DIGEST January 2023

Abortion pills in every medicine cabinet, now

A beautiful feminist New Year to all! May 2023 bring you joy, health, justice, freedom and happiness. And may 2023 also bring abortion pills to your medicine cabinet.

I don’t mean this as a flippant comment. To guarantee abortion rights, the goal should in fact be that every household has packs of abortion pills on hand, before they are needed, to address unwanted pregnancy as it occurs and without obstacles, delays and costs. This would reduce the need for abortion clinics altogether, and put quacks out of business. Abortion pills in every medicine cabinet is really what we need to stop the harm to women, girls and all persons capable of pregnancy that abortion restrictions and prohibitions continue to inflict on them around the world.

What exactly would be in that cabinet? There are two main regimens possible to induce abortion. The first regimen involves mifepristone used in combination with misoprostol. Mifepristone blocks the hormone progesterone, which is essential for pregnancy, while misoprostol provokes uterine contractions. The other option, which works almost as well, is misoprostol alone. Both regimens are very safe (safer than Tylenol or Viagra) and easy to use, and their efficacy is high, especially (but not only) in the earlier stages of pregnancy.

Mifepristone and misoprostol in bottles. They are also sold together in a combination blister pack.
Misoprostol tablets. Some brands have a characteristic hexagonal shape.

In many countries, abortion pills are in fact available over the counter or by mail or courier. In my experience, that’s as true in Nigeria as it is in Mexico, Ethiopia or India. The pills are easy to find, generally of good quality and relatively cheap. The reasons they are not used more often include: a lack of information, a lack of privacy and the continued stigma of abortion, which makes it hard for young women to walk up to a pharmacy or order them for delivery at home. But what if they became as ubiquitous as condoms? On my last trip to Nigeria a few years ago, a doctor at a maternal and reproductive health clinic handed me a pack of 12 misoprostol pills with instructions, as an example of the medication they readily kept on hand, and asked me if I wanted more. Why not indeed?

In the US, pills are now used in 54% of abortions, and that proportion is likely to grow given their ease of use and the many closures of independent abortion clinics. But rapidly escalating abortion prohibitions combined with persistent overregulation have made the picture for abortion pills needlessly complex, creating confusion and hardship.

In the 14 states that have criminalized abortion entirely or at 6 weeks (Georgia), with more likely to follow as court battles evolve, health providers have stopped prescribing pills. Several of these states explicitly ban abortion pills from being sold in-state. That’s where telehealth and mail-order pharmacies operating from US states that protect the right to abortion come into play. The fabulous website Plan C offers detailed information and a range of safe options for people located in states where abortion is banned, as well as for those who live in states where access is guaranteed. One of these options is Aid Access, a group founded by the Dutch physician Rebecca Gomperts and located in Austria, which mails abortion pills to any address in the US in 1–3 weeks at a cost of between $105 and $150.

The brave and indefatigable Rebecca Gomperts, Dutch physician and founder of Women on Web and Aid Access

Very helpfully, the Office of Legal Counsel of the US Justice Department has just issued a ruling stating that, under US law, the US Post Office can deliver abortion pills to any address in the US, including in states that have banned abortion. Prohibition states such as Texas had claimed that mailing abortion pills to their state violated the Comstock Act, a provision originally adopted by Congress in 1873 to restrict the mailing of “obscene literature and articles of immoral use.” In 1873, this included the mailing of contraceptive and abortive products; the abortion provisions have remained on the books since, even after Roe (another example of Congress not acting on abortion when it had the chance). The Justice Department concluded that in every state, despite restrictive laws, there remain legal uses of mifepristone and misoprostol, including to treat miscarriage. Moreover, the Justice Department noted that pregnant persons are, so far, not the target of restrictive abortion laws (the laws penalize health personnel and other persons helping out), so shipping to them doesn't violate abortion laws. It is therefore impossible to conclude that the Post Office knowingly carries material that is going to be used unlawfully when it delivers abortion pills.

(A parenthesis to note that, in response to these developments, Alabama has just announced its intention to use a 2006 state "chemical endangerment law" to criminalize pregnant persons who use abortion pills. Since 2006, that law has been used to arrest and prosecute over a thousand Alabaman women who used drugs during pregnancy, and has targeted - oh surprise! - poor, Black and brown women. So it's important to assess your risk as you proceed.)

Aid Access has promoted “advance provision,” which allows you to request abortion pills even if you are not currently pregnant. Go to https://aidaccess.org/en/i-need-an-abortion and get your very own. They respond within minutes and ship to all 50 states, with doctors from Europe prescribing for those based in prohibitionist states. Women on Web, another Gomperts-founded organization based in Canada, ships abortion pills for immediate or future use to another 120 countries.

