Abortion access faces a monumental crisis, as states across the nation continue to advance and pass restrictive abortion laws, the Trump administration enacts reproductive health policies that ignore science and the Supreme Court is about to decide a major case on the regulation of abortion. year.
Amid this treacherous landscape, two key factors will help determine the future of abortion in the United States: the outcome of the 2020 presidential election and the outcome of ongoing efforts to facilitate medical abortion (also called abortion pill). .
So far, Democratic presidential candidates have not engaged in a solid conversation about their views on the critical issue of expanding access to medical abortion. But they should. And thankfully, that is starting to change.
Just last month, Democratic presidential candidates responded to a New York Times survey of their positions on abortion, including a question about whether to return mifepristone and misoprostol – the two pills used in medical abortion – available over the counter. Seven candidates said they supported over-the-counter medical abortion, two were unsure, and seven did not answer the question.
Growing Abortion Access Crisis
Although there has been public discussion of over-the-counter access to birth control pills, there has been little noise around the possibility of making abortion pills available without a prescription. Public response to the survey results ranges from concern over the sale of abortion pills like aspirin to relief that it could ease the growing abortion access crisis.
Six states now have just one abortion clinic, and some states may soon have none, according to the Supreme Court’s decision in the Louisiana case that it accepted.
I’ve been researching over-the-counter access to medical abortion for several years, both in the United States and internationally, and the reality is that it’s not an immediate panacea. More studies are needed, and it will likely be several years before the Food and Drug Administration considers an application to make abortion pills available without a prescription.
Even so, it’s a milestone that the Democratic candidates were even asked about this policy change, which has the potential to dramatically transform how people access and experience abortion care.
Research increasingly indicates that people are interested in over-the-counter access to abortion pills. In a 2017 survey of more than 7,000 American women ages 18-49 about their interest in obtaining over-the-counter abortion pills, 37% said they supported access to over-the-counter abortion pills. They often cite convenience benefits and how it would make it easier to access care earlier in pregnancy. In another survey we conducted of abortion patients in states with limited access to the service, 80% said they supported over-the-counter availability.
As a practicing OB-GYN, I have few concerns about the safety of making medical abortion available without a prescription or clinical evaluation. This treatment is simple and involves taking the two drugs, usually 24 hours apart, resulting in cramping, bleeding, and expulsion of the pregnancy.
Most of the abortion pill eligibility assessment involves a simple list of questions that patients themselves could easily fill out. For example, we ask patients if they have an intrauterine device in place, as it must be removed before using abortion pills, and we ask them if they are taking blood thinners, which can increase bleeding.
Research shows these pills are safe
Currently, medical abortion is FDA-approved for use up to 10 weeks gestation; after this point, the drug regimen changes. If abortion pills were available without a prescription, one question is whether patients could accurately self-assess their gestational age, and another is whether they might choose to use the pills beyond 10 weeks because they had limited alternatives. We are conducting a study on the accuracy of self-assessment of gestational age, which will help answer at least the first question.
In many parts of the world, people already have access to abortion pills without a prescription. In much of Latin America, where abortion is largely restricted, misoprostol is often available in pharmacies without a prescription – and its expanded access has been associated with reduced abortion-related deaths and complications at risk.
Research from Peru and Bangladesh suggests that women can safely and effectively use the abortion pills they get without a prescription.
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Of course, over-the-counter abortion pills aren’t the answer for everyone. Many patients appreciate the support they receive from clinicians and clinic staff. The future of patient-centered abortion care must include a range of options, including facility-based services.
As in other countries, there are increasing reports of American women accessing abortion pills without a prescription, including through online sources, which the FDA says is illegal.
At least 21 people have been arrested or faced criminal investigation for allegedly trying to induce their own abortions or helping someone else, and women of color have been targeted disproportionately to be criminalized.
Make abortion pills easier to get now
An FDA move toward approving over-the-counter abortion pills would help decriminalize and destigmatize self-managed abortion. But first, for the FDA to approve medical abortion for over-the-counter sale, a pharmaceutical company would have to perform specific research showing that women can use the product safely and effectively without medical supervision. This would take at least three to five years, assuming the studies go well and there is no political interference in the FDA approval process.
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This delay is too long to make a difference for people living in the South and Midwest who face an immediate and potentially worsening abortion access crisis. But there are steps policymakers could take now to improve access to the abortion pill and help people get safe care early in pregnancy: lift medically unnecessary regulations that prohibit doctors from prescribing the pill to distribute it in a pharmacy, lift restrictions in nearly 20 states on telemedicine (which research shows is safe and effective for medical abortion), and allowing nurse practitioners and other advanced practice clinicians to provide the abortion pill (less than 20 states currently do so, although the results are similar).
As more abortion patients seek online options for self-managed care, it’s time to meet their needs with services like over-the-counter access to medical abortion. This is the future of reproductive health care, and we must continue to ask politicians, including those currently running for president, how they plan to make it a reality.
Daniel Grossman, MD, is a professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco and director of Advancing New Standards in Reproductive Health. Follow him on Twitter: @DrDGrossman