In April of this year, when some of Minnesota’s already few abortion clinics started to close because of the pandemic, a new organization popped up with a novel idea: It would bring abortion services to Minnesotans using a mobile clinic. Called Just The Pill, its goal was to connect the state’s most rural corners with medication abortion care, a two-pill regimen that can end a pregnancy.
In the past, it’s been hard for sexual health groups to get medication abortion to people in remote areas. The Food and Drug Administration restricts one of the medications, mifepristone, in several ways. Patients must take the pill at a clinic, for example. On top of that, states have their own rules that can further encumber access. However, the medical data overwhelmingly shows the abortion pill is safe, even to take at home alone. Health experts say politics—not data—are informing these rules.
According to a 2017 report from the Guttmacher Institute, 97% of counties in Minnesota have no access to an abortion clinic. Dr. Julie Amaon, medical director for Just The Pill, says some clinics closed during the pandemic, making it harder for women to get to care. Her organization got to work setting up a roving clinic that could meet women where they were.
As they were figuring out the details of their new clinic, something unexpected happened. In July, a federal judge granted an injunction on the in-person requirement for mifepristone because of the pandemic. This opened the door for a new way of delivering abortion care.
Sexual health organizations rushed to set up their own digital abortion programs. Just The Pill began offering medication abortion last week via telemedicine. Other organizations that are starting to provide digital abortions include Hey Jane—a name that evokes the Jane Collective, an underground abortion group that operated during the early 1970s in Chicago—and a digital sexual reproductive health organization called Choix.
COVID—as scary and horrible as it’s been—really opened up the door for that.”
“Pre-COVID, this was something we were hoping to find an avenue to be able to provide, and then COVID—as scary and horrible as it’s been—really opened up the door for that,” says Lauren Dubey, a nurse practitioner and cofounder of Choix. The organization started out last year, prescribing birth control and treating urinary tract infections as well as connecting patients with testing for certain sexually transmitted diseases. When the July court ruling removed the restrictions on medication abortion, the organization decided to start preparing to send medication abortion through the mail. It opened its medication abortion program at the end of September.
But they may be working on limited time.
The Trump administration appealed the July ruling to the Supreme Court, and many in the industry expected a ruling to come in September. But in a twist of irony, Justice Ruth Bader Ginsberg, a staunch supporter of women’s reproductive rights, passed away. Her seat is expected to be filled by Amy Coney Barrett, a conservative judge who worked under Justice Antonin Scalia. If she is confirmed, it would give the court an overwhelmingly conservative slant. Still, it is unclear whether the court would necessarily reinstate the restrictions on mifepristone given the circumstances of the pandemic.
The July ruling protects Just The Pill and Choix services until the Supreme Court weighs in on whether it’s legal to ease the restrictions on mifepristone given the circumstances. Just The Pill’s Amaon says she doesn’t see why digital access to abortion medication should be rolled back at all.
“We have 20 years of safety data,” says Amaon. “Why can’t we keep doing this?”
The data don’t lie
This week marks the 20th anniversary of mifepristone in the United States. The drug is guarded by a set of Food and Drug Administration rules called Risk Evaluation and Mitigation Strategies, which are designed to manage treatments with high-risk effects. Manufacturers must certify physicians who prescribe mifepristone, a progesterone blocker. They also have to stock the medicine on premises, rather than sending out a prescription to a pharmacy as they would for any other drug. But mifepristone is unlike any of the other 59 medications with REMS in that it has an incredible amount of data behind it showing that it’s safe—even to take at home.
In 2020, there is more data than ever that shows the drug is not only safe and effective but safe and effective even when received at home. The Food and Drug Administration has extensive information on mifepristone. In 2019, the FDA released a report that listed all the health outcomes for women who took mifepristone between 2000 and the end of 2018. Of the 3.7 million women who took the drug, only 24 died. Eleven of those deaths appear to be unrelated to abortion and less than 1% of women experienced a serious adverse event. Additionally, the list of potential concerns surrounding the drug is exceedingly short.
“We prescribe Viagra to men, [where] the list of considerations and contraindications and things you have to be concerned about is three pages long, whereas our section on absolute contraindications and safety about medication abortion is [seven] bullet points,” says Dubey. “It is really so safe.”
We prescribe Viagra to men, [where] the list of . . . things you have to be concerned about is three pages long.”
In addition to this data, the FDA has been overseeing a telehealth abortion program and study called TelAbortion for the last four years. The program, which makes getting an abortion within the first trimester of pregnancy an entirely online affair, is run by an organization called Gynuity. Since launching four years ago, it has expanded to 13 states and the District of Columbia and has connected some 1,300 women with abortion medication. Erica Chong, director at Gynuity, says that there is no indication that getting mifepristone through the mail is adding any kind of health complications. If anything, it’s brought benefits.
The program has successfully connected people who don’t live near an approved clinic or have additional circumstances that might prevent them from getting to a clinic with abortion services during normal business hours. Along with allowing a person to take the medication in the privacy of their own home, TelAbortion may also be a little cheaper. When ultrasounds, which are required to prescribe medication abortion, are given as part of the abortion procedure, insurers sometimes will not cover it. Chong says that the TelAbortion process divorces the medical examination from the doctor consultation, so that a patient can get their examination covered by insurance as a regular health screening. Patients who have insurers that don’t cover abortion services only have to pay the cost of the virtual visit and the medication itself, which runs anywhere from $200 to $750, Chong says.
