Newsletter April 2025
Is it abortion? Is it contraception? Does it matter?
Two studies stopped me in my tracks at the beginning of this year.
In one study in Europe, research showed that a weekly dose of the abortion pill mifepristone can be used as a contraceptive. A few weeks later, a different study carried out in Mexico demonstrated that ulipristal acetate, an emergency contraceptive, can be used to terminate pregnancy. Both studies reminded me that the line between abortion and contraception isn’t perfectly clear—a paradoxical fact at a time when the far-right has been attacking modern contraceptive methods by equating them with abortion.
My first reaction was excitement, because more methods to address unwanted pregnancy are a good thing. Yes to more options! But it also caused me to worry, precisely because of these right-wing tactics. I'm thinking particularly of the activists who have fought to ensure access to emergency contraception (“EC,” the pills that one takes within a short period of time after unprotected intercourse to prevent pregnancy), and who have strenuously argued that EC pills aren't abortion pills. Now what?!
Let's start with the excitement. For starters, mifepristone, the abortion pill, isn’t a hormonal method like traditional birth control pills, which contain estrogen and/or progestin. “This method does not have the contraindications or side effects associated with the estrogens and progestins in hormonal contraceptives, such as weight gain, loss of libido or feelings of depression,” said Rebecca Gomperts in an interview in Ms. Magazine. Gomperts is the Dutch physician who commissioned the research and the visionary founder of Aid Access, an international online abortion pill provider. “It also does not have the increased risk of breast cancer and thrombosis with use of hormonal contraceptives.” Here I must note that those cancer risks have been hyped by far-right opponents of modern contraception, are in fact very low in the now common low-dose pills, and certainly vastly lower than the risks associated with pregnancy and delivery. But they are not nil. Being able to choose another, non-hormonal contraceptive method is therefore a good thing.
Moreover, the contraceptive dose of 50mg of mifepristone only needs to be taken weekly, while hormonal contraceptive pills need to be taken daily. Mifepristone is also more forgiving if one forgets to take it: “If you forget mifepristone one day and you use it the next day or the day after, it will still work. The function still is there and it takes a little bit of time to wear off,” added Gomperts. And given that it can also be taken as an emergency contraceptive, mifepristone can be used irregularly for those who only have sex infrequently. “It would allow us to move flexibly between the medicine’s different indications as a weekly contraceptive, as an on-demand method used before or after sexual intercourse, or as an early medical abortion method, depending on life circumstances,” noted Gomperts.
A very flexible, effective drug to address many dimensions of unwanted pregnancy. Fantastic!
The other study that caught my eye was conducted by Gynuity Health Projects together with the National Autonomous University of Mexico (UNAM) and the Mexico City Health Secretariat. In a “proof-of-concept” study with 133 pregnant women, 60mg of ulipristal acetate, the emergency contraceptive sold in the U.S. in 30mg doses under the brand name Ella, was shown to terminate pregnancy very safely and effectively when combined with misoprostol.
By the way, Ella is also an excellent emergency contraceptive: it is twice as effective as Plan B (a levonorgestrel-based hormonal emergency contraceptive) in preventing pregnancy after unprotected intercourse, and its effectiveness remains constant for at least 120 hours. Plan B becomes ineffective after 72 hours, with its effectiveness diminishing even within that 72-hour window. Ella is also more effective for persons with higher body mass.
This finding is exciting because ulipristal can be obtained in the U.S. at any pharmacy with a simple prescription. It isn’t subject to the same protocols for distribution as mifepristone, which is still under U.S. Food and Drug Administration (FDA) restrictions known as REMS (Risk Evaluation and Mitigation Strategy) that are applied to about 70 drugs (drugs like fentanyl and thalidomide) out of the 20,000 on the US market. Although the most severe of these restrictions (requiring pregnant persons to go in person to a doctor’s office or hospital to pick up mifepristone) were loosened by the FDA after 2016, and mailing of mife and prescription by nurses are now allowed, the REMS hasn't been officially lifted, and an ongoing court case in Texas could reinstate the pre-2016 limitations. Of course, ulipristal might ultimately also be attacked by antiabortion forces, but for the moment, it's just a regular drug.
And let’s remember that the U.S. isn’t the only place where more options are needed. Yep, not everything revolves around the U.S…! As noted by Dr Daniel Grossman in a recent commentary in the New England Journal of Medicine, “ulipristal acetate is registered for emergency contraception in more than 74 countries, and in some of these countries, mifepristone is not yet registered. Even if both drugs are registered, ulipristal may be more accessible or less costly—especially since it is available over the counter in some countries.”
