The Other Pill

Amid the siege of Planned Parenthood, mifepristone is more important than ever.

Unlike a surgical abortion, a medical abortion doesn’t involve anesthesia or require the supervision of a doctor to be safe. 

Photo illustration by Lisa Larson-Walker. Photo by Susie Cushner/Getty Images.

In the present political climate—in which the House votes to defund Planned Parenthood and some elected representatives would choose a government shutdown over continuing to fund the women’s health care provider—simply maintaining the status quo of reproductive choices might feel like a victory. In that spirit, let’s mark the 15th anniversary of mifepristone, also known as the abortion pill: It has been available in the U.S. for a decade and a half as of next Monday, and no one has managed to take it away yet.

A medical abortion actually involves a set of two pills, to be taken within about 48 hours of each other. The first pill, mifepristone (brand name Mifeprex), blocks the hormones necessary for pregnancy. The second, misoprostol, induces contractions. Together, they trigger what looks and feels like a heavy period. This kind of abortion is generally deemed appropriate within the first nine weeks of a pregnancy. Unlike a surgical abortion, it doesn’t involve anesthesia or require the supervision of a doctor to be safe. And it doesn’t need to take place in a hospital or a licensed surgical center.

That last fact is important because, in the past five years, GOP-held state legislatures have passed hundreds of restrictions to block women from getting abortions. The most damaging have been the laws that force abortion clinics to meet the requirements for “ambulatory surgical centers”—a set of expensive-to-follow rules that have nothing to do with the safe provision of abortion and have contributed to the closure of roughly 1 in 10 abortion clinics nationwide. For many women, physically reaching an abortion clinic has become a near-impossible challenge.

With the distances between abortion clinics growing, mifepristone offers a way to fill in the gaps. The World Health Organization has been arguing since 2003 that midlevel providers, such as midwives and nurse practitioners, should be able to administer it. This could be game-changing in places such as Mississippi, where the sole clinic flies its two doctors in from out of state. The Planned Parenthood affiliate in Iowa found another way to collapse the state’s wide-open spaces: telemedicine conferences, in which a patient video-chats with a physician, who prescribes her the pills and watches her take the first dose. More than 7,200 women have used the program since it began in 2008. A team of researchers who studied it found no difference in outcomes for women who didn’t see their doctors in person. Statewide, a woman who lived more than 50 miles from the nearest surgical clinic became more likely to get an abortion, and the number of later-term abortions decreased.

Unfortunately, just as women’s health advocates have gotten creative about the possibilities of mifepristone, anti-abortion forces have likewise gotten creative about restricting its use. Lately, state legislators have fixated on forcing doctors to prescribe the pill according to the Food and Drug Administration’s original and now severely outdated guidelines, which require a dose of 600 milligrams, even though physicians now consider 200 milligrams the ideal amount. As the New York Times reported in 2013, “The 200-milligram regimen is so widely accepted that the 600-milligram dose is now considered bad medicine, and many doctors would refuse the procedure entirely rather than follow the old guideline.”

It’s common for doctors to employ their own judgment—an entirely legal practice known as “off-label use”—instead of waiting for the FDA to revise its guidance, which can take decades if it happens at all. What’s strange in the context of medicine, but all too common in the context of abortion, is having politicians weigh in on what physicians can do. Currently, North Dakota, Ohio, and Texas require the FDA protocol, and Arkansas has a similar law scheduled to go into effect in 2016. That’s not the only strategy that has cropped up to limit the use of mifepristone. Eighteen states have pre-emptively banned telemedicine abortion, even though only one besides Iowa—Minnesota—uses it. Only 12 states currently allow midwives and nurses to dispense the pill.

Unsurprisingly, the GOP has seen Iowa’s pioneering program as a particularly appealing target. Shortly after the researchers published their findings that telemedicine abortion was healthy and safe, the Iowa Board of Medicine banned it. The ban was purportedly “to protect the health and safety of Iowans.” Luckily, that logic didn’t hold up in court. This June, the state Supreme Court sided with Planned Parenthood and upheld the use of both modern technology and rational thinking as they pertain to women’s health in at least one of our 50 states. It may be a small victory, but it’s still something.