How does medication abortion work? Is it safe?

Medication abortions — a two-step regimen of mifepristone and misoprostol — now account for over 50 percent of legal abortions in the United States. A patient first takes mifepristone as a single pill, which blocks the hormone progesterone, preventing a pregnancy from progressing. About 24 hours later, the patient typically takes a four-pill dose of misoprostol, a drug introduced in 1973 to treat stomach ulcers, to soften the cervix and prompt contractions that expel the embryo or fetus. The two-step approach is standard in the United States and is approved as safe for the first 10 weeks of gestation, which begins on the first day of a person’s last menstrual cycle. (The World Health Organization says medication abortion is safe in the first 12 weeks of pregnancy.) It is also possible to terminate a pregnancy using just misoprostol, a procedure that requires three doses of four pills each. While misoprostol is widely used on its own to perform abortions around the world, studies show it is less effective than the two-step regimen, and usually causes more cramping and potential side effects, including diarrhea, fever and chills. The FDA has found that medication abortion is a safe and highly effective method of pregnancy termination. When taken, medication abortion successfully terminates the pregnancy 99.6 percent of the time, with a 0.4 percent risk of major complications, and an associated mortality rate of less than 0.001 percent.

How do the decisions affect abortion access?

The conflicting rulings make it more likely the Supreme Court will hear the debate. In Texas, U.S. District Judge Matthew J. Kacsmaryk stayed his own order for seven days to give the government time to appeal. Access to the two-drug regimen will likely vary across the country. In states where abortion is legal, clinics could limit their offerings to surgical abortions, which require far more time and resources than pills. But many providers say they will continue to offer medication abortions — using only misoprostol if need be. Others say they have been stockpiling mifepristone while it is still FDA-approved, and will continue using that supply of the drug. Washington state officials have stocked up on mifepristone in preparation for the possibility that it could become much more difficult to access, NPR reported . Gov. Jay Inslee, a Democrat, says he ordered the Washington Department of Corrections to use its pharmacy license to buy 30,000 doses of mifepristone, an estimated three-year supply for patients in Washington state. The pills were received on March 31. In addition, experts say that Aid Access, a nonprofit based in Austria, most likely will continue to ship generic mifepristone from India to consumers in the United States. “There will still be ways to get the two-pill regimen,” said Abigail Aiken, an associate professor at the University of Texas at Austin. In a recent column in Slate , several prominent law professors noted that withdrawing approval of any drug is a lengthy process that requires FDA hearings and deliberations. In addition, they wrote, the agency could allow mifepristone to stay on the market under a policy known as “enforcement discretion,” used for products that don’t pose safety concerns.

What does the mifepristone lawsuit allege?

The FDA has repeatedly deemed the two-step medication abortion protocol to be safe and effective. But the lawsuit brought in Texas by several antiabortion groups and doctors argues that the regulatory agency never should have approved mifepristone back in 2000, claiming the government purposely ignored what the plaintiffs contend are harmful side effects. Leading organizations of physicians and other public health professionals have strongly disputed those allegations. These groups told Kacsmaryk that reversing FDA approval of mifepristone would “cause profound and irreparable harm to patients across the country.” Medication abortions with mifepristone have “an exceptionally low rate of complications,” according to their brief.

How can I get abortion pills now?

Both mifepristone and misoprostol require a prescription from a certified health-care provider. In states where abortion is legal, patients can pick the drugs up at clinics or doctors’ offices or order them by mail. In January, the FDA made a long-sought rule change that allows retail pharmacies to dispense abortion medication pills directly to consumers in states where the procedure is legal. But analysts say that implementing the requirements to dispense mifepristone, including being able to maintain provider confidentiality and track shipments, will take some time and may dissuade smaller stores from participating. In early March, under pressure from antiabortion advocates, Walgreens said it would withhold sales of mifepristone in Alaska, Iowa, Kansas and Montana regardless of how Kacsmaryk rules. Some states have adopted strategies to restrict medication abortions including establishing early gestational age limits for the procedure or requiring a physician to be present when the patient takes the medication. Arizona has banned mailing the pills , according to the Guttmacher Institute, a nonprofit research center based in New York and Washington that supports abortion rights. Activists have devised clandestine networks to distribute the drugs in states with bans, often importing the medications from Mexico and then relaying them to pregnant people who have reached out on social media.

Could the lawsuit affect the FDA more broadly?

