Updated April 14, 2023 at 5:11 pm ET
Two federal judges hearing cases involving mifepristoneissued contradictory decisionslast week, calling into question the future of a drug used in nearly all medical abortions in the US.
In Texas, US District Judge Matthew Kacsmaryk ruled that the Food and Drug Administration's approval of mifepristone more than 20 years ago was improper. Kacsmaryk issued a national order to suspend FDA approval.
This would have taken effect on Saturday,but the Supreme Court issued an administrative stayuntil next Wednesday to maintain the status quo while the court rulesrequest by the Department of Justice to block the decision.
Hours after the Texas decision, U.S. District Judge Thomas O. Rice issued his ruling in a separatecase in Washingtonstate, preventing the FDA from "altering the status quo and rights related to the availability of Mifepristone."
Nothing has changed yet, and it's unclear which states will be covered by the Texas ruling if the Supreme Court refuses to block it. It is possible that the 17 states and the District of Columbia involved in the Washington lawsuit are not covered.
Medical access to abortionhad increasingly become the focusof the legal battle for abortion rights in the US, even before the Supreme CourtoverturnedRoe v. WadeinsideDobbs v. Jackson Women's Health Organizationdecision last June. And about half the stateshave moved to ban or severely restrict abortion. This is largely because medication abortion now accounts for more than half of abortions in the US.
As the legal landscape continues to change, here's what you need to know about the drug and how it works.
What is medical abortion?
Medical abortion, also known as medical abortion, usually uses a combination of two drugs to end a pregnancy. This abortion method does not require surgery and can be done at home.
The first pill is mifepristone, which blocks a hormone known as progesterone that the body needs to continue a pregnancy.
The second drug, misoprostol, is taken 24 to 48 hours later. This medicine causes cramping and bleeding and empties the uterus.
The World Health Organizationsaysthat if mifepristone is not available, misoprostol can be used alone. But the two drugs are more effective together.
Why might a person prefer a medical abortion?
Opting to take pills (rather than having the procedure done in a clinic) has become an increasingly common option for abortion seekers since mifepristone was approved by the FDA in 2000.
That may be because it feels more private and less invasive than surgery, says Dr. Gabriela Aguilar, a physician and clinical professor at the NYU Grossman School of Medicine.
"Many people prefer to terminate the pregnancy in the comfort of their own home, surrounded by their support system and loved ones ... rather than having to go to a clinic or hospital for an operation," says Aguilar. The medication route can also feel less invasive, she notes, "because there's no medical abortion equipment."
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The pills may facilitate an abortion if a clinical provider is too far away or difficult to access.
Many people still choose a surgical or procedural abortion, for a variety of reasons. Surgical abortions—an office procedure that often takes just five or 10 minutes—are highly effective and rarely require repeat procedures. Patients may want the in-clinic option to get the procedure done quickly, to avoid the hassle of the medication process, or because it involves the presence of trained medical and support staff. Another reason for choosing the procedure is that a pregnancy may be too far along for the use of medication - pills are most often recommended for pregnancies less than 10 or 11 weeks.
Is medical abortion different from Plan B?
Yes. Plan B is emergency contraception, not an abortion. Plan B and another drug called Ella work by delaying or preventing ovulation. Plan B is most effective if taken within three days of unprotected sex. Ella can be taken within five days. Both are more effective the sooner they are taken.
How effective is medical abortion?
Abortion pills are very effective.A studyof more than 13,000 women found that the two-drug regimen was 97.7% effective for pregnancies up to nine weeks.
The later in pregnancy the pills are taken, the less effective they are.
Dr. Aileen Gariepy, professor of obstetrics and gynecology at Weill Cornell Medicine, says the pharmaceutical route is more effective for abortion than for miscarriage management — another reason the pills are sometimes prescribed. For miscarriages, she says the pills are most effective when someone already has the symptoms of a miscarriage, such as bleeding and cramping.
Why are abortion pills used in case of miscarriage?
The same pill regimen used for abortion can be used to manage miscarriage, depending on how far along the pregnancy is.
Some people learn that their pregnancy is not viable at a prenatal medical appointment — for example, because the fetus has stopped growing but is still in the uterus. A medical abortion or a surgical abortion may be used to help empty the uterus completely so that there is no risk of excessive bleeding or infection.
