Abortion pills: a post-Roe game changer and a new battlefield

The future of abortion in the United States is moving to the mailbox.

Medical abortion, in which a woman takes two drugs to terminate an early pregnancy at home, has become the most commonly used method in the United States during the COVID-19 pandemic, especially after the Food and Drug Administration ceased to require that the prescription be dispensed in health establishments. and allowed it to be delivered directly to users. Many online pharmacies around the world ship them without a prescription at all.

As Supreme Court prepares to give states power to ban abortion, medical abortion could be a game-changer – the last option for women in conservative states who can’t travel elsewhere to end their pregnancies .

“We view medical abortion as a potentially transformative and disruptive technology in the face of these unjust laws being passed,” said Elisa Wells, co-founder and co-director of Plan C, a website that provides research and use information. . medication. “It’s a bit of a safety net, potentially.”

The future of abortion

One of an occasional series of stories about the state of abortion as Roe vs. Wade faces its most serious challenge.

Drugs can be shipped discreetly, in some cases avoiding detection by those hoping to ban their use. It’s so difficult to track that statistics on so-called self-directed medical abortions — those performed without a prescription or without the advice of a doctor — aren’t well documented.

“It will be very different from the pre-Roe era when abortion was illegal in that it’s harder to restrict pills,” said Dr. Daniel Grossman, an abortion provider and director of advancement. new standards in reproductive health at UC San Francisco. “It is easier to potentially access it through various channels. And the pills are very safe and effective, unlike unsafe abortion methods or methods people might have used on their own in the 1960s.”

But just as abortion-rights advocates seek to boost access to medical abortion, anti-abortion groups are focused on enacting additional state restrictions on pills, making drugs the next battleground in the world. the decades-long cultural stalemate on abortion.

Abortion rights protesters display packages labeled “abortion pills” outside the US Supreme Court in December. The use of the pills has increased during the pandemic.

(José Luis Magana/Associated Press)

“It’s one of our biggest priorities and it’s certainly something that a lot of states think about a lot more than they did three years ago,” said Katie Glenn, government affairs adviser. at Americans United for Life, a law firm that opposes abortion and advises states on legislation. “We’ve seen a huge increase in pill use during COVID.”

The process of a medical abortion consists of two medications taken in succession. Mifepristone is taken primarily to block the effects of progesterone, a hormone needed to maintain pregnancy. The second drug, misoprostol, is taken a day or two later to cause cramping and bleeding, like an early miscarriage.

A 2015 study showed that at nine weeks pregnant or less, medical abortion was successful 99.6% of the time.

Even so, medical abortion “is not a solution to the problem” of a Supreme Court ruling that undermines abortion rights, Grossman said.

Obstacles can include drug costs, shipping delays, legal risks, and the relatively short recommended window of use of 10 weeks. A medical abortion also takes longer than an in-office procedure, and sometimes patients worry that they have not used them correctly.

But in states that plan to limit or ban abortion — more than two dozen in the South and parts of the West Mountain have already done so or plan to do so — medical abortion is likely one of the few remaining options.

PlanCPills.org provides convenient options for residents of each state, although in some cases shipping or taking medication may violate local laws.

A packet of mifepristone and a bottle of misoprostol, a combination pill used to end early pregnancy.

Mifepristone is taken first to block the effects of progesterone, followed by misoprostol which causes cramping and bleeding like early miscarriage.

(Jeff Roberson/Associated Press)

For example, a patient in Texas — where abortion is banned after embryonic heart activity is detected, about six weeks pregnant — could cross the border to New Mexico and make an appointment with a doctor there. The pills could be shipped to a friend or temporary mailbox in New Mexico and then delivered to the patient in Texas. Or a patient could stay in Texas and purchase the drugs directly from an online pharmacy for $200 to $500.

Established when President Trump took office on a vow to appoint only anti-abortion judges, Plan C was inspired by the accessibility of abortion pills in other countries, such as Ethiopia, where pharmacies were selling for $7 without a prescription, Wells said.

In the United States at the time, the drug could cost several hundred dollars and required an in-person visit with a doctor and a prescription.

After the FDA dropped the in-person requirement early in the COVID-19 crisis, medical abortions overtook in-clinic procedures as the most common method of abortion in the United States, according to the Guttmacher Institute, a research group that supports abortion. rights.

The impending Supreme Court decision on Roe v. Wade and state moves to restrict access to abortion have only heightened interest in the drug. Before the enactment of the six-week abortion ban in Texas, the Wells site received about 500 visitors a day. After enactment, that figure jumped to 25,000 and has since stabilized at around 2,000, she said.

At Aid Access, perhaps the most well-known medical abortion site, US users are connected with a European healthcare provider and can get a prescription filled by a pharmacy in India. It costs $110 and delivery takes up to four weeks.

Conservative states are already taking steps to restrict the ease with which abortion pills can be distributed.

South Dakota tried to require four clinic visits to get a medical abortion, but the rule was blocked by the courts. A Texas law prohibits medical abortions after seven weeks of pregnancy, even though the FDA says 10.

Nineteen states prohibit prescribing pills via telehealth appointments or mail delivery, and 32 states limit which medical professionals can prescribe abortion pills, according to Guttmacher.

Mailing abortion pills to a patient is prohibited in Arizona, Arkansas and Texas. Similar bans in Montana, Oklahoma and South Dakota have been blocked by the courts.

People are marching and shouting for the right to abortion.

Erika Martinez and Mar Bertran, left, march with other abortion rights supporters Tuesday in Austin, Texas.

(Jay Janner / American Statesman from Austin)

This year alone, more than a dozen states have introduced restrictions on medical abortion, including complete bans, a ban on mailing pills, and a ban on using telehealth to deliver them. .

Others focus on banning all self-managed abortions. The practice is illegal in Nevada, South Carolina and Oklahoma, but patients have been arrested in other states as well.

More recently, a Texas woman, Lizelle Herrera, was charged with murder for self-administering an abortion. The charges were later dropped.

Abortion opponents encourage states to focus on banning early abortions, when drugs are most often used.

“Some states will only go so far as to ban second and third trimester abortions… But the majority – over 90% – [of] abortions take place in the first trimester,” said Kristan Hawkins, president of Students for Life. “We really need to explain to the American people why these abortions are just as horrible as a late abortion.”

Enforcement of state medical abortion laws will likely be more difficult, especially when the process takes place online.

But proponents of abortion rights are nonetheless concerned about the chilling effect the laws may have on women and health-care providers who may believe they should report suspected abortions or deal with them. to their own legal problems.

The EMAA Project, a group that advocates for medical abortion care, is having preliminary conversations with the Biden administration about what can be done to strengthen access, group director Kirsten Moore said.

In addition to dropping the requirement for in-person dispensing, the FDA said it will certify pharmacies that wish to dispense abortion medication under strict FDA rules governing its use.

But states that oppose abortion have already indicated they plan to issue their own certification requirements.

Moore’s concern is that any steps the FDA takes to bolster access to abortifacient drugs under the Biden administration could be undone by a future Republican president. Still, she hopes small steps can be taken, like pressuring insurers to cover drugs, even as the rise in medical abortions takes the legal and political struggle to new ground.

“There’s not one, two, three obvious things to fix the problem,” she said. “We’re going to have to be really creative. And that can only be useful on the margins – which can be significant margins.

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