The rise of medical abortions in the USBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4297 (Published 26 June 2019) Cite this as: BMJ 2019;365:l4297
Rebecca Gomperts, a Dutch physician practising in Austria, says that she has heard from thousands of pregnant women in the United States in recent months who want abortions but cannot get them. In many cases, they simply do not have the hundreds of dollars it takes to get an abortion in the US, she told The BMJ. Others live far from the specialised clinics where many abortions take place. “Some would have to travel six hours,” she says.
So Gomperts offers a service that the US Food and Drug Administration says is illegal but that she and her supporters say is necessary: she writes prescriptions for abortion drugs to be mailed from a pharmacy in India to women in the US.
She runs a global online consultation service, called Aid Access, outside the bounds of the US medical system. Others are working within those bounds with similar goals: to expand the use of medical abortion to fill access gaps.
Those gaps could grow under a spate of new, currently unenforceable state laws aimed at convincing the US Supreme Court to overturn Roe v Wade, a 1973 decision that says abortion is a constitutional right.
Currently, medical and surgical abortions remain legal everywhere in the US, but individual states can and do impose restrictions. Many states ban late abortions, impose waiting periods, mandate counselling, and require parental consent for minors. Federal law also limits the distribution of abortion drugs to authorised providers: women cannot pick them up in pharmacies or get them through the mail, except as part of some research projects.
Despite the restrictions, medical abortions, which are allowed in the first 10 weeks of pregnancy, made up 31% of all non-hospital abortions in 2014, up from 14% in 2005, according to the Guttmacher Institute, a non-profit research organisation that supports abortion rights.1
If Roe falls, abortion pills will inevitably make their way to women in states where abortion is banned or heavily restricted, say abortion rights supporters. Women’s choices would be limited and, in some cases, criminalised, but fewer would die than in the past, they say.
“The availability of medical abortion means we don’t have to think only of a pre-Roe back alley abortion and coat hanger kind of situation,” says Megan Donovan, senior policy manager at Guttmacher. “We have a safe and effective alternative.”
But even today, advocates say, access to medical abortion in the US is not as open as it could be.
“A very safe medication”
When the so called abortion pill was headed towards FDA approval nearly two decades ago, advocates envisaged a new landscape in which women could get a safe, early abortion with the help of any willing physician with a prescribing pad.
That did not happen.
Instead, the FDA set strict rules for how the drug, mifepristone, could be distributed. Mifepristone is one of two drugs used in most medical abortions: it blocks progesterone, a hormone needed to sustain a pregnancy. The second drug, misoprostol, causes the uterus to contract and bleed, ending the pregnancy in more than 95% of cases, Guttmacher says.
Under the FDA rules, only registered providers in clinics, medical offices and hospitals can dispense mifepristone. Women must go to these locations to get the drug; they can’t just pick it up at pharmacies.
“It’s a very safe medication,” says Daniel Grossman, a professor of obstetrics, gynaecology, and reproductive sciences at the University of California, San Francisco.
The FDA is now allowing researchers to test other approaches. In one ongoing study led by Grossman and funded by Fidelity Charitable (a crowdsourced philanthropic organisation that directs funding on donors’ behalf) providers see patients in person, then write prescriptions that can be filled at certain pharmacies. This approach might boost provider numbers, Grossman says, partly because they would not have to keep stocks of medication on hand, which could draw the ire of antiabortion activists. The study is collecting data until the end of this year.
In another study, the non-profit organisation Gynuity Health Projects is tracking providers who mail abortion drugs to patients after video consultations. Patients in eight states can connect from anywhere they like and get referrals for screening tests, including ultrasonography to date the pregnancy. Early results, published online in the peer reviewed journal Contraception, show safety and effectiveness rates similar to those seen in other settings.4
Another approach, already legal in some states, is for patients to visit satellite clinics that stock the drug and get a video consultation from a provider in another location. Grossman studied a Planned Parenthood system in Iowa that provided such telemedicine care and found low rates of complications, under 0.2%.5 But it’s not a solution that will work everywhere: 17 states ban the use of telemedicine for abortion, Guttmacher says.
