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Explainer: What’s next for abortion pills after the fall of Roe

Boxes of mifepristone at the West Alabama Women's Center in Tuscaloosa, Ala. (Allen G. Breed/AP)

The Supreme Court’s overturning of Roe v. Wade has brought a flurry of changes to abortion laws across the country, opening the gates for legal battles in states with or without “trigger bans” on the procedure.

On Friday, President Joe Biden signed an executive order to protect access to reproductive health care services, but the effort does little for people in states that have already banned abortion.

Now, medical abortion — ending pregnancy through the use of medication — is the next focus of questions surrounding abortion care.

Why are people talking about this now?

Abortion pills were used in more than half of abortions in the United States as of 2020, according to data from the Guttmacher Institute, a research organization that supports abortion rights.

After the Dobbs v. Jackson Women’s Health Organization decision, which overturned Roe, demand for abortion pills has continued to rise, as some Republican lawmakers look to restrict access moving forward.

How do medical abortions work?

The most common medical abortion regimen uses two drugs, mifepristone and misoprostol.

The Food and Drug Administration approved mifepristone in 2000, then the two-drug protocol in 2016 to end early pregnancies. It can be used through 70 days, or 10 weeks gestation, which begins on the first day of a person’s last menstrual cycle. The protocol involves taking mifepristone on the first day, then misoprostol 24 to 48 hours after.

The protocol can be done at home, said Holli Jakalow, a professor of obstetrics and gynecology at the Columbia University’s Irving Medical Center. She added that patients can consult a provider or take a pregnancy test four weeks after the regimen to check that it was successful.

Mifepristone blocks the hormone progesterone, making the uterus unable to support a pregnancy, Jakalow said. Misoprostol then causes the uterus to contract and expel the pregnancy.

“People can safely take these pills and safely pass the pregnancy at home and not have any issues like bleeding or needing urgent medical care,” said Emily Godfrey, a primary care physician and family planning researcher at the University of Washington School of Medicine. “It’s a very, very safe way to pass a pregnancy.”

Jakalow added that, in cases when mifepristone is not available, it possible to follow a medical abortion protocol with only misoprostol. Both mifepristone and misoprostol require a prescription from a certified health-care provider.

Guidance from the World Health Organization states that misoprostol alone can be used for medical abortions for pregnancies of up to 12 weeks, or 84 days, gestation. It can also be used for pregnancies over 12 weeks but in different doses.

Stephanie Rand, a New-York based OB/GYN and family planning specialist, said people usually don’t experience symptoms after the first medication but will feel cramping and bleeding after taking misoprostol as their pregnancy passes.

Other possible symptoms within 24 hours of taking misoprostol include increased nausea and vomiting, diarrhea, fever and chills, Rand said.

In rare cases, people may experience excessive bleeding and infections. In the case of mifepristone, the FDA has stated that the adverse events reported to the organizations “cannot with certainty be causally attributed” to the drug.

Are medical abortions safe?

While antiabortion activists have questioned the safety of medical abortions, studies have shown that medical abortion is highly effective and has a low complication rate, particularly for pregnancies in the first trimester. One study found over a five-year period that more than 13,000 women who used the two-drug regimen through 63 days gestation had high success rates.

The protocol ended pregnancy in 97.7 percent of the group.

Although medical abortions have become increasingly common, there are exceptions to using mifepristone outlined by the FDA, such as if a person has an ectopic pregnancy, has bleeding problems or has an IUD.

Rand isn’t worried about the safety of the procedure — she’s worried about its legality.

“I’m not worried if these medications will be safe for people,” Rand said. “I’m worried about: Will people be safe, or will they be criminalized?”

Are abortion pills still legal?

The short answer — it depends on where you live, and it will be the subject of litigation in the future.

The Supreme Court decision placed the discretion of abortion access in the hands of states. For people living in places with trigger bans — laws designed to prohibit abortion if Roe were to fall — abortion by any method is illegal, with some exceptions depending on state law.

Since the Supreme Court ruling, 15 states have banned or mostly banned abortion, which includes medical abortions because the trigger laws largely include medicine and drugs that end pregnancy in their definitions of abortion.

“It’s up to states, really, as to how they want to go about making abortion unacceptable,” said Khiara M. Bridges, a professor at University of California at Berkeley School of Law.

