Health

Understanding Medication Abortion in a Post-Roe World

As U.S. states restrict abortion access, the pill method may remain the sole option for millions of women.

By Molly GlickJul 13, 2022 5:00 PM
Pregnancy test
(Credit: George Rudy/Shutterstock)

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Long before the June decision by the U.S. Supreme Court to overturn Roe v. Wade, medical providers and pro-choice advocates braced for a future with diminishing access to legal abortions. Some states now completely outlaw abortion, even in cases of rape or incest, due to a series of trigger laws set in place before the court ruling. With further bans looming, experts think medication abortions may serve as the sole option for millions of women.

What Is Medication Abortion?

This method of abortion typically involves two types of medication. The first, mifepristone, blocks a hormone called progesterone. The lining of the uterus then thins and prevents the embryo from staying implanted and developing. Between 24 and 48 hours later, patients take misoprostol. This causes the uterus to contract and expel the embryo through the vagina, similar to an early-stage miscarriage — in fact, physicians prescribe this same drug for natural miscarriages. Both pills come in tablet form and can be taken vaginally or orally.

After the FDA approved mifepristone in 2000, this option has grown increasingly popular. Currently, medication abortions make up around half of U.S. abortions performed at or before eight weeks of pregnancy. That marks a notable rise from 2017, when they accounted 39 percent.

People often choose medication abortion to make the process more comfortable, says Ushma Upadhyay, a public health social scientist at the University of California, San Francisco. “Many people prefer a medication abortion because they like to go through the process at home with people they care about,” Upadhyay says. “Some people say it feels a little more natural, like a miscarriage, and they also say it’s more private.”

Medication abortions are usually more prevalent among those living in rural communities because it is often the only option at clinics in remote areas, says Mitchell Creinin, an OB-GYN and family planning specialist at the University of California, Davis.

Despite the abundance of misinformation spread online, medication abortion is very safe and highly effective when performed in early pregnancy, Upadhyay says. She co-authored a 2015 Obstetrics & Gynecology study that included over 11,000 people who had received medication abortions. The results showed that less than .03 percent of people experienced a serious complication. Only around 5 percent of people required an additional procedure to complete their abortion. In fact, these pills are considered safer than aspirin, Tylenol and Viagra.

Efficacy does, however, decrease after about eight weeks of pregnancy. Within the first eight weeks, medication abortion is around 94 to 98 percent effective; that figure drops to about 87 percent between 10 and 11 weeks.

An Uncertain Future

Even before the historical Dobbs versus Jackson Supreme Court decision last month, people seeking an abortion faced multiple barriers in obtaining mifepristone (misoprostol is not regulated in terms of abortion). For example, 32 states require physicians to administer these pills, yet experts say physician assistants and other health care providers are just as qualified to do so. Additionally, 19 states demand that a clinician be physically present to provide medication abortion, which rules out telemedicine — an option that benefits people living in underserved areas and is proven to be just as safe as in-person visits.

Now, we can expect things to get even more complicated. Amid a growing number of prohibitory laws around the country, Upadhyay expects more people will try to take advantage of medication abortion in a post-Roe world. “I expect that […] some people will be creative and use these existing U.S.-based telehealth services to get medication abortion,” she says.

While working on an ongoing study on telehealth-sourced abortions, Upadhyay has observed people go to great lengths to work around growing restrictions. For example, an individual living in Texas had the medications mailed to a friend living in Illinois, who then shipped them to Texas. People living in states who ban telehealth services could also drive across state borders to attend virtual appointments.

Women may also seek out online pharmacies like Honeybee Health or organizations such as Netherlands-based Aid Access to receive pills in the mail, a process that may take up to several weeks. “I think people in restricted-access states, where all abortion is banned, will just go online,” Upadhyay says. “There are many — I guess that we call them ‘rogue’ — providers that offer medication abortion.”

Aid Access is a reputable organization that offers FDA-approved medications, and a 2018 Contraception study found that rogue internet pharmacies generally offer safe and effective medications, though they noted that some pill packets obtained online arrived with holes in them. Overall, ordering any medication online will present risks. “You want to still go to something you consider reputable,” Creinin says. People searching for abortion pills can find vetted resources on the Plan C website.

Ultimately, it will likely be difficult for states that ban abortion to crack down on FDA-approved pills sent through the mail, which is also regulated by the federal government. Even before the Dobbs decision, online services helped people circumvent rising restrictions: When Texas banned abortion with nearly no exceptions after approximately six weeks of pregnancy, residents’ requests for mifepristone and misoprostol via Aid Access increased by 174 percent over three months.

Medication abortion may even become more prevalent for people who are 10 to 11 weeks into their pregnancies despite lower efficacy rates, Mitchell says, when faced with a lack of choices. Yet for the small portion of people for whom this method isn’t successful, getting a procedural abortion could be highly risky. “The big question is: Where and how will they seek care?” Upadhyay says, raising concerns about other disparities that might arise. “Will they be prosecuted or criminalized? Will people of color be more likely to be monitored and targeted?”

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