If it wasn’t clear before the Supreme Court’s decision greenlighting Texas’ draconian abortion ban, it’s certainly clear now that we are in the middle of a safe abortion care crisis. And it’s only going to get worse as other conservative state legislatures aim to follow Texas' lead.
The current crisis in abortion access must push us to accelerate our progress toward over-the-counter abortion pills.
Ironically — and fortuitously — we are also in the middle of a burst of innovation around abortion care, largely focused on new ways to access medication abortion, also known as abortion pills. This innovation will be difficult to constrain, no matter what happens in states like Texas, and undoubtedly will lead to better access to safe options for people living under abortion bans.
The current crisis in abortion access must push us to accelerate our progress toward over-the-counter abortion pills. If the research evidence supports an OTC switch for medication abortion, I am hopeful the Food and Drug Administration will follow the science and approve such a change. States with restrictive laws certainly will try to prevent OTC access, but it could prove difficult to limit online sales or prevent people from purchasing abortion pills in other states and bringing them home to use.
Medication abortion involves using two medicines, mifepristone and misoprostol, and is a safe, noninvasive and effective way to end a pregnancy. It is commonly used through 11 weeks of pregnancy; it can also be used later in gestation, but the protocols change somewhat. It has a safer track record than many common drugs, such as Tylenol and Viagra, and it’s 14 times safer than continuing a pregnancy to term. It is highly effective, with a 97 percent success rate for pregnancies through 10 weeks’ gestation. In 2017, about 60 percent of eligible abortions nationally were done with pills, according to an analysis by the Guttmacher Institute.
Clinicians have been creating innovative ways to provide medication abortion for a while. Telemedicine has been used to provide medication abortion since 2008, primarily to offer the service at clinics without a doctor or nurse practitioner on site. Research I led found this model was safe, effective and well liked by patients. It also helped them access the service earlier in pregnancy and reduced barriers to care.
But while the Covid-19 pandemic led to a massive expansion in the general use of telemedicine, similar changes to medication abortion care were obstructed by a regulation imposed by the FDA requiring mifepristone to be dispensed in person at health care facilities. Thanks to a lawsuit brought by the American College of Obstetricians and Gynecologists, the in-person dispensing requirement has been suspended for the remainder of the pandemic public health emergency.
This change in policy — both by the FDA and even earlier by regulators in other countries — has led to rapid innovation in telehealth protocols that involve screening patients for eligibility for medication abortion based on their answers to a series of questions. Those who meet the eligibility criteria are mailed the pills, while those who don’t are asked to come in person for an evaluation. A large study in the U.K. including over 18,000 telehealth patients found this model was safe and effective, and a growing body of research in the U.S. confirms these findings.
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Even before the current ban, Texas prohibited the use of telemedicine for abortion care; however, that has not prevented all online services from operating there. Aid Access, which is based outside the U.S., provides telehealth medication abortion to U.S. patients using pills from other countries. The last time Texas tried to restrict abortion access — early in the pandemic — there was a dramatic uptick in requests to Aid Access from Texas residents. It remains to be seen if clinicians in other states might offer similar telehealth services to people in Texas, even if the service violated state law.
If clinicians can provide abortion pills by asking patients a series of questions, it’s reasonable to wonder whether patients could just answer those questions on their own and obtain the pills OTC. Not surprisingly, people are interested in OTC access. A 2017 nationally representative survey found that 37 percent of women were in favor of OTC access to medication abortion, and research with abortion patients finds even higher levels of support. The benefits of this approach are wide-reaching, including potential benefits to trans patients, who may want this option to maintain the privacy of their decision and avoid a potentially unsupportive health care experience.
The first step in moving any medication from prescription to OTC status is to develop a simple drug facts label like you see on a bottle of cough syrup, for example. The next step is to demonstrate that people can understand the label and use it to figure out if the product is right for them and to take the medication appropriately.
Working with a broad range of stakeholders, my research team at UCSF recently developed such a label for a future medication abortion product. We evaluated the label by interviewing about 850 people, 36 percent of whom were under age 18 and 19 percent with limited literacy — to see if they understood the important concepts in the label. Our preliminary findings indicate that key label concepts were very well understood across age groups and literacy levels. The next step of our research is to test how well patients can determine on their own whether they are eligible for medication abortion using a simple electronic tool, as compared to a clinician’s evaluation.
The first step in moving any medication from prescription to OTC status is to develop a simple drug facts label like you see on a bottle of cough syrup.
Of course, not everyone is a candidate for outpatient medication abortion, including those later in pregnancy; others have a strong preference for an aspiration procedure instead of pills. As Dr. Jamila Perritt has noted, the U.S. family planning field has a dark history of constraining people’s reproductive health choices, including forcing Black, Indigenous and other people of color to get sterilized or use intrauterine devices.
We must not repeat that history with abortion care, and instead we must work to maintain access to all abortion methods in the face of restrictions. We also must strongly oppose the targeting and criminalization of people who self-manage their abortions. There have been at least 21 arrests of people who allegedly self-managed their abortion or helped someone else, and they have disproportionately been people who are Black, brown and living on low incomes.
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As someone who has dedicated his career to ensuring evidence-based reproductive health policy and practice, I am heartbroken by the legal threat to Roe v. Wade. But even if legislators and judges won’t follow the evidence, I know the scientific progress regarding medication abortion will unquestionably help the people in Texas needing care — especially if we expand these innovative models in other states and remove remaining federal restrictions.