By Randall K. O’Bannon, Ph.D. NRL Director of Education & Research
When most people think of the abortion pill, they think of mifepristone, or RU-486, the chemical abortifacient developed by French pharmaceutical maker Roussel Uclaf back in the 1980s.
Most of these people also know that because of efficacy issues, mifepristone has usually been paired with misoprostol, a prostaglandin that expels the dead baby, thereby helping to ensure most of these abortions are complete.
What few of them realize, though, is that misoprostol is a cheaper, more widely available drug that can be used on its own to facilitate abortions without mifepristone.
And abortion advocates are increasingly interested in exploiting these properties to get women abortions in areas of the country or the world where surgical abortion is not available or abortion itself is illegal.
How the prostaglandin misoprostol got involved
Mifepristone blocks the action of progesterone, the pregnancy hormone, and thereby shuts down the developing baby’s life support system. But by itself, mifepristone may only be able to bring about a complete abortion perhaps 67%-75% of the time.
That’s why the French government in 1988, and subsequent drug agencies in other countries since, have required thata prostaglandin be given to ensure completion of the process. That prostaglandin comes along after mifepristone has begun its work to stimulate powerful uterine contractions to force out the dead or dying child.
While several other prostaglandins were tried initially, the abortion industry has settled on misoprostol, a cheap prostaglandin already in use as an anti-ulcer medication, in large part because of its ready availability and a milder complication profile.
Popular interest in misoprostol as a standalone abortifacient waned in the U.S. once the mifepristone – misoprostol combination was approved in September of 2000. Howeverthere was still interest and demand for misoprostol in other countries where misoprostol was already on the market and mifepristone had not yet been approved.
Abortion advocates in the U.S. did notentirely give up their advocacy for misoprostol as an abortifacient, though. Theycontinuedresearch to find the ideal dose, method and timing of administration, looking for regimens that could be used into the second trimester or beyond.[ 1]
That work appears to be paying off now as the protocols they have developed are being popularly disseminated not only among sympathetic doctors but among women looking on the internet for ways to get misoprostol pills and “self-manage” their abortions.
Trends converge to renew push for misoprostol for abortion
Two recent events have recently converged to energize efforts to promote misoprostol for abortion: the FDA’s decision in December of 2021 to allow abortifacients to be delivered by mail and the Supreme Court’s Dobbs decision overturning Roev. Wade on June 24, 2022.
The advent of telemedical chemical abortions
Ever since the FDA first approved mifepristone in September of 2000, abortion advocates have been intent on reducing or eliminating any and all restrictions on its prescription and distribution of the abortifacient.Theyobjected to dosages, gestational limits, the number of visits women had to make to the clinic, and the qualifications of personnel authorized to prescribe the drugs.
In March of 2016, the FDA caved into many of these demands. It officially dropped the dose of expensive mifepristone from three pills to one, doubledthe dose of the cheaper misoprostol, boosted the gestational ceiling for use from seven weeks to ten, required only a single visit to pick up the drugs, and allowed any “certified healthcare provider” to prescribe the drugs.
Abortion advocates were still unhappy and pressed for telemedical use with no restrictions. They got much of what they wanted when Biden took office and had the FDA review its restrictions in light of the pandemic. Ultimately the FDA decided in December of 2021 to drop any requirement that patients visit the clinic to be screened, examined, counseled and receive their “medication.”
This meant that women could go on line, undergo some sort of online screening and counseling, and have the abortion pills shipped to their homes to be used there. Many new online abortion pill suppliers sprang up to join the some of the web-basedabortion pill promoters and prescribers like Aid Access that were already shipping pills to the U.S.
The Supreme Court allows states to regulate chemical abortion
Just a few months later, the U.S. Supreme Court officially announced its decision on Dobbs v. Jackson Women’s Health Organization, declaring that Roe v. Wade was overturned and that there was no longer a national right to abortion.
While this did not automatically make abortion illegal across the U.S., it did allow states the ability to limit abortion or to outlaw it entirely. Some states with “trigger laws” due to go into effect once Roe was overturned got a full ban while others passed new laws or revived older ones that put limits on the types or timing of abortions that could be performed.
Under the new ruling, it was expected that the “physician presence” laws passed by many states–requiring that a physician examine a woman or be present when she received her abortion pills, or laws directly prohibiting telemedical chemical abortions– could go into effect.
This would mean that there were several states where chemical abortions (or at least those chemical abortions facilitated by telemedicine or any of those performed after a certain number of weeks) could not be legally performed.
And this is precisely what the new efforts to pushthe use of misoprostol aloneare meant to undercut.