The Justice Department wrote in a court filing that the lawsuit has the potential to undermine the country’s process for regulating pharmaceuticals. The judge’s decision to side with conservative groups creates an unprecedented situation by ordering the FDA to remove a medication from the market despite opposition from the agency and the drug’s manufacturer. “The injunction request is extraordinary and unprecedented,” the Justice Department said in its brief. “Plaintiffs have pointed to no case, and the government has been unable to locate any example, where a court has second-guessed FDA’s safety and efficacy determination and ordered a widely available FDA-approved drug to be removed from the market.” Congress created an “onerous and difficult process” for the FDA to take an approved drug off the market, according to Greer Donley, a professor at the University of Pittsburgh School of Law and one of the authors of the Slate column — which means that, once the FDA approves a medication, drug manufacturers can reasonably assume the approval is permanent and binding. “[If] one judge, who literally has no scientific background, can come in and circumvent that whole process and order the FDA to remove a product from the market, it’s just potentially very concerning,” Donley said. She cited concerns about potential backlash to drugs for stigmatized conditions, such as PrEP to reduce the risk of contracting HIV or drugs for gender-affirming care: “This really does have the potential to disrupt a lot of the assumptions that are baked into the drug-approval process.”

Isn’t abortion legally protected in many blue states?

Yes. But state laws only protect access to abortion in a general sense, according to legal experts. They don’t protect any particular form of abortion.

Who brought the lawsuit heard in Texas?

The conservative legal group Alliance Defending Freedom brought the lawsuit on behalf of four antiabortion organizations and four doctors who say they have treated patients with mifepristone. Abortion rights advocates have accused the group of “judge shopping,” filing in Kacsmaryk’s district because they believe the judge may be more inclined than others to rule favorably in the case. Lawyers for Alliance Defending Freedom would not say whether Kacsmaryk’s presence affected their decision to file in Amarillo.

Who brought the lawsuit heard in Washington state?

Attorneys general for 17 states and D.C. sought to eliminate federal regulations on mifepristone that complicate access even where abortion is legal. They also asked U.S. District Judge Thomas Rice in Spokane to block the FDA from taking any action to pull the pill from the market or reduce its availability. The 17 states are Arizona, Colorado, Connecticut, Delaware, Illinois, Michigan, Nevada, New Mexico, Oregon, Rhode Island, Vermont, Hawaii, Maine, Maryland, Minnesota, Pennsylvania and Washington.

Politics

Can I still get a medication abortion?

The answer is complicated and likely dependent on where you live, thanks to dueling decisions by federal judges in Texas and Washington

By Caroline Kitchener

Ann E. Marimow

Laurie McGinley

Rachel Roubein

and

Frances Stead Sellers

Updated April 7, 2023 at 9:35 p.m. EDT|Published March 1, 2023 at 10:00 a.m. EST

Franz Theard watches a patient from Texas take mifepristone, the first medication in a medical abortion, with medical assistant Elizabeth Hernandez, at his clinic, Women’s Reproductive Clinic of New Mexico in Santa Teresa on Jan. 13. (Evelyn Hockstein/Reuters)

8 min

A federal judge in Texas blocked U.S. government approval of a key abortion medication late Friday, siding with abortion foes in an unprecedented lawsuit.

In a competing opinion a short time later, another federal judge in Washington state ruled in a separate case that the drug is safe and effective. He ordered the Food and Drug Administration to retain access in the 17 states — along with D.C. — that are behind the lawsuit seeking to protect medication abortion.

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The dueling decisions create a standoff that will likely go to the Supreme Court, while creating confusion about the legality of the commonly used drug even in states where abortion is legal.

A Texas judge on April 7 blocked FDA approval of a widely used abortion pill. The decision will likely be appealed and could go to the Supreme Court. (Video: Billy Tucker, Zach Purser Brown/The Washington Post)

Here’s a look at medication abortions — the most common method of terminating a pregnancy in the United States — and how the cases could shape abortion care nationwide:

Abortion access in America

Tracking abortion access in the U.S.: After the Supreme Court struck down Roe v. Wade, the legality of abortion is left to individual states. The Post is tracking states where abortion is legal, banned or under threat.

Abortion pills: The Justice Department appealed a Texas judge’s decision that would block approval of the abortion pill mifepristone. The Supreme Court decided to retain full access to mifepristone as the appeal proceeds. Here’s an explanation of what happens next in the abortion pill case.

Post-Roe America: With Roe overturned, women who had secret abortions before Roe v. Wade felt compelled to speak out. Other women who were seeking abortions while living in states with strict abortion bans also shared their experiences with The Post through calls, text messages and other documentation. Here are photos and stories from across America since the reversal of Roe v. Wade.