Reproductive rights advocates have long warned that a reversal of the Supreme Court’s landmark Roe v. Wade decision would return women to a time of desperate back-alley and coat-hanger abortions.
Yet the most common method of abortion today is a discreet prescription regimen that can safely end an early pregnancy at home. If the Food and Drug Administration lifts restrictions this month, as expected, the medication could become more accessible by mail in states that allow it and potentially create an underground market in those states that are poised to prohibit abortion if the Supreme Court allows.
As the nation awaits a ruling that could result in abortion being outlawed in roughly half the states in the country, medication abortion is emerging as a new front in the emotional and sharply contested debate. Last week, a law went into effect in Texas banning medication abortion by mail or telehealth, which followed the state’s adoption of the nation’s strictest abortion ban, after six weeks.
“We’re surely going to see an even bigger surge in the abortion lobby trying to push this chemical abortion method,” said Prudence Robertson, communications associate at Susan B. Anthony List, an antiabortion advocacy network. “We know that it’s the next frontier for them so we’re doing everything we can to encourage states to take action.”
Medication abortion refers to a two-step protocol of prescriptions that can be taken to end a pregnancy up until 10 weeks of pregnancy. The first, called, mifepristone, blocks the hormone progesterone, which is needed to continue pregnancy. Then, misoprostol, taken 24 to 48 hours later, causes cramping and effectively induces a miscarriage.
Medication abortions were already on the rise, accounting for nearly 40 percent of abortions in the United States in 2017, according to the most recent data from the Guttmacher Institute, a think tank that supports abortion rights.
“The overall rate of abortion has continued to go down in our country, but the percent of medication abortions are going up compared to procedure abortions,” said Dr. Nisha Verma, a fellow with the American College of Obstetricians and Gynecologists, which has called for lifting restrictions on abortion-inducing medication.
In Massachusetts, after years of steady increases, medication abortions became the most common method in 2019. Last year, 47 percent of the 16,452 abortions in Massachusetts were done with prescriptions.
The FDA first approved mifepristone in 2000, but until recently the pills were highly restricted. Even though the medication is taken at home, the FDA required it be dispensed in person at clinics — rather than mailed, sold at pharmacies, or ordered online — by providers who are specially certified and obtain the medication directly from a distributor.
“That’s not what doctors usually do. They usually send you to a pharmacy to get a prescription,” said Elisa Wells, cofounder and codirector of Plan C, a campaign to promote abortion medication. “It was enough of a barrier that a lot of general practice doctors who could have prescribed it didn’t do that.”
Activists have long pressed for easier access, pointing to data showing the drugs to be safe. But the FDA concluded that restrictions were necessary to ensure safety as recently as 2016.
The pandemic changed that calculus. Faced with a public health emergency that could make in-person dispensation risky, the American Civil Liberties Union challenged the requirements on behalf of the American College of Obstetricians and Gynecologists. After a back and forth in the courts — in which the Supreme Court overturned a lower court decision and allowed the Trump administration to reinstate the requirement — the FDA under President Biden suspended the in-person dispensing requirement for the duration of the pandemic.
Clinicians and telemedicine providers who could consult patients through the process had been preparing for the shift.
“We were working with telehealth groups saying, ‘Why don’t you get ready?’ ” Wells said. “If ever there were a rationale for mailing pills, this is it.”
What followed was an explosion of access to medication abortion by mail and telehealth, bolstered by research affirming the safety of the method and calling for its broader use.
Today, medication abortion is available by mail in 21 states, with some online providers operating only in certain areas or regions. Carefem mails abortion pills to patients in 10 states, including Massachusetts. Abortion on Demand ships to 21 states, including Massachusetts. Costs range from $150 to $375 and are not necessarily covered by insurance.
“This is just what’s happening fully above-board, fully legally, according to all the laws and regulations,” Wells said.
“These pills are so safe and so effective that really they could be provided over the counter and in many countries these pills are available off the pharmacy shelf,” Wells added.
Abortion opponents, however, dispute the safety of the medication, suggesting that abortion providers are downplaying the risks and endangering women who might use the first-trimester medication inappropriately.
“Women are going to seek them out no matter what stage of pregnancy they’re in,” Robertson said. “They’re being put at risk each and every day.”
But specialists and medical organizations said that research is increasingly demonstrating the method is safe. Patients are advised against medication abortions in cases of ectopic pregnancy — a pregnancy outside of the uterus — as well as in those with adrenal problems and bleeding problems.
The process causes cramping and heavy bleeding, and very heavy bleeding may require a surgical procedure, the FDA notes. Other side effects include nausea, weakness, fever and chills, and dizziness. In 18 years of usage, the FDA recorded 24 deaths possibly related to mifepristone — two of which were due to ectopic pregnancies.
The FDA is expected to announce by Dec. 16 whether it will permanently abandon the prepandemic requirement that abortion prescriptions be dispensed in person; if it does, the decision will likely prompt more states to take action against the practice.
“We’re anticipating that more states will look to limit access to medication abortions because of what’s expected from the FDA and the potential at the US Supreme Court to weaken or overturn abortion rights,” said Elizabeth Nash, state policy analyst for the Guttmacher Institute.
In addition to Texas, the states of Arizona, Arkansas, Montana, Oklahoma, and South Dakota have taken steps to prohibit mailing abortion pills, Nash said.
Other states — Alabama, Wyoming, West Virginia, and Iowa — began taking steps to try to bar medication abortion completely over the past year, Nash said.
It’s unclear how states would enforce such bans. An international group called Aid Access is already providing medication abortion pills online and has defied FDA warnings to stop. Aid Access even offers the pills in advance, allowing patients to obtain the medication before a prospective ban.
With online access to abortion medication, a patient can get treatment, respond to pertinent medical questions, and consult a provider at any time. Abortion pills arrive by mail within three days, some providers promise, and patients have access to a specialist throughout the procedure on telehealth.
“You don’t have to go through the protesters, find child care, take time off from work,” said Kirsten Moore, director of the EMAA Project, which advocates for medication abortions.
That convenience is worrisome to those who oppose abortion and who see the medications as creating an end-run around legal barriers.
“I think there’s definitely a danger for it to be misused on a black market or for mifepristone to end up falling into hands where it wasn’t originally intended,” said Tessa Longbons, senior research associate at the Charlotte Lozier Institute, which opposes abortion.