Dr. Beverly Winikoff, the lead author of the ulipristal paper, president of Gynuity and one of the researchers behind the registration of mifepristone in the U.S., explained that this was for her a leading motivation for this research: “A major problem hindering use of medication abortion is availability. Increasing the number of methods and arsenal of options could have bold and transformative implications for potential users everywhere.”
Again, more choices and fewer obstacles. Yes to that!
For the pharma geeks amongst you, both mifepristone and ulipristal acetate are what scientists call “progesterone receptor modulators,” that is, drugs that are very effective at blocking the hormone progesterone that is necessary to begin or sustain pregnancy. Both affect the uterine endometrium, which must be “fluffy” for a fertilized ovum to implant and grow. Ulipristal acetate and mifepristone molecules are so similar that researchers had suspected for years that ulipristal could be used to induce abortion and that mifepristone could work as a contraceptive. Now we know, although scientific rigor will require randomized clinical trials where uli+miso are compared directly to mife+miso or misoprostol alone in terms of safety and efficacy.
But about those boundaries between contraception and abortion...
One of the peculiarities of the field of reproductive health—one that struck me as odd when I first entered it in the 1990s— is the bright line between abortion and contraception. In many settings in the U.S. and beyond, health personnel will provide all reproductive health services, except abortion. Abortion services are often offered in stand-alone clinics. Laws allow healthcare workers (and sometimes entire hospitals) to preemptively refuse to provide abortions. The annual International Conference on Family Planning actually discouraged discussion of abortion until a few years ago, and while abortion is now included in its guidelines for scientific abstracts, it is only mentioned once in a list of 14 topics. International agreements, such as the Programme of Action of the 1994 International Conference on Population and Development, as well as US law, specify that “in no case should abortion be promoted as a method of family planning.” (What else is it, though, if not a method to plan how many children, if any, one will have?) And of course, in still too many places, abortion was or is completely or severely criminalized.
Interestingly, this divide didn’t (and still doesn’t, in most cases) exist in communist or socialist countries and their successors, such as the Soviet Union, China, Cuba or India, where abortion was legalized and widely practiced in the 20th century. In fact, because modern contraceptives were not usually available or affordable, abortion was the main method of family planning. But where the Catholic Church or the United States (via development assistance) had outsize influence, notably in Latin America and on the African continent, this divide took hold. A divide steeped in Catholic and evangelical belief.
Some of this separation of services was well intentioned, although I think ultimately misguided: the idea being that, in order to protect access to contraception from religious, far-right attacks, the field had to distance itself from abortion. Historian Linda Gordon, in her fascinating 1976 book on birth control, Women’s Body Woman’s Right, Birth Control in America described this process as it played out in the U.S.: ”Historically the legitimacy of contraception was won in part at the cost of the delegitimation of abortion: the campaign for the legalization of contraception in the early twentieth century had for the first time placed it and abortion in different moral categories. Throughout this process, many birth control experts and advocates contrasted “bad” abortion to “good” contraception, and some predicted that advances in contraception would reduce or even eliminate the need for abortion.”
It’s now become crystal clear (if it wasn’t already!) that Catholic/Christian extremists also want to ban contraception (and IVF and stem cell research...) and will attack it any way they can, notably by making it less accessible and affordable. Their ultimate goal is to control women’s bodies and fertility in order to return society to the “natural [traditional, theocratic] order,” including by urging women to marry (a man, needless to say) and have many children, and by preventing and punishing premarital sex and sex outside marriage.
In the mid-19th century, when legislators in the U.S. and Europe became deeply concerned about controlling morality, fertility and sexuality, they in fact criminalized contraception as well as abortion. There was no difference in their minds given their ultimate goal. When Margaret Sanger was jailed in New York in 1911, it was for providing women with information and cervical caps for preventing pregnancy. The 1873 Comstock Act in the U.S. banned the mailing of contraceptives, abortifacients and for good measure, “obscene matters” of any kind. While the provision against mailing contraceptives was rescinded by Congress in 1971, the bans against mailing any drug or article that can produce abortion remain on the books, even if not currently enforced. If the right-wing has its way, Comstock could once again be deployed to ban the mailing of abortion pills and equipment, as well as contraceptive pills and IUDs.
As an aside, it's amazing to realize how sticky restrictions on contraception can be. Incredibly, France banned tubal ligation and vasectomy until 2001 (!), and even now, adult patients are subjected to a four-month “cooling-off period” before they can access the procedure. The pro-natalist “natural order” persists, at least in the minds of Catholic doctors and lawmakers.
