How the US scrapping of Roe v Wade threatens the global medical abortion revolutionBMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2349 (Published 19 October 2022) Cite this as: BMJ 2022;379:o2349
In 2021, a 20 year old woman in Hyderabad, India, discovered she was pregnant. A well educated, city girl, she was nevertheless afraid of the stigma attached to unmarried pregnancy and did not know if she could legally terminate the pregnancy. Around the same time, another young couple living together in Bengaluru were in a similar predicament.
“Both women were not ready for a child but completely clueless about the options they had, and the gestation period up to which abortion is legally allowed in India,” says Anusha Pilli, a doctor who practises privately in Hyderabad. Pilli helped both women to get medical abortions before their first trimesters ended.
Medical abortion —the means of terminating early pregnancy with one or two orally administered drugs—has been revolutionary. It is estimated to prevent millions of unsafe abortions a year globally, and tens of thousands of maternal deaths.1 Over 99% of deaths from abortion occur in developing countries, with 68 000 women dying of unsafe abortion each year.23
“The global decline in maternal mortality since these drugs were introduced has been huge,” says Rebecca Gomperts, the Dutch physician and safe abortion activist behind telemedicine medical abortion non-profit organisations Women on Web and Aid Access. “The turning point was 2004 when India started manufacturing generic mifepristone as it was no longer patented. It’s a market success story, in one sense.”
Sarah Shaw, head of advocacy at MSI (formerly Marie Stopes), a non-governmental organisation that provides contraception and safe abortion services in 37 countries, says that there remain barriers to accessing the drugs, including national legislation—such US state legislation to restrict medical abortion access after the Supreme Court overturned Roe v Wade in June4—illiteracy, and lack of awareness. Even in India, where abortion has been legal for half a century and which produces most of the world’s generic mifepristone, there remains a lack of general knowledge around medical abortion.
“These drugs are revolutionary, yes, but women need to know about medical abortion in the first place and they need to know how to take the drugs safely,” says Shaw.
Medical abortion timeline
1973: Misoprostol is developed by US researchers as a drug to treat peptic ulcers
1982: French pharmaceutical company Roussel-Uclaf develops mifepristone, a pill that could be taken alone or in sequence with misoprostol to induce an abortion
1988: France legalised mifepristone as a drug regimen for medical abortion
1991: UK legalises mifepristone
1999: Legalised by Austria, Belgium, Denmark, Finland, Germany, Greece, Luxembourg, the Netherlands, Spain, and Switzerland
UK leads the way
The leading medical abortion drug is the glucocorticoid receptor antagonist mifepristone (RU-486), a pill that can be taken in sequence with a prostaglandin analogue (initially sulprostone or gemeprost, later misoprostol) to induce abortion. The two drug combination is 97% effective during the first 63 days of pregnancy. Mifepristone can be used alone as a single pill regimen to initiate abortion, with high levels of safety and an 80% efficacy; misoprostol can also be taken alone for this purpose.5
The World Health Organization recommends the combined regimen to initiate abortion medically: 200 mg mifepristone, administered orally, followed one to two days later by 800 μg misoprostol, administered vaginally, sublingually (under the tongue), or buccally (in the cheek).6 The WHO list of essential medicines cites both drugs in a combination product and mifepristone alone for the management of incomplete abortion.7
Mifepristone is now legal and available for use to initiate abortion in 46 countries; misoprostol is available in most nations, but only approved for other uses in some. The UK perhaps leads the way in access. During the early pandemic lockdowns, the Department of Health and Social Care legalised home use for both stages of the two drug regimen up to 10 weeks gestation. Before this, women were required to attend an abortion clinic to take the first pill, though the second could be taken at home. The use of telemedicine for early abortion care was made permanently legal in England and Wales in August 2022.8 A consultation is under way in Scotland on future arrangements for early medical abortion at home following a similar liberalisation of protocols during the pandemic. At-home medical abortion is not permitted in Northern Ireland.
Ranee Thakar, president elect of the Royal College of Obstetricians and Gynaecologists, says the college campaigned for the law change based on the drugs’ proved efficacy and safety and also the implications of the previous treatment protocol for women—this could lead to women travelling large distances while bleeding and expose women in vulnerable situations to risk of discovery, particularly those in abusive relationships.
Hannah Barham-Brown, a Yorkshire GP registrar and deputy leader of the Women’s Equality Party, said the change is “a huge step forwards and will change the lives of many, particularly those with disabilities, or who are experiencing domestic abuse.” Home use also has cost and efficiency benefits for the NHS, she adds.
Legal barriers globally
“Ideally we would see the situation we have in the UK—medical abortion drugs readily available including for home use—worldwide,” says Thakar. But restrictive laws and regulations, on top of poor availability of services and drugs, high costs, and a lack of awareness remain barriers globally.
Abortion is prohibited in 16 countries and severely restricted—permitted only to save the mother’s life or preserve health—in a further 56.9 In the US, where in June the Supreme Court overturned Roe v Wade, a 50 year old ruling guaranteeing women’s right to abortion, medical abortion is now illegal or heavily restricted in 14 states, with some states also attempting to criminalise mail and telemedicine receipt of mifepristone and misoprostol.
Elisa Wells, co-founder of US medical abortion non-profit organisation Plan C, says the US is now two nations when it comes to abortion provision. “One half of the country has clinic based healthcare and modern telehealth where you can get mifepristone and misoprostol sent to you within three days for $150, and the other has very restricted or no access to abortion.”
Wells says that abortion providers and campaigners in US states also struggle with low general awareness of medical abortion, illiteracy, and the spread of misinformation from pro-life actors, which characterises medical abortions as “chemical abortions” which lead to infertility.
