BACKGROUND

A safe and effective option at early gestations, medication abortion accounted for nearly one-third (31%) of all abortions performed in the United States in 2014. Many women prefer medication abortion to surgical abortion, as it is noninvasive and is perceived to be more private.

In 2000, the U.S. Food and Drug Administration (FDA) approved the use of a combination of mifepristone and misoprostol for early nonsurgical abortion. In 2016, the FDA updated their protocol, on the basis of scientific studies, with a regimen that is just as effective as previous regimens but uses less medication, has fewer side effects, has a longer window of time in which it can be used (up to 70 days after a patient’s last menstrual period) and requires fewer visits to the provider. By the time it was approved, this evidence-based regimen was already in widespread use among providers.

Since 2004, states have enacted several types of restrictions targeting medication abortion. Most of the laws take one of two approaches: limiting provision to the FDA protocol or requiring in-person administration. By limiting providers to the FDA protocol, states preclude providers from taking advantage of evidence-based changes in administration of medication abortion. And by requiring in-person administration, states prevent providers from using telemedicine to administer medication abortion; in doing so, they reduce access to abortion in rural areas. In addition, a few states require providers to share with patients the medically unsupported claim that medication abortion can be “reversed.”

STATE LAWS AND POLICIES

For a chart of current laws and policies in each state related to medication abortion, see Medication Abortion.

For information on state laws and policies related to other sexual and reproductive health and rights issues, see State Laws and Policies, issue-by-issue fact sheets updated monthly by the Guttmacher Institute’s policy analysts to reflect the most recent legislative, administrative and judicial actions.

RELEVANT DATA AND ANALYSIS

FDA Protocol

  • The protocol for administering medication abortion approved by the FDA in March 2016 is widely tested and evidence-based. This regimen is supported by the American College of Obstetrics and Gynecologists (ACOG), National Abortion Federation and Planned Parenthood Federation of America.
    • The newly approved protocol calls for a lower dose of mifepristone than was used in the previous regimen. The lower dose has been shown to be safer and just as effective, and it can be administered at home.1–3
    • Because the protocol requires a lower dose of mifepristone, it is less expensive for the patient.
    • The protocol requires only one in-person visit. Follow-up, which occurs 7–14 days after taking mifepristone, can be done by phone.1–3
    • The protocol is approved for use up to 70 days after a patient’s last menstrual period.1,3,4
       
  • The updated protocol is in accordance with standard medical practice. It is safe and effective and has fewer side effects than the previous regimen.
    • Evidence shows that medication abortion is safe. Serious complications requiring hospitalization for infection treatment or transfusion occur in fewer than 0.4% of patients under the updated protocol.1–3
    • The overall success rate using this protocol is 95–99%, higher than the 92% success rate using the 2000 FDA-approved regimen.1,2
    • The updated regimen has been shown to cause fewer gastrointestinal side effects, such as nausea, vomiting and diarrhea.1,4

Use of Telemedicine

  • The recent growth in the use of telemedicine in diverse health care settings has proven to be an effective and important tool for expanding access to care, improving health outcomes and reducing health care costs.5
    • By reducing costs associated with provider visits, mobile and communications technologies can help deliver more accessible medical care at a lower cost.6
    • The American Medical Association supports the use of telemedicine as a means of improving the quality of care delivery to patients.7
    • In testimony before the U.S. Senate Judiciary Committee, ACOG supported policies that increase access to reproductive health services, including the use of telemedicine for early medication abortion.8
  • The use of telemedicine for early medication abortion can help address access barriers for women who live in rural areas and others who may have difficulties traveling to a surgical facility.8
    • In 2014, 90% of U.S. counties had no abortion clinic.9
    • Removing barriers to clinic access for rural women or mitigating the need for travel could reduce delays in receiving care and enable women to obtain an abortion at the earliest stages of pregnancy when it is safest.10,11 Delaying care increases both the risks and costs of abortions.
    • Compared with women who made an in-person visit for medication abortion, telemedicine patients in a study in Iowa were more likely to recommend the service to a friend, and there was no difference in adverse outcomes between telemedicine and in-person patients.11,12 The use of telemedicine for early medication abortion is as safe and effective as an in-person physician visit.

