Editor’s note: On June 24, U.S. Supreme Court overturned the landmark Roe v. Wade abortion case and upheld a Mississippi law that bans nearly all abortions past 15 weeks of pregnancy. That ruling did not affect the availability of abortion in Oregon and Washington, where the procedure is protected by state law. But court challenges to the FDA approval of mifepristone, a drug used to induce abortions in early pregnancy, could affect people wanting to end their pregnancies in Oregon and Washington. For now, the U.S. Supreme Court has blocked lower court rulings that would limit access to the medications. This story — originally published before the landmark ruling — explains what mifepristone and misoprostol actually do when they are used to end a pregnancy. It has been lightly edited from the original to provide up-to-date political context. The way the pills work has not changed.
In 2020, for the first time, medication abortions accounted for more than half of all abortions in the United States. That’s after the pandemic led the Food and Drug Administration to lift a restriction that had required doctors to dispense mifepristone, one of the two pills used to induce abortion, in person.
For the last 23 years, the pills have been approved to terminate a pregnancy. The pills can be taken at home at up to 10 weeks of pregnancy and they cause similar symptoms to spontaneous miscarriage.
Flowers arranged in the shape of a uterus by Krissy Shields are seen near the steps of the Supreme Court on Friday, April 21, 2023, in Washington after the court decided to preserve women's access to a drug used in the most common method of abortion.
Jacquelyn Martin / AP
As long as the pills remain available in states that allow abortion and through online suppliers, they have offered a potential workaround for anyone who wants an abortion but doesn’t have the resources to travel to a state where it is legal. While the number of abortions recorded in the United States has declined overall since Roe v. Wade was overturned, the number of telehealth appointments for prescribing abortion pills has increased by 137% according to data collected by the Society of Family Planning.
In Oregon, a state with no restrictions on abortion, the pills are still available at a wide variety of hospitals and clinics and through telehealth appointments. In April, Oregon Gov. Tina Kotek announced that the state had secured a three-year supply of mifepristone to ensure patient access. Washington Gov. Jay Inslee had made a similar announcement a few weeks earlier.
The number of abortions in both states has risen since Roe was overturned last year.
To put together this guide, we spoke with two experienced obstetrician-gynecologists, the doctors who typically provide prenatal care and deliver babies, about abortion pills.
Oregon Health & Science University’s Dr. Maureen Baldwin has been part of clinical trials of telemedicine abortion — where a medical provider meets with and evaluates a patient via videoconference — before and during the pandemic.
Dr. Paula Bednarek is an associate professor of obstetrics and gynecology at OHSU and the medical director of Planned Parenthood Columbia-Willamette.
Both doctors are supporters of abortion rights.
1. What is medication abortion?
Using pills to end an unwanted pregnancy, or to manage a miscarriage, is known as a “medication abortion.” The most effective method uses two drugs: mifepristone and misoprostol.
Mifepristone, originally known as RU-486, is taken first. It blocks progesterone, a hormone that’s needed to continue a pregnancy.
The second medication, misoprostol, is generally taken at least 24 hours later. It starts contractions and prompts the body to expel the pregnancy. (This medication is also sometimes used to induce labor at the end of a full-term pregnancy.)
Each medication has been used individually to induce abortion, but they are most effective when taken in combination at nine weeks or less. When a pregnancy is less than seven weeks along, there is a less than 1% chance of a pregnancy continuing after following the two-step protocol, according to Baldwin’s research. After seven weeks, the chance of a pregnancy continuing rises incrementally. In the 10th week of pregnancy, the chance of a pregnancy continuing is about 8%.
2. How safe is medication abortion?
In the U.S., medication abortion has an associated mortality rate of less than 1 in 100,000, according to the Kaiser Family Foundation. The mortality rate associated with giving birth is 23.8 deaths per 100,000 live births, according to the Centers for Disease Control and Prevention. In the United States, there are more deaths annually due to accidental Tylenol overdoses than from all types of abortion.
During a minority of medication abortions — less than 5% — complications arise. The most common complication is that it doesn’t work. In that case, a follow-up surgical abortion is required.
In less than 1% of cases, medication abortions can cause more serious and even fatal complications. These include prolonged heavy bleeding, infections and sepsis, and ruptured ectopic pregnancies.
According to the mifepristone label, people should contact their provider or seek help if they have:
- a fever of 100.4 degrees Fahrenheit or higher that lasts for more than four hours
- severe stomach area (abdominal) pain
- heavy bleeding (soaking through two thick full-size sanitary pads per hour for two hours in a row)
- stomach pain or discomfort, or “feeling sick,” including weakness, nausea, vomiting or diarrhea, more than 24 hours after taking misoprostol
In an extremely small number of cases, medication abortion has been linked to infection with clostridium sordellii, a particularly dangerous type of bacterial infection that’s also a rare complication of miscarriage and childbirth. It can trigger toxic shock syndrome and can be hard to diagnose because patients may have an infection without a fever.
