Objective
To examine trends in the number of low-volume and non-metropolitan mifepristone purchasers and their role in the expansion of medication abortion.

Methods
We use de-identified data from Danco Laboratories, the sole distributor of mifepristone during the study period, to examine trends in mifepristone distribution. We focus on customers who purchased < 100 doses a year and a subset of those who purchased < 10 doses for the periods of 2008–2011 and 2014–2017. We use data from the Guttmacher Institute Abortion Provider Census (APC) studies in 2008 and 2017 to examine the extent to which some facilities that purchased mifepristone may be missing from Guttmacher's APC.

Results
Between 2008 and 2017, the number of medication abortions increased 73%, though the number of mifepristone purchasers only increased 15%. The number of low-volume mifepristone customers, or those who purchased < 100 tablets of mifepristone per year, decreased 8% over the study period, while the number purchasing < 10 tablets per year decreased 14%. However, in recent years low-volume customers were more likely to have purchased mifepristone in multiple years. In non-metropolitan areas, the number of sites purchasing mifepristone increased slightly but the amount of mifepristone that was purchased more than doubled between 2008 and 2017.

Conclusions
While reliance on medication abortion increased substantially between 2008 and 2014, there is no evidence that this was due to an increase in the number of facilities that purchased low-volumes of mifepristone.

Implications
While their numbers declined, abortion providers purchasing low volumes of mifepristone likely played an important role for the individuals they cared for. Access to abortion could increase if a wider network of healthcare practitioners, especially those in settings that do not currently provide abortions, were able to offer medication abortion.