Another problem with this distancing strategy is that, in fact, a not insignificant number of pregnancies occur despite use of modern contraceptives. About 7% of U.S. women who use contraceptive pills, which are considered very effective, become pregnant after a year of typical use (rather than so-called perfect use). So even if we managed to protect contraception from far-right attacks, we’d still have plenty of unwanted pregnancy and need abortion services.
Given all of this, Gynuity was fully aware that advocates for emergency contraception (EC) would be worried by the publication of the ulipristal study. While this only concerns Ella and not the over-the-counter Plan B, which as a levonorgestrel-based hormonal method cannot provoke abortion, the facts have never stopped the far-right from attacking any and all contraceptives. Still, we should be able to appreciate this difficulty while also recognizing that the evidence about ulipristal was going to come out sooner or later. For example, a Washington Post article published back in 2010 already indicated that the anti-abortion movement was fully aware of Ella’s potential as an abortion pill.
And that’s the rub: reproductive health advocates and researchers have known for a long time that there isn’t, in fact, such a clear line between abortion and contraception, and between preventing and ending pregnancy. The World Health Organization defines pregnancy as a fertilized ovum implanted in the lining of the uterus. But we don’t know EXACTLY when either fertilization or implantation takes place in a womb, because we don’t have any ways of looking in (those videos of sperm swarming an ovum were taken in a petri dish). It happens over an uncertain period, with a fertilized ovum taking possibly 5 or 6 days to come down from the Fallopian tube into the uterus. At some point, implantation happens and pregnancy begins—usually at what is considered 4 weeks of pregnancy (but might in fact be less).
In today’s context, it’s also easy to forget that, in Europe and the U.S., until the early 19th century, pregnancy was only considered established when the first movements of the fetus (“quickening”) could first be perceived by the pregnant woman, at about 16-20 weeks. That’s pretty late in pregnancy, if you think about it. Linda Gordon wrote that “We must keep in mind that many nineteenth-century women and almost all women before that did not believe that abortion was a sin. Before the nineteenth century there were no laws against abortion done in the first few months of pregnancy. Until then the Protestant churches had gone along with the Catholic tradition that before ‘quickening,’ abortion was permissible.” To be precise, the Church only issued their formal anti-abortion position in 1869.
The religious far-right has used that blurry line to their advantage by claiming to see abortion everywhere they look. One of their main tactics to reduce access to contraception is therefore to equate many modern contraceptive methods—beyond ulipristal— with abortion, based on that relatively recent Catholic dogma that a fertilized ovum is a human life even before it is implanted in the lining of the uterus. The Washington Post reported the following attacks on contraception over JUST a few weeks in 2024: “Republican lawmakers in Missouri blocked a bill to widen access to birth-control pills by falsely claiming they induce abortions. An antiabortion group in Louisiana killed legislation to enshrine a right to birth control by inaccurately equating emergency contraception with abortion drugs. An Idaho think tank focused on ‘biblical activism’ is pushing state legislators to ban access to emergency contraception and intrauterine devices (IUDs) by mislabeling them as ‘abortifacients.’” Anything that could possibly prevent implantation of said ovum is therefore considered “abortifacient” by these religious extremists.
Needless to say, antiabortionists have presented no serious scientific evidence (unlike the bogus studies they regularly churn out) to back up their claims, both because their views are based in religious belief about when life begins, and because it’s been hard to determine whether a given method prevents fertilization or implantation.
The far-right have also been astute in seizing on relatively recent technological advances—such as easily available pregnancy tests and fetal imaging—to bolster their arguments. Think about it: before pregnancy tests were easy to come by (and where they remain unavailable), proof of early pregnancy wasn’t (and isn’t) obvious. A missed period, nausea, sore breasts or weight gain can indicate pregnancy—or not. Hence the focus on much later "quickening."
Over the centuries, women everywhere have relied on that ambiguity to “bring about a missed period” by various treatments, often the very same used for abortion or contraception. In the 1970s, for example, community groups in Bangladesh began to promote the use of “menstrual regulation” via manual vacuum aspiration whenever a period was missed (vacuum aspiration is a common abortion method). Although abortion was and remains criminalized in Bangladesh, what women did couldn’t be called abortion, since they didn’t know whether they were pregnant, just that their period hadn’t come. I first heard about menstrual regulation in the 1990s, when my boss at the International Women’s Health Coalition, Adrienne Germain, who had worked with the Ford Foundation in Bangladesh in the early 1980s, described the approach. It was ingenuous, a testament to women’s resourcefulness. Menstrual regulation was legalized by the government of Bangladesh in 1979, and has contributed to a steep decline in the country's birth rate and maternal mortality rate.
