From convenience to crisis: Here's what will happen if the Supreme Court restricts mifepristone

On March 26, the U.S. Supreme Court will finally hear oral arguments over the safety of mifepristone — the first drug used in a medication abortion. While experts don’t expect to hear a decision from the highest court right away, one in favor of the plaintiffs — Alliance for Hippocratic Medicine — could severely limit access to mifepristone across the country, even in states where abortions are still legal.

This would come at a time when medication abortion has become a more accessible option in a highly restrictive post-Dobbs landscape. For instance, a new Guttmacher Institute report from the Monthly Abortion Provision Study recently found that there were approximately 642,700 medication abortions in the United States in 2023, meaning they accounted for nearly 63 percent of all abortions. As women’s health specialists and doctors have told Salon before, the effects of such restrictions will be "devastating,” and have far-reaching consequences beyond impacting reproductive health. But what’s exactly at stake? 

The first significant way access to medication abortion could change in light of this ruling is the ability for it to be prescribed by telehealth and by mail. 

“More and more people are learning about this new model of care, and finding that it really enables those with more barriers to obtain this care,” Dr. Ushma Upadhyay, a public health scientist at Advancing New Standards in Reproductive Health, based at the University of California-San Francisco, told Salon. “It’s clear that those who have the most barriers to care are finding telehealth really critical to their ability to get a wanted abortion.”

Upadhyay said telehealth has really grown over the last couple of years since the change was implemented during the pandemic. Before the Supreme Court overturned Roe v. Wade, which gave Americans a constitutional right to access abortion care, an estimated 4 percent of abortions were done via telehealth. In data from April 2022 to September 2023, 16 percent of abortions in the U.S. were done via telehealth, according to data by the Society of Family Planning, which was led by Upadhyay. With those who had a telehealth medication abortion, 43 percent said that telehealth made it possible for them to have a timely abortion.

“We found that 2 percent of those patients said they would not have been able to get an abortion at all,” Upadhyay said, noting that "sounds small, but there are over a million abortions in the U.S a year, so 2 percent of a million is quite a large number.” 

In a telehealth medication abortion, a patient usually talks to a provider over video or a secured chat platform. If the patient is less than 10 weeks pregnant and found to be eligible, the provider can prescribe the patient the two-step regimen. First, a patient takes mifepristone, which blocks pregnancy hormones, and then misoprostol, which causes uterine contractions. The medicines can be delivered via a mail-order pharmacy.

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Dr. Kara Cadwallader, who is a family medicine physician in Idaho, told Salon in a phone interview that while she is located in a state where abortions are nearly totally banned, with narrow exceptions, restricting access to mifepristone via telehealth and mail will still have a big impact on those in Idaho.   

“A lot of us are traveling to other states to provide abortion care, and a lot of folks are accessing medication through the mail,” Cadwallader said. “That's a big way to access abortion care, especially for folks who live in states where abortion is illegal or severely limited.”

Dr. Jennifer Kerns, a professor in the department of obstetrics gynecology and reproductive Sciences at UCSF and staff physician at Trust Women, an abortion clinic in Kansas, said she sees firsthand the burden of people having to travel out of state for an abortion — sometimes to even have access to medication abortion.

“Some people are traveling by car, up to 12 hours just to drive to the clinic to access medications,” Kerns told Salon. “We routinely hear about how long it's taken patients to garner all of the resources needed to make arrangements, to make this trip, and we're only seeing the patients who actually ended up getting to us — we're not seeing the patients who made attempts or can't take that much time off of work or can't find anybody to watch their kids.” 

The ability to access medication abortion via telehealth, Kerns emphasized, is serving a population who already faces many barriers to access abortion care. Taking away that option will leave them in very vulnerable situations.

“Those are the populations we really worry the most about,” Kerns said. “People who already face a lot of barriers in accessing care.”

The option to access medication abortions via mail or telehealth isn’t the only way the ruling could impact access to mifepristone. It would also shorten the timeframe that it could be used from 10 weeks to 7 weeks of pregnancy. This would restrict access to medication abortion for those who perhaps haven’t even confirmed if the pregnancy is viable yet, or those who need time to gather the resources to even access the medications.

“Low income people are still trying to gather the money to pay for an abortion,” Upadhyay said. “We do find that people more marginalized show up to a clinic later in pregnancy, because of the cost, because of all of the factors that they have to overcome to make an in-person clinic visit. They really do need the extra time.” 

Additionally, a ruling in favor of the plaintiffs would revert back to the 2000 label approved by the Food and Drug Administration for medication abortion, which would require a ​​higher dosage of mifepristone and a lower dosage of misoprostol. Upadhyay said this shift in dosing will ultimately lead to more failures of the medication, and could lead to an abortion patient experiencing more nausea and cramping during the process. Mifepristone stops the pregnancy hormones while misoprostol expels the fetus, so throwing off the established balance could have unpleasant — and unnecessary — consequences.

“The lining might be separated,” Upadhyay said. “But then your patient is just carrying a separated fetus in the uterus.”

Upadhyay emphasized that when mifepristone was first approved, the FDA put some pretty “onerous restrictions on it” that were not evidence-based. A SCOTUS ruling that restricts access to mifepristone would essentially be rolling back the clock.

Leading up to next week’s hearing, numerous amicus briefs signed by organizations representing the country's leading researchers and physicians have emphasized there is ample scientific evidence to support widespread use and availability of mifepristone. It has a well-established safety profile. But many are expecting the SCOTUS decision to be based on politics and not scientific evidence. 

If mifepristone is restricted, workarounds will vary depending on the state. In states where abortions are legal and easily accessible, it’s possible that clinicians will prescribe mifepristone off-label. 

“I suspect that people like myself who primarily practice in states with a lot of protections around abortion access will feel comfortable prescribing this off-label,” Kerns said, referring to a common practice of prescribing a drug in a way that isn't covered by its FDA label. Lithium, for example, is FDA-approved to treat bipolar disorder, but is very often (safely) prescribed off-label for major depressive disorder. “I'm not so sure that that's true for providers in other states, those providers may decide that it's a little too risky.”

Upadhyay said that in some states prescribing off-label won’t even be an option. 

“Ohio is a totally different case, they have a law on the books that requires them to provide medication abortion according to the FDA label,” Upadhyay said. “So clinicians will have no choice.”