Counseling About Medication Abortion Reversal

  • In 2015, Arkansas was the first state to implement a law requiring providers to counsel patients that a medication abortion may be “reversed” if a woman is given a high dose of progesterone after she takes mifepristone. There is no medical evidence to support this claim.
    • These laws are primarily based on a case study published in 2012 by an antiabortion obstetrician-gynecologist who gave six abortion patients who had taken mifepristone—but not misoprostol, the second drug in the approved two-stage regimen—high doses of progesterone. The study author did not apply for ethical approval and did not use any controls.13–15
    • Scientists and doctors have not replicated the findings and have no reason to think progesterone should be administered for this reason. Specifically, ACOG is concerned that the high doses of progesterone could have negative health effects for patients.15 The FDA has not evaluated the claim that medication abortion can be reversed.
  • Medication abortion is most effective when the patient follows the evidence-based protocol and takes both drugs. Many women (30–50%) who take only mifepristone experience an incomplete abortion.15

DATA CENTER

RECENT STATE ACTION ON THIS ISSUE

States that have addressed this issue over the past three years are listed below.

EState enacted a relevant measure

V: State vetoed measure

A: State adopted measure in at least one chamber

 

States that prohibit prescription of mifepristone via telemedicine

Arkansas (2015)

E

Idaho (2015)

E

Iowa (2014)

A

Kansas (2015)

E

Montana (2015)

V

South Carolina (2016)

E

States where providers must adhere to FDA protocol when prescribing mifepristone

Arkansas (2015)

E

Oklahoma (2014)

E

States that require counseling on medication abortion “reversal”

Arizona (2015)

E

Arkansas (2015)

E

South Dakota (2016)

E

State that repealed counseling on medication abortion “reversal”

Arizona (2015)

E

REFERENCES

1. U.S. Food & Drug Administration, Mifeprex (mifepristone) information, 2016, http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111323.htm

2. Jones R and Boonstra H, The public health implications of the FDA’s update to the medication abortion label, Health Affairs Blog, 2016, http://healthaffairs.org/blog/2016/06/30/the-public-health-implications-....

3. Raymond EG et al., First-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review, Contraception, 2013, 87(1):26–37.

4. Schaff EA, Mifepristone: ten years later, Contraception, 2010, 81(1):1–7.

5. Boonstra HD, Medication abortion restrictions burden women and providers—and threaten U.S. trend toward very early abortion, Guttmacher Policy Review, 2013, 16(1):18−23, https://www.guttmacher.org/gpr/2013/03/medication-abortion-restrictions-....

6. Kvedar J, Joel-Coye M and Everett W, Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth, Health Affairs, 2014, 33(2):194–199.

7. American Medical Association, Council on Medical Service, Coverage of and Payment for Telemedicine, Report 7-A-14, 2014, http://www.modernhealthcare.com/assets/pdf/CH95086612.PDF.

8. Statement by Hal Lawrence on behalf of the American Congress of Obstetricians and Gynecologists, U.S. Senate Committee on the Judiciary, Hearing on S. 1696, The Women’s Health Protection Act, July 15, 2014, http://www.acog.org/-/media/Departments/Government-Relations-and-Outreach/20140715S1696Testimony.pdf.

9. Jones RK and Jerman J, Abortion incidence and service availability in the United States, 2014, Perspectives on Sexual and Reproductive Health, 2017, 49(1):17–27,https://www.guttmacher.org/journals/psrh/2017/01/abortion-incidence-and-....

10. Jones RK and Jerman J, Time to Appointment and Delays in Accessing Care Among U.S. Abortion Patients, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/delays-in-accessing-care-among-us-abor....

11. Boonstra HD and Nash E, A surge of state abortion restrictions puts providers—and the women they serve—in the crosshairs, Guttmacher Policy Review, 2014, 17(1):9–15, https://www.guttmacher.org/gpr/2014/03/surge-state-abortion-restrictions-puts-providers-and-women-they-serve-crosshairs.

12. Grossman D et al., Effectiveness and acceptability of medical abortion provided through telemedicine, Obstetrics and Gynecology, 2011, 118(2 Pt 1):296–303.

13. Delgado G and Davenport ML, Progesterone use to reverse the effects of mifepristone, Annals of Pharmacotherapy, 2012, 46(12):e46.

14. Grossman D et al., Continuing pregnancy after mifepristone and "reversal" of first-trimester medical abortion: a systematic review, Contraception, 2015, 92(3):206–211.

15. ACOG and ACOG Arizona Section, Medication abortion reversal, 2015, http://www.acog.org/~/media/departments/state%20legislative%20activities....