How far into a pregnancy can medical abortion be used?
FDA approves two-drug regimen for pregnanciesup to 10 weeks. The World Health Organization says medication abortions can be safely performed at homeup to 12 weeks.
Gariepy says patients seeking abortions are generally steered toward the surgical option after 11 weeks. "This is not because [medical abortion] is unsafe; it's just not as effective as a pregnancy beyond 11 weeks," he says.
FromRoeoverturned, more people have had to drive long distances to get to a surgical clinic in states where abortion remains legal, and clinics in those states are struggling to serve far more patients than beforeDobbs.
In the case of a pregnancy, which is 11 weeks and 3 days, "maybe it's better to try to see if medical abortion will work," Gariepy told NPR last spring, beforeDobbsdecision.
Is medical abortion safe?
Yes. The American College of Obstetricians and Gynecologists affirms that medication abortion is asafe and effective wayproviding abortions. And the formula is also FDA approved.
But it can be uncomfortable. Cramping and bleeding may occur for several hours after taking the second drug, misoprostol.
"I tell most people it feels like really intense period cramps," says Aguilar. "I've had patients tell me they didn't feel anything – they just felt a little cramping or 'It wasn't as bad as my period.' And then I had other patients tell me it was the worst experience they'd ever had. So I think there's a wide range of experiences, probably more relevant to what a person's baseline pain experience and tolerance is like."
A follow-up consultation with a doctor — either in person or via telehealth — is important to make sure the patient is healed and no longer pregnant, Gariepy says.
Who can prescribe abortion pills?
Mifepristone, the first drug in the sequence, is more strictly controlled by the FDA than many other drugs. Due toFDA requirements, mifepristone can only be prescribed by a certified health care provider who meets certain qualifications, and pharmacies that dispense mifepristone must also be certified.
In December 2021, the FDA dropped the requirement that mifepristone could only be dispensed in individual settings, but as of January 2023, 18 states hadprohibited telemedicine appointments for medication abortion.
In January, the FDA updated the drug's labeling to allow more retail pharmacies to dispense the pills, potentially expanding access to both in-person and online pharmacies that complete the certification process.
Some Republican attorneys general, including in states where abortion remains legal, have threatened to sue pharmacies that dispense the pill in their states.
Some patients have taken the drugsfrom out-of-state and even overseas providers. A growing number of states have moved to make this approach illegal, but experts say that in practice, it is difficult to police. This carries the risk of receiving products that are not FDA approved and patients not receiving proper care before and after taking the drug.
Does insurance cover abortion pills?
Insurance coverage will vary depending on whether the patient has public or private insurance and what state they live in.
The Hyde Amendmentblocks federal fundslike Medicaid from being used to pay for abortions except in cases of rape or incest, or if the pregnancy would endanger the woman's life. However,2019 studyby the Government Accountability Office found that 14 states' Medicaid programs do not cover mifepristone even in these cases.
The Kaiser Family Foundationwere foundthat in 2020, 33 states had no plans available in the Affordable Care Act Marketplace that offered abortion coverage. Six states — California, Illinois, Maine, New York, Oregon and Washington — require state-regulated private health plans to cover abortion, including ACA Marketplace plans, according to Kaiser.
Some insurance plans cover surgical abortion but not medical abortion.
So-called "self-insured" plans — which are not regulated by state insurance laws — may cover abortion because federal law neither prohibits nor requires such coverage in self-insured plans, Kaiser notes.
According to Planned Parenthood, the cost of a medication abortion can be as high as $750, but is often less. Abortion funds in the US may be able to help with the cost of an abortion if a person's insurance does not cover it.
Are there certain people who should not take the pills?
Medical abortions are not a good option for those whose pregnancy is too far along.
Others who shouldn't use abortion pills, Gariepy says, are people who have a rare disorder calledporphyria, take chronic steroids, have a previous allergy to mifepristone, or have severe anemia.
The Cleveland Clinicalso notes that medication abortions are not safe for those who have a blood clotting disorder, chronic kidney failure, or have an IUD (intrauterine device).
It's also not a good choice for treating an ectopic pregnancy (pregnancy outside the uterus) or for those who don't have access to emergency medical care or can't make a follow-up consultation, the clinic says.
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