Abortion pills are now the most common method of ending a pregnancy in the United States for the first time since they were approved more than two decades ago, according to preliminary data released Thursday.
The surge in popularity comes as Republican-controlled states are increasingly restricting surgical abortions and the Supreme Court is weighing a case that could result in a significant blow to abortion access, or overturn Roe vs. Wade, the 1973 landmark case that established a constitutional right to abortion.
The report from the Guttmacher Institute, a research center that supports abortion rights, found that medication abortion—a two-pill regimen approved in the U.S. to end pregnancies up to 10 weeks—accounted for 54% of abortions in 2020. This marks a significant jump from 39% in 2017, the last time the report was released.
“People really like that [medication abortion] removes a lot of the barriers,” says Ushma Upadhyay, an associate professor at Advancing New Standards in Reproductive Health, a research group at the University of California, San Francisco. “They don’t have to take time off from work and especially for people living on low incomes and people of color, it makes life a lot easier and they’re able to integrate this healthcare into their lives.”
But the increasing availability of abortion pills has put the method in the crosshairs of a national battle over abortion. As progressive groups and the Biden Administration have sought to make them more accessible, Republicans and conservative activists around the country are adding new restrictions. Nineteen states currently ban telemedicine visits for medication abortion, and at least 16 state legislatures have introduced bills this year to ban or limit medication abortion in various ways.
Read More: States Push New Abortion Bans, Preempting the Supreme Court
Medication abortion had been growing in popularity before the coronavirus pandemic, but COVID-19 likely made the method more appealing as people sought to minimize medical procedures and trips to health facilities.
In 2020, medical associations sued the federal government to lift the Food and Drug Administration’s (FDA) requirement that the first abortion pill, mifepristone, be dispensed to patients in person. The FDA temporarily removed that requirement last spring and, in December, the Biden Administration made the move permanent. The FDA’s decision allows patients to receive the abortion pills by mail after they have a telemedicine appointment with a provider.
Abortion opponents fear that even if the Supreme Court overturns Roe vs. Wade, people will be able to end their pregnancies using abortion pills. Anti-abortion groups like Susan B. Anthony List and Students for Life of America have made limiting the pills a priority, and are encouraging states to restrict them particularly in light of the FDA’s decision.
“We are trying to really start educating our movement and Christians broadly across the country about what these pills really are, and how just very dangerous they are to women,” Kristan Hawkins, president of Students for Life of America, told TIME earlier this year.
Doctors and abortion rights advocates stress that years of research has shown medication abortion is safe. “We did an analysis of 11,000 medication abortions in California and found that the rate of major adverse events was less than a third of 1%. So it is extremely safe,” Upadhyay says. “We also know that it’s safer than Tylenol and safer than Viagra.”
Read More: Mississippi’s Last Abortion Clinic Faces the Supreme Court
The fight over medication abortion is already playing out in Texas, where nearly all abortions after six weeks have been banned since Sept. 1. Texas also prohibits telemedicine visits for medication abortion and medication abortions after seven weeks, before the FDA’s approved cutoff.
Even with these restrictions, Texas has seen a spike in people ordering abortion pills online since its six-week ban went into effect, according to a new study published in the Journal of the American Medical Association on Friday. Orders for the pills from the international nonprofit Aid Access increased 1,180% in the first week after the Texas law took effect, going from nearly 11 purchases per day to more than 137 per day. While purchases leveled off over the next three months, the researchers found they stayed 174% higher during that time than before the law was in place.
This is exactly what abortion opponents want to avoid. “We’ve seen even in Texas as the Heartbeat Bill is still in effect, we see that the pills are going out the back door,” Sue Liebel, state policy director at SBA List, said in January. “So this is an issue.”
For the Texas researchers, this is evidence that the use of medication abortion is not going away. “We know that putting abortion restrictions in place does not mean the need for abortion just goes away. It’s still there. And people will look oftentimes for other ways to get the care they need,” says Abigail Aiken, a professor at the University of Texas at Austin and the lead author of the study.
Aid Access can mail people abortion pills even in states like Texas that have outlawed sending the pills by mail because it is based outside the U.S. Aiken says that people are also increasingly turning to other online retailers to buy abortion pills on their own from services without doctor supervision, a process known as self-managed abortion, which her research has found can be safe and effective.
Texas’s Health and Human Services agency recently reported that abortions in the state dropped 51% in September 2021 when the state’s six-week law went into effect. Those numbers, and the increase in medication abortion reported by Guttmacher, do not include abortion pills taken outside the formal health care system, so the total number of people using abortion pills in the U.S. is likely higher than reported, experts say, and only going to increase.
“I think as we see more restrictions,” Aiken says, “we’ll see self managed abortion play an increasingly important role in providing an option for people.”
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