In September 2000, exactly 20 years ago, the U.S. Food and Drug Administration (FDA) first approved mifepristone, which—taken along with the drug misoprostol—is known as medication abortion or "the abortion pill." This one advancement in medicine has changed the landscape of how people obtain and experience abortion in this country.
Beyond its exceptionally safe and effective track record, what makes this method particularly significant is how convenient and private it can be—and how radically it could expand access to abortion care if freed from politically motivated restrictions. Of course, these are also the very reasons it is still subject to onerous restrictions and why, 20 years after FDA approval, antiabortion policymakers and activists remain hell-bent on keeping it out of the hands of people who want it.
A 20-Year Track Record
In the two decades following the FDA’s approval, medication abortion has proven to be safe and effective, and has come to be used routinely. An abortion using pills can be completed at home or elsewhere outside of a medical setting and there are any number of reasons why someone might choose this method, including privacy, availability and convenience.
Guttmacher’s most recent research found that in 2017, medication abortion accounted for 39% of all abortions in the United States and 60% of all abortions taking place up to 10 weeks’ gestation. Even before the COVID-19 pandemic, medication abortion use was rapidly increasing: According to forthcoming Guttmacher research, the number of medication abortions increased 73% between 2008 and 2017, even as the overall number of abortions nationally declined over that period.
Extending Access to Underserved Communities
One of the critical benefits—and under-realized promises—of medication abortion is that it has extended care to communities that would not otherwise have an abortion provider. In findings from forthcoming Guttmacher research, clinics that only provide medication abortion reduced the distance women have to travel to the nearest abortion clinic in some states, and most medication-only clinics did not use medication to replace other abortion methods but instead began providing abortion care for the first time when they made medication available. This expansion of care is especially important for people in underserved areas who are more likely to have to travel long distances and overcome punitive barriers to obtain abortion care.
In addition, by providing an option that is simple, safe and effective, medication abortion has changed how we think about self-managed abortion, which is when someone ends a pregnancy on their own and not under the supervision of a health care professional. Self-managed abortions are by no means a new phenomenon, but they may be becoming more common in the United States. Abortion stigma is heightened when it comes to self-managed abortion, and given the broader societal context of discriminatory law enforcement and prosecution, Black, Indigenous and other people of color, low-income individuals and immigrants are at higher risk of being criminalized for self-managing an abortion than other groups.
Access Is Especially Important During a Pandemic
Another way medication abortion can be used to expand access is through telehealth, which has taken on increased significance as a way of delivering a wide range of care while mitigating risk during the COVID-19 crisis. In addition to the safety benefits, the added convenience of telehealth is critical during a time when more people are experiencing burdens such as financial hardship, lack of child care and homeschooling responsibilities.
These advantages are highly relevant to abortion care, especially when people often have to travel significant distances to reach an abortion clinic. The further away someone lives from a clinic, the more obstacles they have to overcome in order to get the care they need, including travel expenses, transportation, time off work and child care. In addition, 13 states impose onerous restrictions on abortion that require patients to make the trip to a clinic twice.
Restrictions Block Mifepristone’s Full Potential
Unfortunately, federal and state restrictions prevent the use of medication abortion to its full potential. Despite its long safety record, the FDA continues to impose burdensome restrictions on medication abortion that prevent it from being sold at retail pharmacies like most other prescription drugs, and that usually require patients to pick up the pills in person at a clinic. FDA restrictions also pose barriers that make it more challenging for individual clinicians, such as family medicine practitioners or obstetrician-gynecologists, to provide medication abortion.
Moreover, although courts have declared that banning medication abortion outright is unconstitutional, state-level policymakers have found devious ways to place limits on who can provide abortion pills and how people can access them. Policies in 32 states require that a clinician administering medication abortion be licensed as a physician, despite the fact that a whole range of medical professionals—including physician assistants and advanced practice nurses—can safely provide medication abortion. These restrictions contradict findings and recommendations from the World Health Organization, the National Academies of Science, Engineering, and Medicine, and the National Abortion Federation.
In addition, 18 states prohibit the provision of abortion via telehealth. Across these 18 states, approximately 5,000 people seek medication abortion every month—people who are forced to see a provider in person and subject themselves to unnecessary risk during the COVID-19 pandemic because of an ideologically motivated ban. Banning telehealth abortion is about control and has nothing to do with patient health or safety. To put an even finer point on it, policymakers in these 18 states strategically and selectively prohibited the use of telehealth for medication abortion before the option was even available in their states.
Under Attack for Being Effective
Today, medication abortion is back in the news and under further attack for political reasons. In early September 2020, 20 antiabortion U.S. senators decided to use their clout, resources and power to try to pressure the FDA into banning the use of medication abortion outright. At the same time, the Trump administration is appealing a federal court’s ruling that the FDA cannot require people to obtain medication abortion in person during the COVID-19 pandemic.
These latest attacks by antiabortion policymakers fly in the face of scientific evidence and a 20-year track record of safe and effective use of mifepristone in the United States. In this moment, when the entire country is looking to the FDA to follow the science—and nothing but the science—in delivering a COVID-19 vaccine to the public, pressuring the FDA with political stunts shows exactly what these antiabortion lawmakers prioritize. It is imperative that the FDA follow the evidence and protect its credibility by not bowing to heavy-handed political pressure.
20 Years of Progress, but Much More to Do
There is significant untapped potential in the use of medication abortion that could be realized through specific policy changes. For one thing, the end of the global pandemic should not spell the end of remote access to medication abortion. The next federal administration must ensure that patients remain able to access abortion pills without having to be handed the medication in person.
The FDA should also revisit and reevaluate the rest of the restrictions currently placed on medication abortion. And state lawmakers should likewise follow the scientific evidence by removing unnecessary in-person requirements and expanding the range of providers who can prescribe medication abortion. Finally, people who self-manage their abortions should be supported and protected by public policy and community responses, not subjected to scrutiny or punishment.
The past 20 years have given us a glimpse of the fully transformative potential of medication abortion. We must pursue policies that support pregnant people’s decision making concerning how, when and where to have an abortion safely and with dignity.
