmacy with a prescription would also aid in the expansion of telemedicine services for patients in rural and underserved areas. When patients who live in remote areas—such as an island—can connect with health-care providers via video or teleconference, research has shown they can better access abortion services, and earlier, too.
In many ways, this policy change simply opens the door to more options. “If someone wants to go to the same pharmacist they’ve been using and knows everyone in their family, they can do that,” Rafie explained. “Or if they want to go somewhere where they’re just like, ‘Here ya go,’ no ‘How’s your mom doing?’ that’s totally their choice.”