Other recent developments at the federal level are helpful. You might have read that the Food and Drug Administration (FDA) now allows mifepristone pills to be sold in pharmacies like any other drug. Mifepristone has been around for decades (it was developed in 1980 by French scientists, under the name RU-486). Extensive research has shown it to be extremely safe. But from the time the FDA approved it for use in the US in 2000, mifepristone has been subject to substantial and unusual restrictions. Since 2007, those restrictions have come under an FDA drug safety program known as REMS (Risk Evaluation and Mitigation Strategies). As a result, mifepristone has been only available in the offices of doctors or clinics certified to dispense it or in hospitals. That’s right: pregnant persons had to come in person to pick up mifepristone, with all the time, costs and hassle that this entailed.

Why wasn’t this drug allowed to be sold in neighborhood American pharmacies until now? The politics of abortion! There is no other reason. REMS are “require[d] for certain medications with serious safety concerns to help ensure the benefits of the medication outweigh its risks.” Drugs such as fentanyl and other opioids, antipsychotics and thalidomide are on the FDA list—62 drugs out of the approximately 19,000 FDA approved medications for sale in the US!

What is mifepristone doing on that list? Dr. Beverly Winikoff, the President of Gynuity Health Projects who also worked on the approval of mifepristone at the time, noted in a recent interview: “I think there was just a heightened fear about the credibility of the agency, about their own jobs as professionals, about being pilloried in the press,” she said of how the FDA handled the review process. “It was astounding to me that the regulatory mechanisms were so divorced from women’s lives.”

In their recent research on whether pharmacies could dispense mifepristone safely, Grossman et al. noted that “ … there is no evidence that in-person dispensing improves safety, and medications associated with more risks to the patient do not have similar restrictions. Twenty years later, such evidence is still lacking and countries such as Australia and Canada have approved mifepristone without dispensing restrictions.” In a 2020 Practice Bulletin, the American College of Obstetricians and Gynecologists stated: “However, the restrictions for mifepristone do not make the care safer, are not based on medical evidence or need, and create barriers to clinician and patient access to medication abortion. The American College of Obstetricians and Gynecologists advocates the removal of REMS restrictions for mifepristone.”

Politics and religious right-wing pressure, not science. The COVID-19 pandemic helped loosen things up, with the FDA allowing a pregnant person to have a consultation online with those specially certified doctors and for the pills to be sent to the patient directly by a mail-order service. When that worked remarkably well (as would have been expected!), it became harder for the FDA to return to the previous rules.

Still, because of politics, the FDA just couldn’t let go like that. Mifepristone is still subject to REMS. While the FDA no longer requires an in-person trip, it maintains special certification for doctors and will now require pharmacies to go through a special registration process to dispense the drug. The new FDA requirements do nothing for pregnant persons, except for the last one:

Frustrating. Thankfully, this doesn’t seem to have deterred large pharmacy chains. CVS and Walgreens have both announced they will seek certification for mifepristone. Let's hope they stay the course.

By the way, allow me to rant a tiny bit more, about the foot dragging of the FDA on the gestational age until which abortion pills are effective. The FDA has approved them for use until 70 days of pregnancy, or 10 weeks. That’s a short period of time. Why hasn’t the FDA aligned its time frame to those of the World Health Organization, which recognizes that abortion pills can be used effectively until 12 weeks of pregnancy? Or aligned it to the evidence published by international researchers, which shows that women around the world have used abortion pills (either regimen) to safely terminate pregnancies until 22 weeks of gestation? Dare I use the P word again? Thankfully, US doctors have at least begun to recognize that 12–13 weeks is absolutely fine and are prescribing mifepristone abortion pills for use off-label, given the volume of evidence for efficacy and safety.

Of course, doctors are always free to prescribe the other abortion regimen—misoprostol alone—, and more should do so. Around the world, misoprostol is easy to get over the counter since it is commonly sold to deal with gastric ulcers, its original intended use. For a long time, there was concern that misoprostol alone was not as effective as the mifepristone and misoprostol combination and might leave women with incomplete abortions, but that has now been put to rest. Ample evidence also shows that pregnant persons can easily use misoprostol on their own, or with community accompaniment or counselling via a hotline. Self-use of misoprostol for abortion was a longstanding project of my former organization, the International Women’s Health Coalition. Its simple fact sheet on Self-Managed Abortion with Misoprostol, updated in 2020 with the latest evidence, now resides on the website of the Asia Safe Abortion Partnership (ASAP) at https://asap-asia.org/information-booklets/. Download it and keep it on hand.

So, it’s time to stock up your medicine cabinets and take matters into your own hands. Liberate abortion pills! And if you use Aid Access or another abortion pill service, please write to me to tell me how it went.

In feminist liberation and solidarity,