In some countries where medical abortion is illegal, market availability combines with underground activism to give rise to a black market in mifepristone and misoprostol, and a black market was common in many countries in the 1980s and 90s before the drugs were widely legalised. Activist groups supplying these drugs include Con Nosotros a Casa in Chile (where abortion is restricted) and Las Libras, which supplied underground medical abortion drugs to women in need in Mexico for decades before abortion was legalised there in 2021. Underground networks also supply the drugs through black markets in Brazil, a nation of 212 million people where abortion is only permitted to preserve a woman’s life.10
Indian reproductive health charity the Foundation for Reproductive Health Services studied the availability of medical abortion drugs in 10 Indian states between 2018 and 2020 and found “abysmal stocking” of these drugs as well as black market and improperly sold products.11
Pilli says that outside of big cities, awareness of medical abortions, and market access to mifepristone and misoprostol, are patchy. Drug shortages are acute in areas that have seen police crackdowns on sex selective abortions because of pharmacists’ fear of reprisals, according to Vinoj Manning of Indian safe abortion charity Ipas Development Foundation.
The cost of medical abortion drugs varies depending on whether a nation allows generic drugs to be sold. At the time of writing, the two drug regimen costs around $150 in the US, £350 in the UK where bought privately, and around €500 in Europe, where the drug regimen is usually covered by national health systems. In India, where 23 companies manufacture generic drugs, the cost is around Rs304.38 (£3) for mifepristone and Rs15.80 (£0.17) for misoprostol.
With mifepristone typically being more expensive and less readily available than misoprostol, some women opt to use misoprostol only. This is what happens in Nigeria, says Friday Okonofua, a gynaecologist and centre leader for Reproductive Health Innovation at the University of Benin. He wants to see a wider acceptance of the single drug method to expand medical abortion access in low and middle income countries.
“Mifepristone is not officially registered for abortion in Nigeria and although available it is expensive at a whopping $14.50 a dose,” he says (the Nigerian living wage for full time employment is $99.20 a month). Okonofua told The BMJ that he tends to prescribe misoprostol alone for first and second trimester abortions since a tablet costs $0.29 in Nigeria.
Cost is not just a problem in Africa. Says Gomperts, “The problem in Europe is that women who have to pay for medical abortion drugs—such as undocumented women, including rejected refugees and asylum seekers, immigrants whose resident permit has expired, victims of human trafficking, and stateless refugees—don’t have access to free state prescriptions and cannot afford the drugs available.” And in 2014, despite the known efficacy and safety of the one drug regimen,5 Armenia restricted access to misoprostol alone as many women were opting for this cheaper one drug method, which was available over the counter, rather than the two drug combination, which requires a prescription.
The way forward
Thakar says that much of the needed work to expand access to medical abortion in low and middle income countries is around tackling stigma, including towards medical professionals working in abortion, and busting the myths promulgated by anti-abortion activists as well as raising awareness about the safety and efficacy of mifepristone and misoprostol.
Pratigya Campaign, a network of organisations working to advance access to safe abortion care in India, calls for investment in comprehensive awareness campaigns about types of abortions and their legality and that the drugs should be sold over the counter in India without prescription.
For Wells, England and Wales’s rollout of telemedicine abortion using self-administered mifepristone and misoprostol shows that this protocol could be lifesaving for women in the 14 US states that have restricted clinical access to medical abortion following the Supreme Court ruling. Plan C fund advertising campaigns in US abortion dark states to advise women there how to access medical abortion drugs from providers through postal forwarding, and how to avoid criminalisation “by not telling friends about their abortion or telling medical professionals why they are bleeding in the small number of cases that they will need follow-up care after home medical abortion use.”
Telemedicine abortion care providers Hey Jane and Abortion on Demand top internet searches in these states, Wells adds, helping women to find these services readily.
Gomperts, who is studying the potential of mifepristone as a hormone free contraceptive, would also like to see a global liberalisation of telemedicine medical abortion along the lines of that seen in the UK. A 10 year survey of 30 344 women who used Women on Web’s telemedicine service found a low rate of surgical interventions, ongoing pregnancies, and blood transfusions in women who had self-managed their own medical abortions,12 with similar studies showing high levels of treatment success and low levels of adverse outcomes.1314
“The safety profile of these drugs is excellent and they are very forgiving when it comes to dosage,” Gomperts says—meaning that higher and lower doses than those WHO recommends will also terminate a pregnancy with limited side effects. There is also, she says, no evidence of abuse or overuse of these drugs as a contraceptive method as detractors historically claimed.
“It’s time to treat women as adults and move towards over-the-counter availability with no gatekeepers,” she says.
Medical abortion under attack in the US
In Mississippi, the June 2022 Supreme Court ruling has triggered a 2007 law that makes abortion illegal, including medical abortion. It was argued by Mississippi Attorney General Lynn Fitch in federal court that under US federal law it is already illegal to mail abortion pills. Those who break the law are technically punishable with up to five years in prison, although the federal government does not enforce these laws
In South Dakota, a July 2022 house bill banned medical abortion prescribed through telemedicine and increased the punishments for those prescribing the drugs without a state licence
The Human Life Protection Act of 2021, triggered in Texas in August, made it a crime for anyone to provide a pregnant woman with drugs for abortion. Prior to the June Supreme Court ruling, Texas also passed a law that imposes criminal penalties on doctors who use telehealth to prescribe abortion pills or mail them to patients
Additional reporting by Lia Freeman in Seattle.
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Commissioned, not peer reviewed.