Not Your Grandma's Abortion

Medical Abortion and Telemedicine

In the year 2000, the Federal Drug Administration approved medical abortion for pregnancies of fewer than 10 weeks. This method of abortion entails taking mifepristone (sold under the brand name Mifeprex), which blocks progesterone, the hormone required to continue developing a pregnancy. This is followed within 24-48 hours by a second drug, misoprostol, which causes the cramping and bleeding that will expel the contents of the uterus. The combination of these drugs, according to the FDA’s website, “is used to end an early pregnancy (70 days or less since the first day of the last menstrual period)” and can be used as soon as pregnancy is confirmed. According to the FDA, medical abortion is safe and effective—it has a 99.6 percent success rate. It is cheaper than surgical abortion. The Kaiser Family Foundation states that “the median cost of mifepristone-misoprostol products ordered online is approximately $205, about half of the average charge for a clinic abortion.”

Pre-pandemic, a woman would make an appointment at a clinic, confirm the pregnancy, have an ultrasound, and be prescribed the medication. Basically, she was required to receive the medication and take the first dose under medical supervision. She would take the first pill at the clinic and the second one a day later in the privacy of her own home—or wherever she wanted.

Then the pandemic hit, and telemedicine took off. Abortion providers knew that requiring a woman to come to a clinic to obtain the medication necessary for a medical abortion added an increased burden and risk for both the patient and the care providers. Pam Belluck, writing for the New York Times, reported on a lawsuit filed by medical and reproductive rights groups that challenged the in-person dispensary requirement. A judge allowed the restriction to be lifted, but after a challenge by the Trump administration, the Supreme Court reinstated the restriction. It was the first abortion case the Court heard since Amy Coney Barrett replaced Ruth Bader Ginsburg.

Then, in April of 2021, the FDA under the Biden administration allowed the in-person restriction to be lifted temporarily, and then, just days ago on Thursday, December 16, the federal government permanently lifted the in-person requirement, allowing for the “dispensing of mifepristone by mail via certified prescribers or pharmacies, in addition to in-person dispensing in clinics, medical offices, and hospitals.” This is supposed to be a permanent change, but since female reproductive rights are at the mercy of politicians, a future Republican administration may summarily dispense with said permanence.

I was curious about the risks involved with medical abortion. According to the Mayo Clinic, potential risks of medical abortion include:

• Incomplete abortion, which may need to be followed by surgical abortion

• An ongoing unwanted pregnancy if the procedure doesn't work

• Heavy and prolonged bleeding

• Infection

• Fever

• Digestive system discomfort

According to the Planned Parenthood website, “The abortion pill is very effective. The effectiveness depends on how far along you are in your pregnancy when you take the medicine.” For people who are 8 weeks pregnant or less, it works about 94-98 out of 100 times; for people who are 8-9 weeks pregnant, it works about 94-96 out of 100 times; for people who are 9-10 weeks pregnant, it works about 91-93 out of 100 times—and if you're given an extra dose of medicine, it works about 99 out of 100 times. For people who are 10-11 weeks pregnant, it works about 87 out of 100 times—and if you're given an extra dose of medicine, it works about 98 out of 100 times. If the abortion pill doesn’t work, a woman can take more medication or have an in-clinic abortion.

USCF provides information comparing first-trimester surgical abortion (which they refer to as “suction curettage” and is also known as vacuum aspiration abortion), with medical abortion:

·      98 percent of suction curettage abortions are successful; only about 2 percent of women need a repeat procedure or other intervention.

·      95 percent to 97 percent of women respond successfully to the medications. About 3 percent to 5 percent of women will need a suction curettage abortion due to continued pregnancy, prolonged or excessive bleeding, or patient choice.

Yet, here’s my concern: What if a woman experiences complication from a medical abortion in a state that restricts abortion past a certain time? What if she’s in a state where there’s only one clinic that can complete the incomplete abortion with a surgical one? Complications are rare, but if you’re experiencing them, you’d want help right away—compassionate, competent, accessible, legal help.

