In my experience as an OB-GYN, when women decide to end a pregnancy, they want to obtain an abortion quickly. One good reason is the simple fact that early abortion is associated with a lower risk of medical complications compared to later abortion. In many settings, however, women face barriers accessing early care, ranging from mandatory waiting periods to difficulty putting the money together to pay for the procedure.
Texas is an unfortunate illustration of how restrictions on access can force women to obtain abortion later in pregnancy. In 2013, the Legislature there passed one of the most restrictive abortion laws in the nation. More than half of the state's clinics closed, forcing women living outside of the biggest cities to travel farther to access care and increasing the wait times at the clinics that stayed open. In the year following the law's implementation, second-trimester abortion increased 27%. Women seeking an abortion said it took time to find an open clinic, arrange for days off from work and set up affordable transportation, all of which contributed to delays in obtaining care.
One way to help women access termination services early in pregnancy is through medication abortion. This type of abortion involves the use of two drugs, mifepristone and misoprostol, to end a pregnancy up to 10 weeks' gestation. An article published last week in the New England Journal of Medicine (whose lead author was Elizabeth Raymond) explains how overregulation by the Food and Drug Administration is restricting access to medication abortion. Ever since mifepristone — which is also known as the abortion pill, or RU-486 — was approved by the FDA in 2000, it has been burdened by an extra layer of regulatory scrutiny that has limited the way the medication can be distributed.
Unlike most other drugs, mifepristone may only be dispensed at a doctor's office or a hospital. A doctor or nurse practitioner who wants to provide medication abortion has to register with the drug's distributor and stock the medication in his or her office. At a minimum, this process is burdensome for clinicians, and it discourages them from making these abortions available to patients. Given how common violence is against abortion providers, doctors may not want to get on the drug distributor's list. Writing a prescription, as doctors do for just about all other drugs, is a simpler process.
The ostensible reason for the hurdles is patient safety. After almost 17 years of experience with mifepristone in the United States, its extensive, positive safety record supports the removal of such restrictions. The drug can be prescribed by clinicians and dispensed in pharmacies without increasing risks for patients.
Just as less access in Texas was associated with an increase in later abortions, research shows that more access leads to earlier ones. In Iowa, an innovative program was started in 2008 to provide medication abortion using telemedicine. State law in Iowa mandates that only a physician can provide an abortion, and there are just a handful of doctors who offer the service. Telemedicine extends their reach.
Women can visit a clinic close to them, where they will get an ultrasound and obtain any necessary blood tests. They then video-consult with the providing doctor, who reviews the clinical information and determines if medication abortion is appropriate. Through a telepharmacy system, the doctor can then remotely open a lockbox at the clinic and dispense the drugs. In the two years after telemedicine was introduced in Iowa, there was a significant increase in medication abortion — particularly among women living in rural areas of the state — and a significant reduction in second-trimester abortion.
Some people have voiced concerns that making abortion easier to access will make the abortion rate increase. But that was not the case in Iowa. After the introduction of telemedicine, the abortion rate continued to decline statewide, probably because the state also invested in a program to improve access to the most effective contraceptive methods.
As the New England Journal article points out, if the regulatory restrictions on mifepristone were removed, more clinicians would provide medication abortion and make use of new ways of providing it. Telemedicine in particular would expand, and prescriptions could be picked up at a local pharmacy or ordered by mail so that women could have a private abortion without traveling long distances to a providing doctor and clinic.
In the United States, 39% of women of reproductive age live in a county without an abortion provider. Proactive policies aimed at improving their access to abortion seem unlikely to gain traction in the current political climate. But adding hurdles that force women to obtain an abortion later in pregnancy — or to seek out options on their own, such as online medications of unknown quality — is bad for women's health.
The FDA can unburden medication abortion from outdated overregulation and allow pharmacy dispensing of the drug, a move that would help more women obtain care as soon as they have made their decision to terminate a pregnancy.
Daniel Grossman is a professor of obstetrics, gynecology and reproductive sciences and director of the research group Advancing New Standards in Reproductive Health at UC San Francisco.