Even before the U.S. Supreme Court ruled to overturn Roe v. Wade, interest in medication abortion had skyrocketed.
Right after the draft opinion of the Dobbs v. Jackson Women’s Health Organization decision overturning the constitutional right to an abortion was leaked in May 2022, internet searches for “abortion pill” surged 162%, according to a study published in June in JAMA Internal Medicine. And nonprofit abortion access providers Just the Pill and Aid Access have reported a spike in calls from women seeking more information about the pills.
At the same time, a Kaiser Family Foundation poll released in June found that less than a third of U.S. adults (27%) have even heard of medication abortion, though more women ages 18-49 (40%) are familiar with the medications. By contrast, while most U.S. adults (91%) have heard of emergency contraception, a full 73% of those incorrectly believe that so-called Plan B pills can end a pregnancy in its early stages.
AAMCNews spoke to several academic reproductive health experts to clear up misconceptions about abortion medication and emergency contraception, as well as explain how each works and how physicians are providing care in the wake of the Dobbs decision.
What is medication abortion?
Medication abortion is the process of ending a pregnancy through medication. There are two medications that are taken successively. The first, mifepristone, stops the pregnancy, and the second, misoprostol, induces uterine contractions, which allows the body to expel the pregnancy tissue. Medication abortion was used in 54% of all abortions in the United States in 2020, according to the Guttmacher Institute, a nonprofit dedicated to sexual and reproductive health research and policy.
How are the pills taken?
The first medication, mifepristone, is one pill and can be taken either in a doctor’s office or at home. The second medication, misoprostol, is a series of four pills that are taken 24 to 48 hours after the first pill and are placed either buccally (dissolved between the cheek and the teeth) or vaginally. If the pregnancy is beyond 9 weeks, some physicians will prescribe a second round of misoprostol to be taken four hours after the first round, says Sirapanth Nippita, MD, director of the Division of Family Planning in the Department of Obstetrics and Gynecology at NYU Langone Health in New York.
What are the side effects?
Most people will experience bleeding and cramping on the day they take the second medication, says Lauren Thaxton, MD, MBA, an assistant professor of women’s health at The University of Texas at Austin Dell Medical School. “Everybody is a little bit different but most everyone will have their heaviest bleeding and heaviest cramping on the day that they take their misoprostol,” she says.
Because some pregnant people also experience stomach cramping, diarrhea, and other gastrointestinal issues, physicians may advise their patients to take the misoprostol vaginally, Thaxton says.
Either way, patients may experience some irregular bleeding for the next couple of weeks, but then are likely to resume their regular menstrual cycles.
A follow-up visit with the provider is recommended to ensure the abortion is complete.
Is medication abortion safe and effective?
The Food and Drug Administration (FDA) has approved the use of mifepristone and misoprostol to end pregnancies up to 10 weeks, but clinical guidance allows use up to 11 weeks. “Somewhere between 10 and 11 weeks is really the evidence-based recommendation for when you might prescribe medication abortion,” Thaxton says. “After that point, we do tend to recommend a procedural abortion in places where that is available.”
A meta-analysis of 87 clinical trials shows that medication abortion is safe, with serious complications requiring hospitalization (for vaginal bleeding, pelvic pain, or infection) occurring in less than .3% of patients. Approximately .1% of patients required a blood transfusion. Signs that you might need to seek emergency medical attention include prolonged heavy bleeding, severe abdominal or back pain, fever lasting more than 24 hours, or foul-smelling vaginal discharge.
The pills also are highly effective, with ongoing pregnancy reported in just 1.1% of patients.
During the COVID-19 pandemic, many providers prescribed medication abortion via telemedicine. A study published in the journal Contraception subsequently found that safety and effectiveness for the pills prescribed via telemedicine were on par with those prescribed in a doctor’s office, with .7% requiring hospitalization and .4% requiring a blood transfusion. The study also found that 99% of patients were satisfied with their care.
Are medication abortion pills used for other reproductive health procedures besides abortion?
“These are the exact same two medications that are evidence-based for use in miscarriage management,” Thaxton says. For instance, sometimes a pregnancy terminates naturally, but the pregnant person does not naturally expel the pregnancy tissue.
“People are a little bit on edge and a little bit fearful of prescribing these medications, even for the purpose of treating miscarriage, as it could be perceived as an abortion,” Thaxton says. “I went to medical school; I didn’t go to law school. I think that’s how a lot of OB-GYNs feel right now. We’re just trying to do the thing that we actually studied to do, which is provide evidence-based medical care.”
Are there any risks for people who obtain abortion medications through telemedicine or through the mail?
“Research shows that when people have access to accurate information about how to manage their abortions, they can do so safely on their own,” says Jen Villavicencio, MD, an OB-GYN and lead for equity transformation at the American College of Obstetricians and Gynecologists, which has compiled resources for OB-GYNs in the wake of the Dobbs decision. However, Villavicencio says, “state laws may control where you can take abortion medication pills and how and whether someone can get abortion medications.”
Where is medication abortion banned?
Abortion is now banned starting at conception in 10 states — Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, South Dakota, Texas, and Wisconsin. Bans are expected to take effect in Idaho and Tennessee at the end of August. Another five states — Arizona, North Dakota, Utah, West Virginia, and Wyoming — have banned abortions but the courts have blocked those bans from taking effect. Florida has banned abortions after 15 weeks, and Ohio, South Carolina, and Georgia ban abortions after six weeks, before many people realize they are pregnant. In many of those states, providers who provide abortions, including medication abortions, are subject to criminal penalties.
“There certainly is a lot of uncertainty and a lot of worry about how we are going to be able to provide our patients with this care,” adds Nippita, who also works at Planned Parenthood. “We spent years training to provide care, so the fact that it’s been so politicized is just incredibly disheartening.”
What is emergency contraception?
Emergency contraception, also known as the morning-after pill, is a medication that prevents or delays ovulation. It can be used after unprotected sex or in cases where the primary method of birth control fails and is most effective when taken as soon as possible after unprotected sex.
There are two types of FDA-approved emergency contraceptive pills: Plan B is an over-the-counter medication that is available at many drugstores, and ella (ulipristal acetate) is a prescription medication.
“Ella is more effective than Plan B,” says Thaxton, who often prescribes the medication for her patients who may not yet be sexually active but who want to be prepared if the need arises. “It can also be used a little bit further out from unprotected sex than Plan B.”
Once a person is pregnant, emergency contraception will not stop the pregnancy.
What is the difference between emergency contraception and medication abortion?
“The key difference between emergency contraception and medication abortion is that emergency contraception prevents a pregnancy from occurring, while medication abortion ends a pregnancy,” says Villavicencio.
“Because of that, [emergency contraception] should never be subject to laws banning abortion,” she adds. “Any impact of abortion bans on emergency contraception is a misapplication of the law and a misunderstanding of the medical science.”