3. What about the safety of medication abortion provided via telemedicine, without an ultrasound and in-person doctor’s visit first?
That’s also safe, according to research conducted during the pandemic.
A study published in 2021 looked at more than 50,000 patients in the United Kingdom who received medication abortions. One group had received the pills at an in-person clinic visit that included an ultrasound. The other group received the pills by mail, after a telehealth consultation.
The study found no evidence of worse outcomes linked to telemedicine abortion. It found telemedicine abortion had significant advantages. Patients had shorter waiting times and there was a 40% increase in the number of abortions provided at 6 weeks gestation or less.
The FDA warns against purchasing mifepristone and misoprostol outside of the American medical system.
4. Who can get a medication abortion?
Medication abortion is used to end pregnancies that are less than 10 weeks, or 70 days along, counted from the last day of the most recent period.
It’s also an option that can help manage pregnancy loss when the process of miscarrying has started but hasn’t been completed naturally.
Medication abortion can be used at any point after getting a positive pregnancy test, around four weeks.
In a clinical or hospital setting under medical supervision, medication abortion can sometimes be used to end a pregnancy that is further than 10 weeks along. There is a higher risk of significant and dangerous bleeding after 10 weeks.
There are relatively few risk factors that make the procedure unsafe for people seeking an abortion in early pregnancy. Medication abortion is not used for people with a known allergy to mifepristone, certain bleeding disorders, suspected ectopic pregnancy, chronic adrenal failure, or people on chronic steroid therapy. It is also not used when someone has gotten pregnant with an IUD in place.
5. Can Oregon-based doctors prescribe abortion pills to people from other states?
Yes, but only if those people are physically located in Oregon for their appointment or telehealth appointment.
That is part of how all telemedicine is regulated. Providers have to be licensed in the state where the patient is located and follow the laws of the state where the patient is located.
The patient also needs an Oregon mailing address if they plan to receive pills by mail.
6. How does someone get a medication abortion in Oregon?
In the United States, getting mifepristone requires a consultation and prescription from a doctor or health professional. In Oregon, that can happen in person, or through telemedicine — over the phone or online.
First, a doctor evaluates the patient to confirm how far along they are in pregnancy and to determine if there are any reasons the procedure might not be safe for a particular patient. An ultrasound is usually unnecessary.
Patients can pick up the medication in person at a doctor’s office or Planned Parenthood clinic, or have the medication mailed to them. As of January, pharmacies with special certifications have been allowed to stock mifepristone, but the drug is still not widely available at most brick-and-mortar pharmacies.
After taking the second medication, misoprostol, the patient may feel nauseous and throw up. They will have a lot of bleeding and cramping.
The length of time it takes to pass the pregnancy tissue can vary. It can be a very fast process, 90 minutes overall. Or the bleeding and pain can last a few days, and come and go in waves.
Standard care includes a follow-up evaluation to ensure the pregnancy tissue has all been passed.
At OHSU, for example, there are three options: a self-evaluation and home pregnancy test a few weeks afterward, an ultrasound in a clinic following the abortion, or blood tests for pregnancy hormone levels before and after the procedure.
“Some people really want to have a visual,” Baldwin said. “In fact, we know that a lot of people come to emergency departments after a medication abortion for reassurance actually that the pregnancy has completed.”
7. Where is medication abortion available in Oregon?
Abortions are available at all Planned Parenthood health centers, at many private obstetrics and gynecology practices and in the Kaiser Permanente, OHSU and Legacy Health systems.
Providence Health Services provides medical and surgical abortions for patients experiencing miscarriage, pregnancy loss, or a life-threatening emergency, along with resources to cope with the loss. Providence will not provide induced or elective abortions. Providence patients who are Oregon Health Plan members can access abortion through a different provider, regardless of the reason, by calling Oregon Health Plan client services at 1-800-273-0557.
Neither the Indian Health Service nor Veterans Affairs provide abortions, due to the Hyde Amendment, a law that restricts federal funding for abortion.
Federally Qualified Health Centers, which provide primary care to low-income, uninsured, rural and historically disadvantaged populations, also do not provide abortions, due to congressional restrictions. They do provide referral services for abortions and other options for their patients.
Boxes of the drug mifepristone line a shelf at the West Alabama Women's Center in Tuscaloosa, Ala., on Wednesday, March 16, 2022. The drug is one of two used together in "medication abortions." According to Planned Parenthood, mifepristone blocks progesterone, stopping a pregnancy from progressing.
Allen G. Breed / AP
8. How is medication abortion regulated federally and in Oregon?
Mifepristone was invented in France and was first approved by the FDA for abortion, in combination with misoprostol, in 2000.