In a post-Roe world, more legal telemedicine providers would probably set up satellite clinics in far flung corners of states with permissive laws to serve women in more restrictive states nearby, Grossman says.
“I know what I want”
So why are US women using an online service based in Europe?
“There are so many people with a legal right to abortion under Roe v Wade, but they have no way of accessing that right,” says Abigail Aiken, an assistant professor of public affairs at the University of Texas in Austin and an associate editor at BMJ Sexual and Reproductive Health. In a study published in 2018, Aiken and colleagues interviewed 32 US residents who contacted online abortion providers operating outside the US medical system.6 Most were concerned about cost, time, and privacy.
A woman identified as Tami, 32, of Louisiana told the researchers: “I’m hours away from a clinic, and I would literally have to go through counselling at 8 am and then stay there seven hours to speak to a doctor and get an ultrasound . . . They are gonna make me listen to the heartbeat, they’re going to make me have counselling, and then I have to watch a video, and I just feel like that’s a bunch of bullshit. I know what I want, but the laws in the state make it so hard.”
Gomperts says that she will keep serving US patients, despite a warning letter she received from the FDA in March,7 which said that Aid Access violated US law by facilitating the sale of unapproved versions of mifepristone and misoprostol.
The FDA’s stance was praised by 120 members of Congress in a letter that accused Aid Access of “placing the lives of women and their children at risk.”8 Some abortion opponents have also expressed alarm. In a statement, Kristan Hawkins of Students for Life of America called Aid Access “a disaster waiting to happen.”9
Aiken plans to study outcomes for US clients of Aid Access, just as she has studied results from Women on Web, a non-profit operation started by Gomperts in 2006 for women in countries where abortion is illegal in most cases. In one study of 1000 women in Northern Ireland and the Republic of Ireland (before it legalised abortion), 94.7% reported completing abortions without surgery; 3% had problems that required treatment, such as antibiotics, and none died.10
Aiken says that Aid Access received about 21 000 US inquiries between March 2018 and March 2019, resulting in 2581 prescriptions by the end of 2018.
Gomperts says that she urges US residents who contact her to get local care if they can. One reason: a pill order from India can take up to 18 days to reach the US. When she does prescribe pills, she charges €80 (£70; $90) but waives the fee for those who cannot pay.
A legal medical abortion through conventional means in the US cost an average of $535 in 2014, according to Guttmacher.
Women who search for abortion pills online can find overseas pharmacies that send drugs—of unknown origin and quality, for various prices—without any medical consultation.
Whether such services cross a safety line is not a black and white issue, says Beverly Winikoff, president of Gynuity. “Desperation draws the line,” she says. “If you restrict access, women become more desperate and they will try anything.”
Legality of online access
US women who buy abortion pills online from overseas providers are unlikely to be prosecuted for illegally importing drugs, but they may face some legal risks, says Jill Adams, executive director of If/When/How, a legal advocacy group.
Prosecutors in several states have used a variety of laws to criminalise self managed abortion, she says. In one case, a woman in Indiana was convicted of “feticide” for ending a pregnancy with pills bought online from a pharmacy in Hong Kong. The conviction was later overturned.11
But recently passed state laws yet to be enacted that are designed to overturn abortion rights do not call for jailing women who get abortions, even when they call for jailing doctors, Adams says. “Prosecutors in these states would be abusing these laws if they used them to go after people who self manage abortions,” she says.
Meanwhile, it’s unclear what the Food and Drug Administration can do to overseas physicians who write abortion pill prescriptions for US women. “We cannot comment on a potential future action at this time,” the FDA press office said in an email. “But we remain very concerned about the sale of unapproved mifepristone for medical termination of early pregnancy on the Internet, because this bypasses important safeguards designed to protect women’s health.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.