In a recent article in Ms. Magazine, public health expert Naomi Michelson argued for reviving menstrual regulation in the U.S.: ”Today, mifepristone and misoprostol in the United States for the purpose of menstrual regulation are relatively accessible. Organizations such as Period Pills connect individuals with menstrual regulation providers, while the Period Pills Fund covers the cost of the medication for those who cannot afford it. The National Working Group on Period Pills has been advocating for the promotion of menstrual regulation in the United States since 2019. They’ve aptly compared the practice to taking emergency contraception after unprotected sex, or even anti-malarial pills after traveling to a malaria-endemic area. Study after study has proved that period pills are safe, effective, and can relieve the mental burden of unwanted or unplanned pregnancy.”
Some have expressed concern that menstrual regulation might reinforce abortion stigma (a kind of “don’t ask, don’t tell”), but I’m not sure about that. In a way, it circumvents the stigma by focusing on a person’s desire to restore their menstrual cycle. It does, in this sense, downplay the difference between pregnancy/no pregnancy. That’s what Professor Joanna Erdman of Dalhousie University in Canada thinks: “Abortion laws are premised on this idea that there’s an absolute categorical difference between terminating a pregnancy and preventing one. But the truth is that this line was never very clear because pregnancy isn’t this definitive moment.”
“This liminal space,” according to Michelson, “is a point of opportunity. For example, within this time frame, 10 to 20 percent of pregnancies end in miscarriage. So rather than draw a hard line between pregnant and not pregnant, perhaps we should embrace the ambiguity at the start of a pregnancy to provide people with options. If they don’t want to be pregnant, they can simply take medication to bring their period back.” I’m intrigued by this idea.
The far-right have also used pictures of fetuses, including via now ubiquitous fetal ultrasound imaging, to picture the “unborn child” earlier and earlier in pregnancy. The brilliant feminist Ros Petchesky saw the potential of these images back in 1987, when she published a famous essay entitled Fetal Images: The Power of Visual Culture in the Politics of Reproduction. Analyzing the fabricated 1984 antiabortion video “the Silent Scream” and the final image of the fetus-like cyborg floating over the Earth in the 1968 movie 2001: Space Odyssey, Petchesky underlined “the strategy of antiabortionists to make fetal personhood a self-fulfilling prophecy by making the fetus a public presence..."
The far-right understood the power of these images in a media saturated world, and they created more of them to promote the idea that “the fetus's identity as separate and autonomous from the mother (the ‘living, separate child’) exists from the start,” like “‘man' in space, floating free, attached only by the umbilical cord to the spaceship. But where is the mother in that metaphor? She has become empty space.” The gigantic posters of baby-like fetuses we’ve seen at “pro-life” marches are fiction, but they’ve occupied imaginations and packed a huge emotional punch. The fully formed “unborn child” now exists in many people’s minds, irrespective of its actual physical development. Moreover, wrote Petchesky, the promotion of the fetus-as-baby-astronaut, endowed with personhood, set the conditions for the demonization of the pregnant person as an outsider and a potential threat.
And to me, that points to the true issue at hand. Our concern shouldn’t really be whether we are preventing or terminating pregnancy, or whether the particular methods we use are what religious bodies and political actors object to or approve. Our concern should be to place women and other persons capable of pregnancy—without whom no fetus can develop—at the heart of reproductive health policy and practice, something that has never been truly the case. Our goal should be, to paraphrase the 1995 Beijing Platform for Action of the Fourth World Conference on Women, that all persons have the right to have control over and decide freely on matters related to their sexuality, fertility and reproduction, free of coercion, discrimination and violence, and have the information, education, the means and support to do so. We should assert that boldly and without hedging or apologizing.
That is, in the end, the true objective of contraception or abortion: freedom to control of one’s body, fertility and reproduction in any circumstance. Whatever works safely for people should be what is used, and the full range of options should be available to meet everyone’s needs. Whatever new technology is offered should be used to support that freedom, rather than to disempower and mislead. And in keeping with the understanding of reproductive justice developed by African-American feminist advocates at SisterSong in the 1990s, we should insist on not being forced to make these decisions outside a context of community and state support. Reproductive justice is the only sustainable response to far-right, religiously motivated attacks.
Now THAT is an exciting vision I can get behind.
In reproductive justice and solidarity,
FG