Laurie Sobel, the associate director of women’s health policy at the Kaiser Family Foundation, said the overturning of Roe has created an open question of who gets authority to regulate mifepristone for abortion — the FDA or states.

“We’re in a bit of a gray zone,” Sobel said.

How have abortion pills been restricted before?

Even before Roe was struck down, many states had passed laws that added specific requirements to the process of getting abortion pills, such as counseling for patients. In five states, that counseling requires patients be told that personhood begins at conception, according to the Guttmacher Institute.

More than 30 states also allow only physicians to dispense mifepristone, according to a Kaiser Family Foundation analysis published in April.

Before the pandemic, mifepristone had to be picked up at hospitals, clinics or medical offices.

When the FDA lifted that requirement in December 2021, it allowed mifepristone to be prescribed through telehealth appointments and mailed to patients in states where the medication was legal.

But this didn’t affect the 19 states that had already banned receiving medical abortion drugs through telehealth appointments, according to Elizabeth Nash, a state policy analyst at the Guttmacher Institute.

Nash said she expects lawmakers to continue limiting medical abortions.

“What I’m anticipating is that states will try to enforce abortion bans to the fullest extent that they can,” she said.

Can the federal government protect access to abortion pills?

While the Dobbs decision allows states to restrict abortion access, the looming legal crisis over abortion pills remains centered on state versus federal authority.

Attorney General Merrick Garland vowed to “protect and preserve access to reproductive care” in a statement issued after the Supreme Court ruling, specifically mentioning mifepristone.

“In particular, the FDA has approved the use of the medication Mifepristone,” Garland’s statement said. “States may not ban Mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy.”

But Bridges, the UC Berkeley law professor, said that despite Garland’s statement, the issue will likely be “a long-term battle.”

“That statement is aspirational, because that’s a huge legal question that will have to be litigated,” she said. “And the question is whether federal law would preempt state law on that issue.”

A federal court in Mississippi is considering this question. GenBioPro — which makes mifepristone — filed a lawsuit in 2020 challenging restrictions against medical abortion.

On Thursday, the company said FDA approval of the medication should override any state ban, citing Garland’s statement, Reuters reported.

Evan Masingill, president of GenBioPro, said in a statement that the company believes in “reproductive autonomy.”

“Medication abortion care is safe, effective and the FDA has set clear guidance for how to administer it, whether at a health center, or delivered to their home,” Masingill’s statement said. “These guidelines are what should determine how medication abortion care is administered in all states and we look forward to making this argument in court.”

The Department of Justice declined to comment on the case.

What happens next?

Even with legal questions left to be resolved, the Supreme Court decision has limited access to abortion pills in the United States, leading some patients to drive across state lines for telehealth appointments to access the drugs where they’re still legal.

The confusion over abortion pills has also spiked concerns about emergency contraceptives, such as Plan B. But emergency contraceptives are not related to abortion — they are taken to prevent a pregnancy rather than to expel one.

Health experts say the Supreme Court decision will lead to surges in telehealth consultations for medical abortions, purchasing the pills online and “self-managed” medication abortion — when someone seeks out the drugs themselves and does the protocol on their own.

“That’s been happening already,” Sobel said. “That’s going to be very hard to monitor or to enforce any state laws against, because it’s through mail and mail is private.”

Roe v. Wade and abortion access in America

Roe v. Wade overturned: The Supreme Court has struck down Roe v. Wade, which for nearly 50 years has protected the right to abortion. Read the full decision here.

What happens next?: The legality of abortion will be left to individual states. That likely will mean 52 percent of women of childbearing age would face new abortion limits. Thirteen states with “trigger bans” will ban abortion within 30 days. Several other states where recent antiabortion legislation has been blocked by the courts are expected to act next.

State legislation: As Republican-led states move to restrict abortion, The Post is tracking legislation across the country on 15-week bans, Texas-style bans, trigger laws and abortion pill bans, as well as Democratic-dominated states that are moving to protect abortion rights enshrined in Roe v. Wade.

How our readers feel: In the hours that followed the ruling in Dobbs v. Jackson Women’s Health Organization, Washington Post readers responded in droves to a callout asking how they felt — and why.