Despite what seems like an overwhelming data set confirming mifepristone’s safety and efficacy, the FDA has not repealed its restrictions on the drug.
Politics as usual
The rules surrounding medication abortion are almost certainly the product of political machinations rather than scientific data. It is part of the general uphill battle abortion has faced in the United States. Following the Supreme Court’s 1973 decision in Roe v. Wade, President Ronald Reagan introduced several restrictions to dull the ruling’s usefulness. He banned clinics receiving federal money from referring patients to abortion services; backed legislation that would prevent federal dollars from going to abortion services; and appointed federal officials who hid abortion research that found there were no negative emotional impacts on women who terminated their pregnancies.
When medication abortion came on the scene in the late 1980s, Reagan’s successor, President George H.W. Bush, dutifully banned doctors from importing it from France, where it was legal. But his successor, Bill Clinton, sought to change that.
Almost immediately upon being elected in 1993, Clinton rolled back many of the restrictions put into place over the preceding 12 years. However, it wasn’t until Clinton’s final term in office that the FDA finally approved mifepristone, one of the two pills used to terminate a pregnancy. Though it did get approved, it was beset by the restrictions that have remained to this day.
These restrictions have real effects. In 2016, there were 623,471 abortions reported to the Centers for Disease Control and Prevention from 47 states and New York City. Of all the people who qualified for a medical abortion, only 41.9% opted for this method.
“Despite the fact that it has this long track record of effectiveness, of safety, it’s still for better or worse not as familiar to folks who would be eligible to use it,” says Destiny Lopez, codirector of All Above All, a nonprofit organization fighting various bans and restrictions on abortion across the country.
It’s not just the need to be physically present at the clinic that is keeping these figures low. The rules require doctors to scale several walls in order to get approved to provide medication abortion. They must be certified by one of the two pharmaceutical companies that make the drug. Family practice doctors, who could very well administer medication abortion, may not be able to obtain liability coverage for medication abortion. Malpractice insurance seems to cover abortion services for obstetricians and gynecologists, but not other doctors. The medication also must be doled out on premises, which means the practice has to stock mifepristone at their in-house pharmacy, and doctors and nurses at the practice must agree to sign off on their colleague providing medication abortion.
“There is a long history of violence against abortion providers in the United States, and there continues to be harassment of abortion providers and their families,” says Angel Foster, chair of Women’s Health Research Institute of Population Health at the University of Ottawa. “So there are real concerns among healthcare providers, who maybe don’t identify themselves as abortion providers but who would incorporate abortion care into their practices, that they will be targeted.”
In the event the Supreme Court reverses the July decision, Just The Pill has a backup plan.
Amaon says the organization will begin sending its mobile clinic around to host consultations with abortion seekers. A patient will enter the mobile clinic and videoconference with Amaon, who upon determining that medication abortion is safe for the patient, will give them the code to open a lockbox with the medication abortion inside. Amaon will then watch the patient take the pill inside the mobile clinic. While 18 states require the doctor to be physically present for the abortion consultation, Minnesota does not. The rule is that the patient must receive the medication abortion on-site at an abortion provider.
Another set of organizations are taking a different tack. Aid Access, SASS, and Plan C are three groups that aim to educate women on how to source medication abortion online and manage the process themselves—effectively promoting modern-day DIY abortions. This has certain advantages: Not only is the course of medication safe, but it’s unlikely women would face legal repercussions for self-managing their own abortion so long as they do so within the first trimester. While some states do have feticide laws, medication abortion works like a miscarriage. Even if a person were to have severe bleeding or other adverse effects from the medication and need to go to the hospital, doctors are unlikely to be able to distinguish a medically induced miscarriage from a natural one. In an article for Ms. Magazine, experts said that such prosecutions often arise when law enforcement finds a fetus that someone attempted to get rid of.
In some states, abortion may increasingly become a homespun activity with no medical oversight.
Self-sourced abortions may be the way of the future. An increasingly conservative Supreme Court has raised concerns that Roe v. Wade may be overturned, meaning that not only does medication abortion face challenges, but women may lose the legal precedent that gives them a right to an abortion altogether. While such a decision may open the floodgates for states to constrain abortion services, abortion seekers could still find mifepristone for sale online.
Politicians such as Senator Ted Cruz have called for the medication to be taken off the market in the U.S. But as Kirsten Moore, director of the Expanding Medication Abortion Access Project, points out, it would be extremely unlikely for the FDA to do that.
“Given the fact that there is not an issue—there is not a safety question or concern—having the pill removed from the market would be an egregious violation of how FDA regulates the marketing and distribution of drugs in the U.S.,” she says.
What that means is that in some states abortion may increasingly become a homespun activity with no medical oversight. In an environment with tough laws on abortion and feticide, the online availability of mifepristone represents a precarious choice. Women may be too afraid of legal repercussions to seek out care online. Alternatively, if a woman does experience some sort of complication after taking the medication, she might be too scared to seek out medical help. While hazards such as these have not always deterred women from getting an abortion, even under perilous circumstances, pro-choice organizations are hoping to counter that fear with information.
“Yes, we need more providers to provide it,” says Lopez of All Above All. “But the work that groups like mine are doing is really to educate folks of reproductive age that this is a method that exists and that can and should be available to them.”