Medication Abortion Access Should be Based on Science, Not Politics

In October of 2018, the international group AidAccess.org, led by Dr. Rebecca Gomperts, began offering mifepristone and misoprostol, commonly known as medication abortion or abortion pills, by mail to patients in the United States. After an online medical consultation with a patient, Dr. Gomperts writes a prescription and a pharmacy fills the prescription and ships pills to the patient. According to analysis conducted by a research team at the University of Texas at Austin, in its first year of operation AidAccess.org received over 21,000 requests for abortion pills, without any advertising or outreach.¹

The two-medication combination that AidAccess.org is providing has been demonstrated to be safe and effective in extensive research and is the same combination approved for use in the United States by the Food and Drug Administration (FDA). Yet, despite the strong safety record of medication abortion, in March 2019 the FDA sent warning letters to AidAccess.org and Dr. Rebecca Gomperts, stating that they are violating the Federal Food, Drug, and Cosmetic Act by offering mifepristone and misoprostol directly to U.S. consumers seeking to end a pregnancy. The agency demanded that AidAccess.org immediately cease offering these medications to people in the United States.

If the laws and regulations that determine the terms of abortion access in the United States were based on science – not politics – medication abortion would be widely available in the United States without medically unnecessary restrictions on distribution. Abortion with quality pills delivered by mail directly to one’s home with instructions for use in multiple languages and access to medical counseling and back-up, if needed, should be one of an array of abortion options available, ensuring everyone who needs to end a pregnancy has the freedom and control to do so in the way that best fits their lives. However, due to the politics of abortion, medication abortion has been over-regulated² by the FDA, and pushed further out of reach for many by state restrictions.

The high demand for medication abortion by mail should come as no surprise. Access to abortion is under direct threat today, with near-total bans on abortion care recently signed into law in Alabama, Georgia, Kentucky, Mississippi, and Ohio.³ This is happening in a context in which abortion is already inaccessible for many: 90% of U.S. counties have no abortion clinic.⁴ In addition to having to travel a long distance to the nearest abortion clinic, many people have to endure legally-mandated waiting periods. These medically unnecessary waiting periods create further challenges for people who have to take time away from work or school or arrange for childcare.⁵ These hurdles may increase the cost of an abortion, which averages $500 in the first trimester and only becomes more expensive as pregnancy progresses. In 35 states and the District of Columbia, Medicaid does not cover abortion care except in rare cases, making abortion financially inaccessible for low-income people.⁶ These restrictions are about control and limiting options, not safety or health.

So it is not surprising that online sources such as Aid Access are the only way for some women, and others who become pregnant, to access abortion pills to get the health care they need. What might be a surprise to some is that self-managing an abortion with quality pills, instructions for use, and access to medical counseling and back-up, if needed, is a safe and effective way to end a pregnancy.⁷ After decades of use by millions of people in the United States and throughout the world, the evidence supporting the safety and effectiveness of medication abortion is clear.⁸ In Canada, the same medications are available at pharmacies, like other prescription medications, without the unusual and burdensome restrictions imposed in the United States. Research in countries, such as Ireland, where services very similar to Aid Access have been provided, indicates that patients are able to safely use the medications as directed and self-refer to a health care provider when needed.⁹ And in an article about expanding available options for abortion care in the United States, the Guttmacher Institute, one of the leading research institutions on abortion, argues for “access to the full range of safe and effective options for abortion care, including self-management with medication.”¹⁰

The risk for a person self-managing an abortion with pills in the United States today is not medical but legal. Since the year 2000, there have been at least 21 known arrests in the United States of people for ending their own pregnancy or helping someone who has made the decision to do so. Some have gone to jail, but even those who have not have had their lives turned upside down by investigations and in some cases have suffered economic and social harm caused by negative media exposure. The threat of investigation, arrest, or punishment is particularly of concern for those who live under heightened government surveillance, including many in immigrant communities. Five states currently have laws on the book that criminalize self-managed abortion.¹¹ The fact that these laws are generally outdated and likely unconstitutional¹² does not mean that they are inert; they have been used in the last decade to arrest, investigate, and prosecute people who ended or who were suspected of ending their own pregnancies. And in states without such laws, prosecutors who wish to punish people for abortion have used laws that were never intended to apply to self-managed abortion to target people who have ended, or are suspected of ending, their own pregnancies.¹³

The anti-abortion politicians and activists who propose and enact abortion restrictions are attempting to legislate legal abortion out of existence. They are well aware that the FDA’s restrictions and actions are a key element in the success of their own efforts to make abortion inaccessible.

The undersigned experts and organizations stand in solidarity with the millions of people who are trying to make the best decisions for themselves and their families and with those who are unable to access safe abortion care under the politically constricted conditions in the United States. We stand against punishing people for seeking health care, and we stand against using the FDA as a pawn to advance a political agenda that aims to deprive people of their dignity and humanity as well as their constitutional right to make intimate decisions about their pregnancies. We urge the FDA, state legislators, and all policy-making bodies to be guided by the science and support the removal of unnecessary regulatory barriers that make safe and effective abortion medications inaccessible to people who need them.

