Othen the FDA mifepristone approved in late September 2000, supporters believed it would change abortion care in this country. Mifepristone causes abortion when used with another long-approved drug, misoprostol. (In the United States, this regimen is used for ten or eleven weeks of pregnancy.) “Medical abortion,” as this new modality was called, raised the possibility of a dramatic expansion of abortion provision in involving new categories of service providers. As a sociologist studying abortion, I wanted to document the spread of this new method. Shortly after FDA approval, I tried to find new providers who would start providing medical abortion care, but initially found very few. But on this 20th anniversary, mifepristone is finally bringing about major changes, due to COVID-19[feminine].
In the twelve long years between when the drug was first approved in France (1988) and in the United States, the anti-abortion movement has loudly campaigns against mifepristonespreading false information and threatening to boycott the global drug maker at the time, Hoechst SA, a German company. (In response to the controversy, Hoechst eventually stopped the production of the pill and gave up its patent rights.) At the same time, the violence of abortion extremists was increasing. The first one murder of a doctor who performed the abortion took place in 1993, followed a few years later by several other murders of people in the abortion community.
Tired of both this violence and the problems caused by a chronic shortage of abortion providers, the pro-choice movement has pinned its hopes on medical abortion care as a solution to both problems. This method held the promise of increasing the number of providers because it did not require the specialized medical training of other forms of abortion care. If many primary care physicians, for example, incorporated medical abortion care into their practices, abortion care could drift away from specialty clinics and protesters would not know why someone is entering a particular facility.
In retrospect, those hopes were inflated and naïve. Medically speaking, medical abortion care is quite simple. Socially, however, this method, like abortion care in general, is quite complicated. Potential new providers were surprised to learn that integrating medical abortion care into their mainstream practices meant that they would be subject to restrictions governing abortion in their states, such as parental consent, waiting and other rules. Likewise, those who launched this offer quickly realized that it was logistically impossible to alert patients to this new service while keeping it “secret” from the demonstrators.
This impossibility of confidentiality became clear when I interviewed a family physician in the rural Midwest who began providing medical abortion care to his patients. She was surprised when a patient came into her office and said, “Doctor, do you know they call you ‘Satan’s daughter’ on Christian radio? This doctor was not the only one I met whose decision to initiate medical abortion care became controversial and attracted unwanted attention from protesters, and in some cases, refusal of medical colleagues in their community.
An additional hurdle for new suppliers: The FDA took the unusual step of placing mifepristone in a program known as the Risk Assessment and Mitigation Strategies (REMS). This program was established to regulate drugs known to be very dangerous, such as thalidomide, which cause serious birth defects. But there was plenty of evidence from trials in the US and Europe of mifepristone security. Presumably, this step was taken in response to the drug controversy, not the science.
The REMS classification imposed heavy restrictions. Mifepristone could not be dispensed from a pharmacy, but had to be obtained from a clinic or doctor’s office. Physicians offering mifepristone had to register with the distributor, which no doubt raised apprehensions among potential adopters about having their names on a list of known abortion providers.
Gradually, however, the use of medical abortion expanded. According to the most recent data, approximately 40% of all abortions in the United States are by this method. Some 17 states enable advanced practice clinicians (nurse practitioners, midwives and medical assistants) to perform medical abortion, which has particularly benefited rural women. Simultaneously, however, beginning in 2000, red state lawmakers sought many ways to restrict this method. Seventeen states, for example, ban the use of telehealth for medical abortion, although this has been very successfulwhere permitted.
But, as no one could have predicted, medical abortion care really came into its own during the COVID-19 crisis. This method involves considerably less caregiver-patient interaction than other abortion methods. I have seen in recent interviews with providers that more and more patients are opting for this regimen. The clinic staff is growing new protocols minimize face-to-face interactions as much as possible, for example by doing preliminary counseling using telehealth and sending patients home with a pregnancy test, thus eliminating the need for a follow-up visit for s ensure a successful abortion.
But the REMS requirement still meant patients had to go to clinics to get the two diet pills, risking exposure to COVID-19. Leading medical organizations, including the American College of Obstetricians and Gynecologists (ACOG), have long maintained that the REMS were useless. Abortion providers have therefore been encouraged by the recent decision, in a lawsuit brought by ACOG, which temporarily overturned REMS due to the pandemic. (The Trump administration has appealed to the Supreme Court to reinstate this restriction, but the Court has yet to respond.) Currently, where state laws do not explicitly prohibit it, relevant drugs can be mailed to patients. Proponents hope that a paper trail of the safety of this measure will allow this policy to continue even after COVID-19 is under control.
When I started documenting medical abortion care, I didn’t think the promise of this method would take so long to realize. I wish it didn’t take a pandemic for the FDA to start easing restrictions, but I’m grateful that progress is being made now.
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