As I have not experienced medical abortion, I sought testimonies from women who had. I found an article in Cosmopolitan in which three anonymous women—ages 20, 27, and 39—were interviewed about their experiences. (I used to read my mother’s Cosmos as a child in the 1970s—it was where I discovered horoscopes, among other things; apparently, the magazine has been around since 1886.) As these testimonies were given before the telemedicine option, all three women went to clinics for their prescription. Here is how the three women described what they experienced:

The 39-year-old, a mother of two toddlers, became pregnant despite being on birth control, and she and her husband decided to abort the pregnancy. They opted for medical abortion at eight weeks and made an appointment at a Planned Parenthood in Southern California:

I was really unsure how I would react, physically, to the mifepristone. Turns out I had no reaction at all. I went to work the next day and felt totally normal. I went out for dinner with my family that night and midway through I felt some vaginal activity, like I was getting my period. I excused myself to go to the restroom and a decent sized clot came out. That evening I continued bleeding and had a bit of cramping.

Friday, I took the day off work, dropped my kids off at daycare, got some ice cream at the market, and went home to take the misoprostol pills. They gave me four pills, and I was supposed to dissolve two [pills] in each cheek, by my lower gums. The Physician Assistant said if they weren’t totally dissolved in 30 minutes to just swallow the rest, which I did. There was a gradual increase in cramps and bleeding, but none of it felt any worse than a bad period. I never took anything for the pain or discomfort.

I thought I might watch TV or something, but all I wanted to do was lie down and close my eyes. The one side effect I did experience was diarrhea. There was plenty of that, which was mildly unpleasant, but nothing too dramatic. No nausea at all. I was definitely passing clots but nothing that was noticeably an embryo or pregnancy sac. I never soaked an entire maxi pad or anything either. I went back for my checkup last Friday and they did another vaginal ultrasound to make sure the pregnancy was expelled. All clear.

The 20-year-old, a university student who suffered from anxiety and depression, knew that going through with the pregnancy “was not an option”:

There wasn’t any bleeding for at least three or four hours, but I had half a box of maxi pads on just in case. The codeine they gave me actually put me to sleep and I woke up about four hours after it started, and was bleeding a lot. I went to the loo and passed the fetus. It wasn’t distinguishable as a fetus, but more like gray tissue. I knew what it was immediately, but I felt relief and nothing else. I sat and looked at it on the [toilet paper] for a minute or so, just sort of to get closure, then it was gone. After that, the pain subsided quite a lot, and I was able to clean up and go back to sleep.

The 27-year-old, also married, didn’t have a college degree or a job and was still living in her mother’s house. She knew as soon as she got the results of her pregnancy test that she and her husband had “nothing to offer a child” at that point:

Physically, aside from normal pregnancy feelings of tiredness, I felt fine. There was cramping after the first dose in clinic, but it wasn’t very bad. Felt like normal period cramps. Emotionally I was a wreck. I cried through the entire ordeal. I was so sad even though I knew it was the right thing to do right now. It’s one of the most overwhelming experiences of my life. On the second day, after taking the misoprostol, I got an upset stomach from that and the ibuprofen, and cramps intensified, but not to a level near what I’d heard online or from the staff at Planned Parenthood. 

I hung out in the bathroom listening to Les Misérables so I could be in good sad company. I passed the pregnancy within the hour. With that, everything was over. I had moderate bleeding that night followed by light bleeding, which continues today. It could last four to six weeks with spotting. It truly was no more painful than cramps on a medium day. I was floored. Easy and almost painless, I couldn’t have asked for more.

They were all asked the following: What do you wish more people knew about medical abortion?

39-year-old: I wish people knew how not scary it actually is. The whole process felt very gentle for me (though I’m sure everyone has different experiences), and was not physically traumatic or difficult in any way…Emotionally, it was a hard decision to make. It was painful, and I was angry and sad that I had to make the choice at all. I was using birth control and felt betrayed that it didn’t work. I feel like I made a difficult emotional decision, but intellectually I know it was the right choice. Part of being an adult is that sometimes you have to make the hard choices that don’t feel good but are the best thing in the long run.

