When the FDA approved mifepristone in late September 2000, advocates believed it was going to change abortion care in this country. Mifepristone causes an abortion when used with another long-approved drug, misoprostol. (In the United States, this regimen is used through ten or eleven weeks of pregnancy.) “Medication abortion,” as this new modality was called, raised the possibility of a dramatic expansion of abortion provision by bringing in new categories of providers. As a sociologist studying abortion, I was interested in documenting the dissemination of this new method. Shortly after the FDA approval, I tried to locate new providers who were going to start delivering medication abortion care, but initially I found very few. At this 20th anniversary, however, mifepristone is indeed finally leading to major changes—due to COVID-19.
In the twelve long years between when the medication was first approved in France (1988) and in the United States, the anti-abortion movement had vociferously campaigned against mifepristone, spreading misinformation, and threatening boycotts against the medication’s then global manufacturer, Hoechst A.G., a German firm. (In response to the controversy, Hoechst eventually stopped production of the pill and gave up its patent rights.) At the same time, violence by abortion extremists was increasing. The first murder of a physician who performed abortion took place in 1993, followed a few years later by several more murders of people in the abortion-providing community.
Weary both of this violence, and of the problems caused by a chronic shortage of abortion providers, the pro-choice movement fastened their hopes on medication abortion care as a solution to both these issues. This method carried the promise of increasing the number of providers because it did not require the specialized medical training of other forms of abortion care. If many primary care doctors, for example, incorporated medication abortion care into their practices, abortion care could move away from specialized clinics, and protestors would not know why someone was entering a particular facility.
In retrospect, these hopes were inflated and naïve. Medically speaking, medication abortion care is quite straightforward. Socially, however, this method, as with abortion care generally, is quite complicated. Would-be new providers were taken aback to learn that incorporating medication abortion care into their primary practices meant that they would be subject to the restrictions governing abortion in their states, such as parental consent, waiting periods and other rules. Similarly, those who did start this provision soon realized that it was logistically impossible to alert patients of this new service but simultaneously keep it “secret” from protestors.
This impossibility of confidentiality became clear when I interviewed a family medicine doctor in the rural Midwest who began providing medication abortion care to her patients. She was startled when a patient came into her office, and said, “Doctor, do you know that they are calling you a ‘daughter of Satan’ on Christian radio?” This doctor was not the only one I encountered whose decision to initiate medication abortion care became controversial, and led to unwanted attention from protestors, and in some cases, pushback from medical colleagues in their community.
An additional hurdle for new providers: the FDA took the unusual step of placing mifepristone in a program that came to be known as Risk Evaluation and Mitigation Strategies (REMS). This program was established to regulate drugs known to be very dangerous, such as thalidomide, which causes severe birth defects. But ample evidence existed from trials in the United States and Europe of mifepristone’s safety. One can speculate that this step was taken in response to the medication’s controversy, not the science.
The REMS classification imposed cumbersome restrictions. Mifepristone could not be dispensed in a pharmacy, but it had to be obtained at a clinic or doctor’s office. Doctors who offered mifepristone had to register with the distributor—no doubt causing apprehension among potential adopters about having one’s name on a list of known abortion providers.
Gradually, however, the use of medication abortion has expanded. According to the most recent data, about 40% of all abortions in the United States are by this method. Some 17 states permit Advanced Practice Clinicians (nurse practitioners, midwives and physician assistants) to provide medication abortion, and this has particularly benefitted rural women. Simultaneously, however, from 2000 on, red state legislators have sought in numerous ways to restrict this method. Seventeen states, for example, prohibit the use of telehealth for medication abortion, though this has been very successful where allowed.
But, as no one could have predicted, medication abortion care has really come into its own during the COVID-19 crisis. This method involves considerably less close provider-patient interaction than other abortion methods. I have found in recent interviews with providers that increasingly patients are opting for this regimen. Clinic staff are developing new protocols to minimize face-to-face interaction as much as possible, for example by doing preliminary counseling using telehealth, and by sending patients home with a pregnancy test, thereby eliminating the need for a follow-up visit to ascertain a successful abortion.
But the REMS requirement still meant that patients had to travel to clinics to obtain the two pills of the regimen, thus risking exposure to COVID-19. Leading medical organizations, including the American College of Obstetricians and Gynecologists (ACOG), have long argued that the REMS were unnecessary. Abortion providers were therefore encouraged by the recent ruling, in a suit brought by ACOG, that temporarily overturned the REMS due to the pandemic. (The Trump administration has appealed to the Supreme Court to reinstate this restriction but the Court has not yet responded.) Currently, where state laws do not explicitly prohibit this, the relevant medications can be mailed to patients. Advocates hope that a paper trail of the safety of this measure will allow this policy to be continued even after COVID-19 is under control.
When I started to document medication abortion care, I didn’t think this method’s promise would take this long to be realized. I wish it didn’t have to take a pandemic for the FDA to start loosening restrictions, but I’m thankful that progress is happening now.