26 Scientific American, March 2022
THE SCIENCE
OF HEALTH
Claudia Wallis is an award-winning science journalist
whose work has appeared in the New York Times, Time, Fortune
and the New Republic. She was science editor at Time and
managing editor of Scientific American Mind.Ever since it was approved in 2000 as an abortion pill, mifepris-
tone has been regulated as if it were a dangerous substance. The
U.S. Food and Drug Administration required doctors to be spe-
cially certified to prescribe it. Patients had to sign an agreement
confirming that they had been counseled on its risks. Most oner-
ously, the pill had to be given in person in an approved clinical
setting—even though a second drug used to complete the abor-
tion, misoprostol, could be taken at home. In addition, 17 U.S.
states have passed laws requiring an ultrasound scan before
mifepristone can be prescribed. Yet decades of study have shown
that the medication is safe and that those restrictions are need-
less, according to the American College of Obstetricians and
Gynecologists and other medical groups. The rules have more
to do with politics and ideology than with science.
It took the COVID pandemic to strip away the fig leaf of sci-
entific justification from one regulation. The U.S. and several
other countries that restrict mifepristone suspended the require-
ment of in-person distribution. Patients could access care via
telemedicine and get the pills by mail rather than risk catching
COVID at a clinic. A natural experiment unfolded that highlight-
ed the safety of this approach. Last December the fda acknowl-
edged as much by permanently scrapping the in-person rule.
The agency did not, however, remove the other regulations.
And although patients will be able to get their prescription at
a drugstore or by mail, the fda is requiring a new certification
for pharmacies that dispense the drug. Such measures “contin-
ue to be necessary to ensure the benefits of mifepristone outweigh
the risks,” according to the fda. Researchers who study medical
abortion see this split decision as both a step forward and a
missed opportunity at a time when abortion rights are in peril.
Mifepristone works by blocking progesterone, a hormone that
maintains pregnancy. In a standard protocol, the drug is followed
by a dose of misoprostol, which triggers contractions and expul-
sion of the embryo. “It is identical to how we often treat early
miscarriage,” notes Lesley Regan, who chairs the abortion task
force of England’s Royal College of Obstetricians and Gynecolo-
gists. In the U.S., the pills may be used during the first 10 weeks
of gestation, although the World Health Organization considers
them safe up to 12 weeks. Research confirms that medication
abortion is about 95 percent effective in ending pregnancy. The
risk of complications that require further medical attention—
such as hemorrhage or infection—is less than 1 percent.
During the COVID era, at least three studies showed that the
efficacy and safety hold up without in-person clinical visits. In
fact, a large study done in the U.K.—where the government also
provisionally allowed telehealth care—identified distinct advan-
tages. It compared outcomes in more than 52,000 medication
abortions during the two months before and after the government
decision. Researchers found no increase in complications.
Moreover, the average wait time for treatment dropped from
10.7 days to 6.5 days, and 40 percent of abortions were complet-
ed at six weeks or earlier; only 25 percent met that mark with in-
person drug treatment. Patient satisfaction was also higher with
telemedicine, says the study’s lead author, Abigail Aiken, an expert
in reproductive health policy at the University of Texas at Austin.
One reason is that people can be treated sooner: “When someone
is facing a pregnancy that they didn’t want, the mental stress and
anxiety take a toll.” Telemedicine is also more convenient and less
expensive. Regan notes that it takes fewer health-care resources
and better serves people who live far from an abortion clinic.
The U.K. study, along with two done in the U.S., also showed
that an ultrasound scan is unnecessary except when patients
report issues that warrant it, such as symptoms of an ectopic
pregnancy (one outside the uterus), or if they cannot recall the
date of their last menstrual period. Research shows that the date
suffices to determine gestational age before abortion.
Ironically the fda’s sensible move on telemedicine is likely to
widen state-by-state inequities in access to abortion. In most
states access will improve. But 19 have laws mandating in-per-
son abortion care, and “six specifically ban mailing the pills,”
notes Elizabeth Nash of the Guttmacher Institute. Further restric-
tions are probable in abortion-hostile states if the U.S. Supreme
Court fails to protect abortion rights later this year, as is widely
expected. Aiken predicts that “we’re going to see this picture of
uneven access—this zip code lottery—diverge even further.”Abortion Pill
Barriers
Politics, not science, restrict access
to a safe, effective drug
By Claudia Wallis
Illustration by Fatinha Ramos