As originally published on Friday, April 7, 2023 in the San Francisco Chronicle.
By suspending a drug used in medicated abortions Friday, a conservative federal judge in Texas did more than make it harder for people to obtain abortions.
U.S. District Judge Matthew Kacsmaryk also made it more painful.
And that may be the point, abortion rights advocates say.
Kacsmaryk’s ruling suspending the Food and Drug Administration’s approval of the abortion pill mifepristone in 2000 means that patients who want a medical abortion will have to use misoprostol only to end their pregnancies. Unless the Fifth Circuit Appeals court stays the judge’s ruling within seven days, patients could lose access to mifepristone.
Until now, the two medications have been used together to end pregnancies through 10 weeks — and very safely for the most part. More than 5 million people have used mifepristone since it was approved. Complications after medication abortions occur “in no more than a fraction of a percent of patients,” according to a 2018 report published by the National Academies of Sciences, Engineering, and Medicine.
Typically, patients take one 200 milligram mifepristone pill, which blocks the hormone called progesterone that is necessary to continue a pregnancy. Within up to 72 hours, patients typically follow up with misoprostol, which allows the uterus “to contract to get rid of its contents,” said Josie Urbina, an obstetrician/gynecologist and clinical instructor at UC San Francisco.
When used in combination with mifepristone, “most pregnancies are passed with just one dose of the misoprostol,” Urbina said. “However, with the misoprostol-only protocol, a person may have to take misoprostol every three hours for up to three to four doses in order to pass a pregnancy.”
Patients can experience severe cramping after one dose of misoprostol. Urbina is concerned that some patients will balk if they have to take more than one dose.
“Some people may feel like just having to take it one time was a lot. But having to take it up to three or four times is a lot to ask for a person,” Urbina said.
Urbina worries that “that they may give up after one dose and say, ‘I don’t want to proceed anymore with any further doses,’ and would not be able to pass the pregnancy.”
Mini Timmaraju, president of NARAL Pro-Choice America, has heard concerns from providers across the country that a misoprostol-only regimen is a “much more unpleasant procedure.”
It creates a “miscarriage-like medical situation, which is painful, uncomfortable, unpleasant,” Timmaraju told The Chronicle. “A lot of physicians have said they haven’t used that protocol. So they’re a little bit like, ‘Well, we know it can medically work, but this has not been the preferred protocol.’ So, we’re all trying to figure it out in real time, and that’s anxiety-inducing.”
Creating anxiety among those who are seeking abortions may be part of the reason behind the drive to remove mifepristone from the market, some advocates say.
A misoprostol-only regime “can more dramatically interfere with (a patient’s) day-to-day ability to go to work, their ability to travel, those sorts of issues,” said Ramona Thomas, general counsel for Planned Parenthood of Orange and San Bernardino Counties.
“And we think that that’s kind of part of what’s driving this initiative: They’re trying to make the process harder for people. They’re trying to make people suffer more,” Thomas told me. “That just seems so contrary to the stated purpose of this movement, that they want to make women suffer in order to be able to exercise their free will.”
The patients most affected by this change, Urbina said, “will be populations that are historically already marginalized — like minority populations, immigrant communities and those that are typically not prioritized in our current healthcare system.”
“Getting rid of one of the two medications necessarily for medication abortion is just going to create more barriers for patients to have to overcome in order to get the care that they need,” Urbina said.
Advocates and health care providers believe there is an adequate supply of misoprostol for now, even if patients will be required to take more doses. Maintaining that supply, however, could become an issue, Urbina said, “because we use misoprostol for other things other than abortion” including helping induce labor and as a tool to manage postpartum hemorrhaging.
Abortion rights advocates fear that this physically painful change in medication abortions will viscerally illustrate something that they’ve been trying to tell Californians ever since the Supreme Court overturned the constitutional right to obtain an abortion established in Roe v. Wade: California may be a haven for abortion rights, but it is not immune from federal laws restricting the procedure.
“I can’t tell you how many times I keep hearing, ‘We’re safe in California. We’re safe in California,’” said Nichole Ramirez, senior vice president of communication at Planned Parenthood of Orange and San Bernardino Counties. “So, we’re trying to explain to people now that this is a federal ban. We have to adhere to this, too. We’re definitely not safe.”
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