Misoprostol is FDA-approved to treat ulcers. It’s used for abortions and, at a lower dose, for labor induction. The medication’s uses in gynecology are included in the labeling for mifepristone and are considered safe by the American College of Obstetricians and Gynecologists.
The FDA regulates mifepristone more tightly than most drugs and collects more complete safety data on it. Since 2011, the FDA has added what is known as a Risk Evaluation and Mitigation Strategy (REMS) to the drug. Doctors who prescribe it have to follow some special record-keeping practices and report any cases of complications, and patients who take it have to sign a form saying they’ve been informed of the risks.
In December 2021, the FDA rolled back some prior restrictions on the drug. That change was challenged in a federal court in Texas in fall 2022 in a case brought by a conservative group calling for the invalidation of the drug’s FDA approval. Simultaneously, a collection of state attorneys general challenged the extra restrictions that still exist, arguing they were unnecessary and political. Both cases are now making their way through the federal courts. Until the legal challenges are resolved, the U.S. Supreme Court has ruled that mifepristone will remain available as a medication prescribed to end pregnancy in states where abortion is legal.
9. Why are more people choosing to end pregnancies with pills rather than undergo a surgical abortion?
Some may prefer being able to have an abortion in the comfort of their home. Some people may feel it is less invasive or more natural than a surgical procedure. Medication abortion via telehealth may be easier for those who live in parts of the state without a nearby abortion provider.
It is also easier to book an appointment for a medication abortion, according to Bednarek. Surgical abortions are only available in some Planned Parenthood locations in Oregon, on specific days of the week.
There is a similar safety profile for medication abortion and surgical abortion for early pregnancy. Surgical abortions do have advantages. They are more predictable and over more quickly, with less bleeding.
“If somebody wants to have sedation and be asleep and have it be less pain and be over with more quickly and not have to experience the process of the abortion, that is an option” with surgical abortion, Baldwin said.
10. What does it feel like to have a medication abortion?
A person’s pain level can vary based on their prior experience with pregnancy, birth or pregnancy loss. It can also vary based on how far along a pregnancy is. For some people, the cramping may be as painful as labor contractions. For others, it is more like bad period cramping.
Ibuprofen, a heating pad, and a warm bath or shower can be effective in helping patients manage the most significant cramping, which typically lasts for four to six hours.
People should not take aspirin. It can cause them to bleed more.
Some patients may want stronger pain medication.
“We talk with patients and we provide whatever pain medicine they feel that they need, which might include a prescription for a narcotic pain medicine, but most often over-the-counter medicines are really effective,” said Bednarek.
There can be a physical and emotional recovery process afterward, that can vary with the circumstances that surround a person’s choice to get abortion care. Some feel relief. Others feel sadness. Many feel lots of things all at once.
11. Does insurance cover medication abortion?
For someone living in Oregon, often. Medication abortion is covered by the Oregon Health Plan and by many private insurance plans. It is not covered for tribal members who get care through the Indian Health Service, nor to veterans who get care through the VA, due to the Hyde Amendment.
It is not covered for people on a Providence health plan.
12. What role does medication abortion play in states where abortion is no longer legal?
The pills may make illegal or self-managed abortions safer than they were in 1973.
“In terms of what options are for self-managed abortions we’re a world away from where we were,” Bednarek said.
There is some evidence, for example, that the availability of misoprostol in some Caribbean, Latin American and African countries has reduced maternal mortality from unsafe abortions.
And while the U.S. Department of Justice has stated that the drugs can legally be mailed to any address in the country, self-managed abortion may carry legal risks for people in states where abortion is banned.
A new law in Idaho, for example, makes it a crime to help a minor obtain abortion pills without their parent’s knowledge. In Texas, three women have been sued for helping a friend obtain abortion pills. That case is still playing out, and the women have filed their own countersuit.
The Oregon Department of Justice has created a hotline, staffed by volunteer attorneys, for anyone with questions about Oregon state laws and abortion. It’s free to use the service. The Oregon Reproductive Rights Hotline can be reached at 503-431-6460.
In some states with laws that oppose abortion, prosecutors have filed homicide charges against people who tried to end their pregnancies outside the medical system, even before the Supreme Court’s Dobbs decision.
Bednarek says in states where Planned Parenthood cannot legally provide medication abortion, it can provide information to anyone who has obtained pills outside the regular health care system.
“If patients call us with questions and need help, we are here to support them at any point through their process,” she said.
Anyone who has started the process outside the health care system and is experiencing complications or warning signs can also get help at Planned Parenthood.
“We can still do an ultrasound, we can help them with additional medications or an aspiration procedure if that’s part of what’s needed, we can evaluate them for ectopic pregnancy,” Bednarek said. Patients should “not feel worried that they will be judged or turned in or something like that.”
Lillian Mongeau Hughes contributed reporting to the updated version of the story published here.