The 20-year-old: You should never ever feel ashamed for the decision to have an abortion. You need to do what is best for your life. More power to you if having a baby is what you want to do, but if you don’t, do not have one just to please anyone or thinking you’ll warm to the idea. It doesn’t hurt as much as people try to scare you into thinking it will, I promise you. Put your needs first.

The 27-year-old: There’s nothing that says you can’t be a mother later if that’s what you want, and it’s actually safer to have an abortion than to give birth.

There are a few reasons women choose medical abortion over surgical abortion. According to a study published by JAMA, the peer-reviewed Journal of the American Medical Association, “the cost of in-clinic care was the most commonly cited reason for accessing self-managed abortion using online telemedicine.” The study found that “clinic access barriers were the most common reason for accessing self-managed medication abortion, and both distance to an abortion clinic and living below the federal poverty level were associated with higher demand for self-management.” Some states have few—or only one—clinic. Money, too, is an obvious issue, as a medical abortion is about half the cost of a surgical abortion (and about 50 percent of abortion patients live below the federal poverty level). The study concluded that “at the state level, the highest rates of requests to the service were found in states with more restrictive abortion policy climates.”

However, as one can imagine, those states with more restrictive abortion policies also put policies in place to limit access to medical abortion. For instance, though the federal government lifted the in-person restriction for dispensing the pills for medical abortion, in Texas, where, according to the Texas Tribune, medical abortion is the most common method women turn to for terminating abortion, a law was just passed that "makes it a felony to provide the medication after seven weeks of pregnancy, putting Texas at odds with federal regulations.” Texas already required women to obtain the prescription in person rather than the mail, which is against the law. But now, providing those pills for someone more than seven weeks pregnant could mean being charged with a serious crime. The Texas law could only change if someone brought a legal challenge to it, but we’ve seen how that’s going with the state’s six-week ban on abortion, a law that, for the time being, isn’t being blocked by the Supreme Court.

Pam Belluck was interviewed on Thursday, December 16th, 2021 by Sabrina Tavernise on The Daily podcast. Belluck explained that while in many states medical abortion by mail is illegal, the organization AidAccess, based in Europe, allows women to “go online, fill out a form” and “get a doctor to prescribe pills that, if they live in a state where it’s illegal,” can be mailed from a pharmacy in India. Apparently the FDA has tried to restrict AidAccess without much success. Now Rebecca Gomperts, who runs AidAccess, has taken things one step further and is “sending pills to women who are not yet pregnant just to have kind of on hand in the event they have an unplanned pregnancy.” The idea is to proactively have the pills on hand in case of emergency.

Obviously, anti-abortion groups are unhappy with the FDA’s decision. In Belluck’s article from last Thursday in the Times, she reported a statement from the Susan B. Anthony list:

“The Biden administration today moved to weaken longstanding federal safety regulations against mail-order abortion drugs designed to protect women from serious health risks and potential abuse….The Biden administration policy allows for dangerous at-home, do-it-yourself abortions without necessary medical oversight.”

But according to the UCSF Medical Center Bixby Center for Global Reproductive Health, “Medication abortion is safer than many common drugs in the US, including acetaminophen (Tylenol) or sildenafil ( Viagra).”

The 39-year-old from the Cosmopolitan article was irked by the fact that her regular ob-gyn did not provide abortion services. She said: “It was such a simple procedure that I don’t understand why it’s not available through my ob-gyn or even my general practitioner’s office. It also makes me angry that I couldn’t go through this with my regular OB, who I know and trust, and who knows all my medical history. Wouldn’t that be better for women’s health?”

Since many ob-gyn providers do not provide medical abortion services, here are some resources for organizations and clinics that do:  

The National Women Health’s Network

Planned Parenthood

AidAccess

Thanks for reading The Quickening. Feel free to share it with anyone you think might be interested or benefit from its information.

Take care and see you next week.