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Commentary Abortion

Anti-Choice Activists Fighting a Losing Battle Against Medication Abortion

Carole Joffe & David S. Cohen

Medication abortion is a gamechanger for pregnant people, particularly when other forms of abortion are difficult to access or even unavailable.

With the recent news that almost 40 percent of the abortions in this country in 2017 were by pill rather than surgical procedure, now is a great time to appreciate the seemingly unstoppable revolution this medical advance has brought about.

Abortion providers all over the country have witnessed this revolution firsthand. As the director of a network of clinics in a large Western state told us, “We’re doing medication abortions with nurse practitioners all over the state, and it’s particularly important in the mountains.” She explained that before medication abortion, in a particularly remote area, “if the doc was there on Tuesday and you came in on Wednesday, you had to wait another week or two.” This pushed some patients too late in pregnancy to have an abortion. But now, patients in the region “can come in on the day the nurse practitioner is there, which is almost every day, and be taken care of.”

The providers whom we interviewed for our forthcoming book on abortion restrictions have made it clear the profound impact of this form of abortion provision. So it comes as no surprise that as we mark the 19th anniversary of the Food and Drug Administration (FDA) approval of the drug mifepristone for use in the United States, abortion opponents are ramping up their attacks on medication abortion. But the newly released data about the increased incidence of medication abortion from the Guttmacher Institute shows that they are fighting a losing battle.

Medication abortion has been so revolutionary because it involves a different skill set than surgical abortion, considerably expanding who can provide one. In contrast to surgical abortions, which involve medical instruments inserted into the uterus, medication abortion consists of dispensing mifepristone along with misoprostol, another drug that has long been approved for different conditions.

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Clinic staff offering this health-care service must determine the length of a pregnancy (the regimen is generally used through ten weeks’ gestation) and provide good counseling skills. These are skills held by a variety of medical practitioners, not just doctors. More than a dozen states permit nurse practitioners, physician assistants, and midwives, along with physicians, to provide medication abortion. It stands to reason that part of the increase in the number of medication abortions is due to provision by clinicians other than doctors.

Medication abortion has also made abortion provision via telemedicine possible, an innovation that can benefit even more patients. Telemedicine abortion allows a patient in a rural area, hundreds of miles away from an abortion clinic, to go to a nearby local general health clinic and videoconference with an abortion provider. If the provider on the video call determines that a medication abortion is appropriate, the patient is given the first drug, mifepristone, in the local clinic and is instructed to take the follow-up drug, misoprostol, at home, 24 hours later. All patients are instructed to return to the local clinic in two weeks to confirm that the abortion was successful. Research published in 2017 found that telemedicine medication abortions are as safe as clinic-based ones.

Anti-abortion lawmakers, understanding this revolution, have attempted to thwart almost every attempt to make medication abortion more accessible. They have passed laws limiting the ability of non-physicians to provide them: To date, 34 states require licensed physicians provide medication abortions, despite no scientific evidence supporting the legislation. And 18 states have banned abortions via telemedicine, even as telemedicine is used for other medical procedures in those states. In addition, lawmakers have, in spite of medication abortion’s excellent safety record, pressured the FDA to retain a cumbersome standard for the distribution of mifepristone, which requires that it be treated like the most dangerous drugs. As a result, it cannot be dispensed in pharmacies, a standard that has doubtless deterred some potential providers from treating patients because of the onerous process of dispensing the medicine on their own.

While the battles over medication abortion continue, the abortion pill regime has also been playing a new role in an old phenomenon: self-managed abortion. In the pre-Roe v. Wade era, numerous women died or were seriously injured when attempting their own abortions via the proverbial coat hanger and other dangerous methods. Today, medication abortion represents a far safer alternative for people choosing to go it alone. Both mifepristone and misoprostol can be ordered over the internet, and travelers from countries where misoprostol is more available sometimes bring it here. Misoprostol alone as a method of self-abortion—though not as effective as when used together with mifepristone—is about 85 percent to 93 percent effective and just as safe.

While no precise figures are available on how many people have self-managed abortions in the United States, it is clearly on the rise following increased restrictions on abortion access in many states and heightened concerns over Roe being overturned. One recent study estimated that 8 percent of women of reproductive age in Texas, where 23 clinics closed after strict regulations took effect, had attempted their own abortion.

Of course, medication abortion is not the solution to every aspect of the abortion battles in this country. Already, some women who have attempted their own abortion have been prosecuted, disproportionately affecting people of color. This unjust system will undoubtedly continue, especially in conservative jurisdictions. And medication abortion provides little help for those who need an abortion later in pregnancy.

Nevertheless, the relative availability of these drugs is a gamechanger for pregnant people, particularly when other forms of abortion are difficult to access or even unavailable.

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