Why the Abortion Pill Didn’t Change Everything

Photo: Bill Greenblatt

In 1993, Time magazine declared mifepristone — the abortion pill that’s often called RU-486 — “The Pill that Changes Everything.” In 1999, The New York Times Magazine called it a “little white bombshell” with “enormous political consequences.” On a political level, activists hoped that it would allow women to sidestep clinic protests and make abortion less controversial. Advocates hoped — and anti-abortion groups feared — that the abortion pill would be prescribed by regular doctors, family practitioners and OB/GYNs, allowing women to have an abortion in the privacy of their home, far from the picket lines. It would move abortion toward the mainstream realm of routine health care. And on a medical level, women were curious about the method: taking a pill seemed to promise a more convenient, less invasive experience. 

By 2013, though, it’s become clear that the pill hasn’t revolutionized the way most women get abortions; it’s become just another front in the legislative and legal battles over reproductive rights, one more method pro-choice activists must fight to defend. This week the Supreme Court ruled in favor of a lower court’s decision that Oklahoma had gone too far in its attempt to ban medication abortions. And even though the World Health Organization says the pill is safe to be administered by medical professionals who aren’t doctors, many states have passed bills that say only a physician can administer it — in person. In Iowa this week, a judge blocked an effort that would have prevented women from obtaining a prescription for the abortion pill from their doctor over the phone. But as with most abortion regulations, these restrictions just make the procedure harder to get, not safer. And in many cases, they make it more dangerous, forcing doctors to go against the best medical knowledge about providing medication abortions.

Some veterans of the abortion wars saw this coming. “I said at the time that neither of these extremes would be the case,” former Planned Parenthood president Gloria Feldt told me several years ago. “It wouldn’t be a panacea for women and for abortion rights, nor would it be as easy as popping a pill. It was so hard to get that across. Because people just want the abortion debate just to go away.”

To understand both the high hopes for and the modern controversy over medication abortion, you have to understand how it works. It actually involves two pills: mifepristone to terminate a pregnancy, plus another pill, usually misoprostol, taken later to induce cramping and expel it. The FDA approved the first pill, mifepristone, for use in abortion in 2000 after a twelve-year political and legal fight led by pro-choice activists. Misoprostol, the cramping drug, is technically FDA approved for use as an ulcer treatment, so every time doctors prescribe it for use in abortion, they’re going “off-label.” (This doesn’t mean it’s dangerous; there are lots of drugs that medical science says are safe for use beyond the FDA-approved usage, and even the FDA agrees. These days, only 4 percent of medication abortions are performed according to the outdated FDA guidelines.) Since 2000, more and more women have chosen medication abortion — about one quarter of abortions prior to nine weeks are performed with the pill. Pregnancy is rarely detectable before four weeks, and the earliest surgical abortions are performed at seven weeks, making medication the only option for women who find out about an unplanned pregnancy early and want to end it quickly.

Of the 1.52 million women who have had a medication abortion, there are eight cases of women dying from an infection after taking mifepristone. The anti-choice movement has been quick to publicize them — most recently, an anti-abortion site carried an exhaustive report of a British woman who died after taking mifepristone. And every few years, a woman makes headlines after she orders abortion pills illegally and administers them herself at home. Cases like these are used to justify restrictions like the Oklahoma law, which said that doctors had to adhere to the original FDA guidelines. (It bears repeating that doctors prescribing medication off-label, in accordance with decades of research, and women ordering it online and taking it themselves are very different scenarios.) So much for medication abortion circumventing the political meddling that has plagued other medically safe abortion methods.

Then there’s a general false perception among women that medication abortion will be quicker and easier than a surgical procedure. “The majority think, ‘Hey, I’m gonna pop a pill and that’ll be it,’” the receptionist at an abortion clinic in Nebraska told me. With an early surgical abortion, a woman goes into a clinic and is sure she’s no longer pregnant when she comes out a few hours later. With medication abortion, the process can take up to 48 hours. Even after counseling at a clinic, many women are unprepared for the experience. “I took one pill at home, and I remember at one point actually feeling my cervix open. It was a terrifying feeling,” says Katie, who had a medication abortion in 2004. Another woman described pain that was “so intense that it’s hard to really remember. You sort of feel like you’re tripping or something.” A nurse at an abortion clinic once told me, “Women who have done both will go back to surgical. I’ve never had anyone who’s done both go back to medical.”

In some ways, medication abortion does offer more privacy. The most intense part of the process happens at home. Originally the FDA suggested women come to the clinic three times: to take the mifepristone, then two days later to take the misoprostol, then two weeks later to ensure the whole process worked. In the twelve years since the pill was approved, doctors have fine-tuned the process and realized that they can give women a lower dose of the first drug (a third of the amount) and allow them to take the second drug at home rather than coming back to the clinic for it. (This doesn’t make women any less safe.)

But these details are buried deep on medical websites and in private chats between women. The mainstream conversation is still dominated two extremes: The promise of a more private, less clinical abortion experience at home, and a dramatic and dangerous picture painted by anti-choice activists of a life-threatening, non-FDA-approved procedure. This is ultimately one of the biggest ways the political battle over abortion hurts women. In the absence of a rational dialogue about the pros and cons of all abortion methods, it can be hard to know where the truth lies. The debate also puts doctors under a microscope. Even the FDA itself encourages doctors to prescribe medication as they see fit — which is even more difficult to do in a politically charged environment. Which, in turn, ends up hurting their female patients.

For those of us who are pro-choice, it can be easy to forget that our task isn’t just to push back against abortion restrictions and, as the classic stickers say, keep abortion legal. It’s to be educated about abortion options — after all, one in four women American under age 30 has already had one — and talk fearlessly about the pros and the cons. It means knowing the statistics about how safe early abortions are, but also acknowledging the possibility that something could go awry. It means telling women frankly that the price of a private, non-surgical, at-home abortion is that it may take longer and be more painful. Open, fact-based dialogue — not a little white pill — is what has a real chance of moving the abortion debate forward.

Why the Abortion Pill Didn’t Change Everything