Laws Targeting Medication Abortion Threaten Women's Safety, Trend Toward Early Abortions

April 25, 2013 — Summary of "Medication Abortion Restrictions Burden Women and Providers and Threaten U.S. Trend Toward Very Early Abortions," Boonstra, Guttmacher Policy Review, Winter 2013.

"Over the last several years, a wave of provisions hostile to medication abortion have been introduced by antiabortion state and federal legislators," writes Heather Boonstra -- a senior public policy associate at the Guttmacher Institute -- noting that there are two main categories of provisions aimed at restricting medication abortion.

"The first requires that medication abortion protocols hew strictly to an outdated regimen specified by [FDA] when medication abortion was first approved, which prohibits alternative, evidence-based protocols in wide use for at least the past decade," Boonstra explains. The second category of restrictions "requires that medication abortion be provided only by a physician who is in the same room as the patient, essentially ruling out provision by physician assistants and advanced practice nurses or by telemedicine," she adds.

Boonstra states, "Antiabortion leaders disingenuously insist that these restrictions are necessary to protect women's health and safety," but "these restrictions are an attack on abortion itself" that "burden[s] women and potentially threaten[s] their health."

History of Medication Abortion in the U.S.

The medication abortion regimen, which is sold in the U.S. under the brand name Mifeprex, consists of two medications: mifepristone and misoprostol. Boonstra notes that medication abortions are both "highly effective" and "safe, as severe complications are extremely rare."

FDA originally approved Mifeprex in 2000 for use up to 49 days after a woman's last menstrual period, Boonstra writes. Under FDA's approval guidelines, women seeking medication abortions were required to make three trips to the doctor's office: one visit for counseling and to receive a 600-milligram dose of mifepristone, a second visit two days later for a 400 microgram dose of misoprostol, and then for a follow-up appointment two weeks later.

Regimen Modifications

By 2001, "an estimated 83% of U.S. providers were no longer using the FDA-approved regime" and were following alternative evidence-based guidelines "that provide numerous advantages to women, including making medication abortion available for an additional two weeks of gestational age and enhancing patient privacy," Boonstra writes. Specifically, the new guidelines -- based on studies conducted under the auspices of the World Health Organization -- reduced the dosage of mifepristone to 200 mg and stated women can safely take misoprostol at home.

Boonstra writes, "Requirements that Mifeprex be provided in strict adherence with the antiquated FDA-approved regimen both burdens women and threatens their health" by subjecting them to "a higher dose of mifepristone" and requiring them to make multiple trips to the doctor's office. She also notes that "prescribing drugs in ways that vary from those specified when they were originally approved is a widespread practice by physicians in every specialty of medicine, far beyond abortion care."

Midlevel Professionals and Medication Abortion

As early as 2003, WHO "began recommending that midlevel providers" -- such as nurse-midwives, nurse practitioners and physician assistants -- "be trained to administer medication abortion," Boonstra writes.

She continues, "In many ways, training midlevel providers to administer medication abortion makes sense for a procedure that requires extensive patient education and counseling -- skills that are emphasized in the education of these providers." However, Boonstra notes that most states mandate that only physicians may administer medication abortions, which means women who want the method might face long wait times or have to travel to reach a clinic with an attending physician. Further, requirements that a physician be physically present "also preemptively ban the use of telemedicine" in medication abortion provision.

State Regulations Governing Medication Abortion

"To date, two states (Arizona and Ohio) require that Mifeprex be provided in accordance with the FDA-approved regimen," Boonstra writes, adding that North Dakota and Oklahoma have adopted similar laws, but they are not in effect because of litigation.

"In addition, 39 states require clinicians who perform medication abortion to be licensed physicians; 10 require in-person counseling or ultrasound, necessitating multiple clinic visits by women; and eight require that the clinician be physically present during the procedure," according to Boonstra.

Abortion-rights opponents claim the proliferation of efforts to restrict medication abortion is meant to protect women's health and safety. In truth, the restrictions "are not an attempt to make the procedure safer, and certainly not to make it more effective," Boonstra writes. "Rather, they are an attack on abortion itself."

While state attacks on abortion rights are nothing new, "what makes this recent onslaught of restrictions both significant and especially ironic is its focus on abortion at the very earliest stages," Boonstra notes, adding that about nine out of 10 abortions occur in the first 12 weeks of pregnancy, with 73% in the first nine weeks. "Importantly, the availability of Mifeprex is credited with accelerating the trend towards very early abortions," she writes.

Therefore, "[i]n addition to burdening women and providers, the new onslaught of provisions hostile to medication abortion -- promoted by those whose primary concern is not women's well-being, but the opposition to abortion at any stage -- threaten[s] this trend toward very early abortion," Boonstra concludes.