Shipping misoprostol in under the radar
According to a story by Patrick Adams in The Atlantic (9/19/22), Aid Access, the Dutch-based online abortion pill promoter, seller, and prescriber, helped thousands of women obtain misoprostol only abortions in the first several months of the pandemic when mifepristone was hard to obtain. Adamsalsosays Carafem, which bills itself as a luxury abortion chain (Washington Post, 3/30/15) has been offering the misoprostol only option for nearly two years.
The legality of telemedical abortions in the new post-Roe era is a matter of dispute between the federal government and states which have outlawed or restricted chemical abortions. The Biden administration asserts that the FDA has the ultimate authority to determine the safety of drugs and particular drug protocols, not the state, and they say that state regulations limiting their use, particularly if safety was the rationale given for the limitation, are invalid.
While that dispute over whether federal policy or state law takes precedence plays out, abortion pill promoters have apparently adopted one of two strategies: defy the states and find some way to get mifepristone into the hands of women from those states where its import is banned, hoping the Biden administration will bail them out, or, as Adams suggests, direct them toward misoprostol, a drug already readily available in their states for other purposes.
Schemes to skirt the law
While Aid Access has admitted to shipping abortifacients to Texas in defiance of that state’s abortion ban (NY Times, 3/6/22, 7/25/22), others have tried to skirt the law in other ways.
Some, like Abortion Telemedicine, one of the new telemedical abortion startups, set up video appointments in states where that is legal, but admit they don’t actively check to see where their patients actually live (NY Times, 9/3/22).
Patients sometimes indicate on the booking form that they come from states where such abortions are illegal, but say they are traveling to states where they can pick up the pills at an address there where the pills can be legally shipped.
Plan C, what theTimes calls“an online clearinghouse for information about medication abortion,” takes it further. They suggestwomen and abortion pill suppliers use“virtual mailboxes” in states where abortion pills can legally be shipped and then resent, perhaps unknowingly, by a mail forwarding company to woman’s home addresses in states where there are restrictions.
But as long as these laws limiting abortion pills are in place and the federal government’s authority to override those laws is in dispute, The Atlantic’sAdams says “ending a pregnancy with misoprostol alone could become a more common choice for people with few options.”
Returning to the “bad old days” of Brazil
Adams envisions a situation similar to that in Brazil, where misoprostol’s popularity “exploded” once the drug was approved for stomach ulcers there and women there found it “safer and more effective than other clandestine methods” for abortion. Once Brazilian researchers began publishing reports about the drug’s off-label abortifacient use, knowledge of that “spread rapidly” among women and pharmacy employees.
Because misoprostol was legal, as an anti-ulcer drug, but abortion was not, Brazilian women and sympathetic doctors developed a ruse to work around the prohibition. Pregnant women might goto a doctor willing to prescribe misoprostol for a temporary “ulcer condition” or implorea pharmacist to sell or give thema few extra misoprostol pills for a visiting aunt with ulcers who had ‘forgotten” her medication.
Ultimately, after multiple reports of failed misoprostol abortions and the births of children with significant developmental anomalies like club feet, fused fingers, missing toes, the Brazilian government clamped down on use of misoprostol.
Authorities thereregulated misoprostol it as a controlled substance whose possession or supply (presumably for uses other than inhibiting ulcers) carried more severe penalties. Sales and use of misoprostol for abortion continued, but costs for the drugs rose and many transactions moved to a more underground market. (FN? In addition to The Atlantic, 9/19/22, see the American Journal of Public Health, May 2020 on “The ‘Abortion Pill’ Misoprostol in Brazil.)
Adams appears to aspire to return to those glory days of Brazil of the late 1980s and early 1990s, but with the new wrinkle of prescribing these drugs by telemedicine and shipping them to women’s homes.
Adams cites Mariana Prandini Assis, who he calls a “Brazilian social scientist” saying “the fall of Roe may well lead to the normalization in America of self-managed abortion with pills.”
Whether Adams’ or Assis’ vision will be realized remains to be seen. Both are part of a growing chorus of chemical abortion researchers and activists pushing for widespread, unregulated self-managed abortion. (See NRL News Today, June 15, 2020 www.nationalrighttolifenews.org/2020/06/if-adopted-proposed-no-test-protocol-would-move-dangerous-diy-chemical-abortion-ever-closer-to-reality.)
One can only hope that this will not lead to the widespread mis-prescription and abuse of misoprostol and a parade of injured women and babies killed or damaged by the drugs. But don’t expect those warnings to come from abortion pill advocates like Adams and The Atlantic.
Mifepristone was originally approved only for use up through seven weeks of pregnancy (49 days after a woman’s last menstrual period); the FDA extended that cut off to ten weeks in 2016, still weeks earlier than researchers were testing misoprostol.]
 Ms. Magazine is more direct, calling Assis a “Brazilian human rights lawyer, researcher and activist who harnesses the law to advance movements for social and reproductive justice” – msmagazine.com, “author” page, 9/20/22].