What overturning Roe means for medication abortion

The Supreme Court is poised to overturn its seminal 1973 decision Roe v. Wade — stripping Americans of a federally protected right to abortion. A draft of the opinion, leaked to Politico on Monday, would allow states to determine whether or not they want abortion to be legal, and to what extent.

While the states would be able to shut down clinics and medical professionals providing surgical abortion, the implications for medication abortion are far less clear.

In 2000, the FDA approved the use of mifepristone, also known as RU486 — in combination with misoprostol (a drug used for ulcers and to induce labor) to end a pregnancy. Today, it’s approved for use for up to 10 weeks into a pregnancy or 70 days after the last day of menstruation, though some doctors prescribe it “off label” beyond that. In 2020, the Guttmacher Institute, a nonprofit researching reproductive health found that over half of abortions in the United States are now medication abortions.

These abortion medications come with what’s called a REMS label: a set of guidelines providers have to agree to before they can provide the medication. This means instead of getting prescribed something by a doctor and going to a pharmacy to pick it up, the prescriber and provider of the medication are one and the same.

Those restrictions significantly reduce the number of people who offer it. For abortion medications, for example, one of the REMS conditions used to be that the first pill had to be taken in the provider’s office. During the pandemic, however, the FDA changed its rules for the drug: Doctors can now prescribe it via telehealth. As a result, online pharmacies like heyjane.co, justthepill.com, and Carafem.org are able to prescribe and mail abortion medications to people in certain states.

If and how they’ll be able to do that in the absence of federal protections enshrined by Roe, though, is still unclear.

Can people in states with abortion restrictions currently get medication abortion?

Kirsten Moore, Director of the EMAA Project, a nonprofit dedicated to expanding abortion access, tells Inverse some abortion restricted states have already placed restrictions on the abortion pill which go beyond the FDA safety guidelines.

While the REMS label is burdensome, she says, it also means the FDA has gone through the science many times and determined how the drug can be used safely.

“That FDA assessment should preclude states from being able to override and impose stupid state regulations,” she says. The fact that there's an FDA-approved drug for use up to 10 weeks and states are saying ‘no, you can only use it for six,’ makes no sense.”

Still, most states currently have some options for medication abortion because of Roe and Casey, the two Supreme Court Decisions that concretized abortion rights for decades.

What’s more, some states actually have laws that require providers to tell patients a medication abortion is reversible, despite lacking evidence to support that claim. Those states are Arkansas, Idaho, Kentucky, Nebraska, Oklahoma, South Dakota, and Utah. Similar laws were passed in Arizona and North Dakota but ultimately blocked by the courts.

Is medication abortion safe?

While the REMS label may give the impression abortion medications are dangerous, they really aren’t. A 2013 review of data for 45,000 women found that only .3 percent of women who took the medication ended up hospitalized. In contrast, acetaminophen, the active ingredient in Tylenol, is the most common cause of liver failure in the United States; in 2009, “unintentional acetaminophen-related adverse events” were responsible for 50.2 of 1000 emergency room visits for adverse drug events. Abortion medications are also 14 times safer than childbirth.

“Medication abortion is extremely safe,” Moore stresses. “It’s an FDA-approved drug that’s been approved for nearly 20 years.”

How does medication abortion work?

Pregnancies need a hormone called progesterone to grow. Mifepristone blocks the production of progesterone.

The second pill, misoprostol, is taken anywhere from right away up to 48 hours after the first. This causes cramping and bleeding to empty the uterus. The bleeding can last for several hours, something that is normal and not dangerous but may be alarming to people who aren’t expecting it.

Is medication abortion effective?

Medication abortion is a very effective way to end a pregnancy; Planned Parenthood outlines the details on their website:

• For people who are 8 weeks pregnant or less, it works about 94 to98 out of 100 times.
• For people who are 8 to 9 weeks pregnant, it works about 94 to 96 out of 100 times.
• For people who are 9 to10 weeks pregnant, it works about 91 to 93 out of 100 times. If you're given an extra dose of medicine, it works about 99 out of 100 times.
• For people who are 10 to11 weeks pregnant, it works about 87 out of 100 times. If you're given an extra dose of medicine, it works about 98 out of 100 times.

What is the difference between the morning-after pill and medication abortion?

Moore says there’s a lot of confusion about the difference between emergency contraception (also called Plan B or the morning after pill) and medication abortion. Plan B simply prevents a pregnancy from occurring following sex by preventing or delaying ovulation. A medication abortion ends a pregnancy.

What will happen with medication abortion if and when Roe is overturned?

States with the strictest laws already on the books will make them even stricter, likely prohibiting access to medication abortion entirely. Whether they can withstand legal challenges is an open question.

“In some states, the law will say that women can’t have access to an FDA-approved drug. Moore says. “That’s bonkers.”

The question of whether the state can do exactly that will be a hotly debated legal question. But what we know for sure is that access will be severely restricted and many of the people who want to have control over their reproductive future won’t be able to access necessary care.

Will people be able to access abortion pills overseas?

“We know that people are doing what’s called self-managed care, where they get medication from someone other than a legal prescriber in this country,” Moore says. “That’s already happening. But it wouldn't be better if people had access to an FDA-approved method, ideally, through their own health care provider? That's what we really want to see.”

Because even while self-managing is possible from a clinical standpoint, she explains, it’s still going to be a big deal for some people. It’s a process that can take 24 to 48 hours, sometimes longer, and can be uncomfortable.

“We know from the health care providers who do this for a living that patients just want some support,” Moore says. “They want to be able to pick up the phone and call somebody and say, ‘Wait a minute, is this okay?’ And just have the reassurance of somebody saying, ‘Yeah, your body's doing what it's supposed to be doing.’”

When people are forced to manage their own abortions, they can’t access that kind of care. Because history has clearly demonstrated that making abortion illegal doesn’t make abortion go away, it just makes abortion significantly more burdensome and dangerous.

What can people do to support abortion rights?

Moore stresses the importance of donating to abortion rights funds like abortionfinder.org. These organizations are helping people who need abortions but are in restrictive states travel to other states to get care. They pay for transportation, childcare, lodging, etc.

While those are important efforts, they’re not going to affect everyone who wants an abortion. A Texas teenager who has been raped by a family member, for example, may not be able to explain why she suddenly needs to go to New Mexico for a few days by herself.

Even with important organizations doing this essential work, nothing can completely counteract the harms of overturning Roe.

“It’s going to be like Prohibition,” Moore says. “The ‘rulers,’ not the policymakers, not the legislators, the rulers have figured out how to screw us. It’s going to be 10 plus years of hell. And at some point, it’s going to break apart because it’s not sustainable. But not until we’ve had at least 10 years of sheer misery.”