Thanks to a recent column by Nicholas Kristof, the celebration of the 10th anniversary of the FDA’s approval of mifepristone, and a creative use of teleconferencing to bring abortion care to women living in rural Iowa, medical abortion is in the news. As a provider who is, above everything, pro-choice, I am of course thrilled that women have had another choice for ten years. I also welcome the media coverage of medical abortion; we need to talk more about abortion, and women deserve to know all the options available to them.
I am, however, less than pleased about how this issue has been covered in the media, particularly on the Internet. The information I’ve seen isn’t wrong; it’s just incomplete. I hope this post can clear up some of the confusion.
Medical abortion basics:
Medical abortion is a safe alternative to surgical abortion. It is used in the US for pregnancies up to 9 weeks after the first day of the last menstrual period. In some countries it is used up to 13 weeks after the first day of the last menstrual period, although there are some differences in the timing and dosages of the 2 medications used. (Of note, the US packaging states one of the medications used, mifepristone, can be used up to 7 weeks after the last period; however, it is labeled for up to 9 weeks in Europe and we have ample evidence that it is safe and effective even later than this).
In the US, medical abortion is usually done using two different medications. The first medication is called mifepristone. It is also called Mifeprex (its brand name) or RU-486 (its experimental name). Mifepristone causes the lining of the uterus that is necessary to maintain the pregnancy to start to recede, softens the cervix, and starts to cause uterine contractions.
The second medication is misoprostol, which further softens the cervix and causes the uterus to contract, expelling the pregnancy. It is taken anywhere from 6-48 hours after the mifepristone (depending on the protocols of the clinic you go to), and is used either buccally (absorbed through the cheek), vaginally, or orally (swallowed).
Mifepristone has the disadvantage of being very expensive (about $80 per pill). When medical abortions were first introduced, 600 milligrams (or three pills) were used; now we know just one pill is equally effective, which has brought the cost down considerably, but remains out of reach for most women in developing countries (and, unfortunately, for many women in developed countries as well).
Another disadvantage of mifepristone is that its availability depends on the politics of the country in which the woman resides. Although mifepristone has been available in France since 1988, its spread around the world has been accompanied by political drama. The company’s initial distributor in France announced its intention to remove the drug from the market following objections from its majority owner, only to be required by the French government to resume sales in the interest of the public good. Availability expanded gradually through Europe and mifepristone became available in the US in September 2000; however, it is treated differently from most other medications in that it can only be purchased and dispensed by approved physicians, meaning that I can’t simply give a woman a prescription to have filled at a pharmacy. (Mifepristone is still unavailable in Canada, so medical abortions there are done using a different medication, methotrexate.)
Unlike mifepristone, misoprostol is inexpensive (usually less than $1, significantly less in some countries) and widely available throughout the world, thanks to its other use as a treatment for stomach ulcers, as well as to induce labor in women with further advanced pregnancies. Because of this, in countries in which mifepristone and unsafe aspiration abortion are unavailable, misoprostol alone is sometimes used for medical abortion (though used alone it is less effective than using both medications together, especially when used later than 9 weeks).
The combined mifepristone/misoprostol regimen is somewhere between 95-99% effective (depending on which study you read). In other words, the procedure almost always works. Most women know whether it worked or not because they no longer feel pregnant; however, to be sure most providers will either check a blood test for the level of the pregnancy hormone or check an ultrasound. In the rare circumstance that the medication didn’t lead to a complete abortion, women usually have the option to either take the medicine again or undergo an aspiration procedure.
In the global scheme of things, medical abortion has increased the options available to women worldwide. In countries where mifepristone is available, women can choose between undergoing a procedure or taking the pills and having the abortion at home. Women in rural areas can access the medications without having to travel hundreds of miles from home, and there is mounting evidence that women can safely take both the medications at home at a time that is convenient for them, and that they don’t need to return to their provider to ensure that the abortion is complete.
In countries where legal abortion is unavailable, women can buy misoprostol at the pharmacy to induce abortions on their own. This is far from ideal; while it may work most of the time, there are plenty of ways it can cause harm. However, for women who are desperate not to be pregnant, it presents a safer option than many of the alternatives.
So, here’s to 10 years of mifepristone in the US, and to all the woman-centered changes in care to come.