Signed:

Organizations

Abortion Access Front
Abortion Care Network
ACCESS Women’s Health Justice
Advocates for Youth
All-Options
Carolina Abortion Fund
Catholics for Choice
Chicago Abortion Fund
Civil Liberties and Public Policy Program
Clarinda Regional Health Center
Feminist Women’s Health Center
Forward Together
Gateway Women’s Access Fund
If/When/How: Lawyering for Reproductive Justice
In Our Own Voice: National Black Women’s Reproductive Justice Agenda
Ipas
Legal Voice
Maine Family Planning
Mariposa Fund
Medical Students for Choice
Midwest Access Coalition
NARAL Pro-Choice Arizona
NARAL Pro-Choice Colorado
National Abortion Federation
National Asian Pacific American Women’s Forum (NAPAWF)
National Latina Institute for Reproductive Health
National Institute for Reproductive Health
National Organization for Women
National Partnership for Women & Families
National Network of Abortion Funds
National Women’s Health Network
New Voices for Reproductive Justice
Nurses for Sexual and Reproductive Health
Pendergast Consulting
Physicians for Reproductive Health
Plan C
Planned Parenthood Federation of America
Progress Florida
Public Leadership Institute
Religious Coalition for Reproductive Choice
Reproaction
Reproductive Health Access Project
SisterLove, Inc.
SisterReach
Surge Reproductive Justice
URGE: Unite for Reproductive & Gender Equity
West Virginia Free
Whole Woman’s Health/Whole Woman’s Health Alliance
Women on Web

Individuals (affiliations included for identification purposes only)

Abigail Aiken, MD, MPH, PhD, University of Texas at Austin
Maureen Baldwin, MD MPH, Oregon Health & Science University
Antonia Biggs, PhD, University of California, San Francisco
Sharon Camp, PhD
Don Downing, Pharmacy, University of Washington
Marji Gold, MD
Kelsey Holt, ScD, Person-Centered Reproductive Health Program, University of California, San Francisco
Sarah Horvath, MD, MSHP
Jennifer Karlin, MD/PhD, University of California, San Francisco
Katrina Kimport, PhD, Advancing New Standards in Reproductive Health, University of California, San Francisco
Amy Levi, PhD, CNM, WHNP-BC, University of New Mexico
Ghazaleh Moayedi, DO, MPH, Physicians for Reproductive Health
Kathleen Morrell, MD, MPH
Sumathi Narayana, MD, Montefiore Medical Center/Department of Family and Social Medicine
Elizabeth Newhall, MD, Whitebird Free Clinic
Melanie Pena, MPH, MA, Gynuity Health Projects
Citlali Perez, Person-Centered Reproductive Health Program, University of California, San Francisco
Jamila Perritt, MD
Karen Plafker, MA, MSc
Rev. Katherine Ragsdale, D. Min., National Abortion Federation
Reiley Reed, MPH, Person-Centered Reproductive Health Program, University of California, San Francisco
Sarah Roberts, DrPH, Advancing New Standards in Reproductive Health
Corinne H. Rocca, PhD, Advancing New Standards in Reproductive Health, University of California, San Francisco
Ilana Silverstein, BA, Person-Centered Reproductive Health Program, University of California, San Francisco
Mindy Sobota, MD, MS, Mphil, Brown University – Alpert Medical School
Karen Thurston, All-Options Pregnancy Resource Center
Rena Tucker, MSW, The Center For Reproductive Health Education In Family Medicine, Department of Family and Social Medicine – Montefiore Medical Center (RHEDI)

Endnotes

¹ Hannah Devlin, Revealed: 21,000 US women order abortion pills online in past year, The Guardian, May 22, 2019.
² Mifeprex REMS Study Group (2017). “Sixteen Years of Overregulation: Time to Unburden Mifeprex.” N Engl J Med 376(8): 790-794.
³ None have taken effect, and it is expected that all will be challenged in court.
⁴ Jones, R. K. and Jerman, J. (2017), Abortion Incidence and Service Availability In the United States, 2014. Perspect Sex Repro H, 49: 17-27.
⁵ Roberts, S. C., Turok, D. K., Belusa, E. , Combellick, S. and Upadhyay, U. D. (2016), Utah’s 72‐Hour Waiting Period for Abortion: Experiences Among a Clinic‐Based Sample of Women. Perspect Sex Repro H, 48: 179-187.
⁶ Reproductive Health Technologies Project, Two Sides of the Same Coin: Integrating Economic and Reproductive Justice, 2015, http://rhtp.org/wp-content/uploads/2016/08/Two-Sides-of-the-Same-Coin-Integrating-Economic-and-Reproductive-Justice.pdf
⁷ Aiken, A. R., Digol, I., Trussell, J., & Gomperts, R. (2017). Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland. BMJ, 357.
⁸ National Academies of Sciences, Engineering, and Medicine. (2018). The safety and quality of abortion care in the United States. National Academies Press.
⁹ Aiken, A. R., Digol, I., Trussell, J., & Gomperts, R. (2017). Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland. BMJ, 357.
¹⁰ Donavan, M.K. (2018) Self-Managed Medication Abortion: Expanding the Available Options for U.S. Abortion Care. Guttmacher Policy Review, 21: 41-47.
¹¹ Roe’s Unfinished Promise Update, https://www.ifwhenhow.org/resources/roes-unfinished-promise-2019-update/
¹² See McCormack v. Heideman
¹³ Roe’s Unfinished Promise Update, https://www.ifwhenhow.org/resources/roes-unfinished-promise-2019-update/