By Carrie Baker for Ms. Magazine.
Broadcast version by Roz Brown for Texas News Service reporting for the Ms. Magazine-Public News Service Collaboration

Over half of clinician-supervised abortions in the U.S. in 2020 were done with a combination of two medications: mifepristone and misoprostol. A Trump-appointed judge in Texas will soon decide a lawsuit brought by anti-abortion extremists asking him to force mifepristone off the market in all 50 states. If he does, as anticipated, reproductive rights advocates are ready to offer a safe and effective alternative to end pregnancy through three months: a higher dosage of misoprostol taken alone.

Misoprostol is a widely available ulcer medication that can induce a miscarriage by causing contractions of the uterus to expel a pregnancy. In the 1980s, Brazilian women began using misoprostol to end their pregnancies because abortion was unavailable through the medical system. Self-managed abortion with misoprostol resulted in precipitous declines in infection, hemorrhaging and death from unsafe abortion.

Today in countries where abortion is legally restricted, misoprostol is often used alone for self-managed abortion because it is inexpensive and widely available, often over the counter, unlike mifepristone.

Many studies from around the world have found that self-managed abortion with misoprostol alone is 93 to 99 percent effective and very safe. Because of the widespread availability of mifepristone in the United States, the use of the misoprostol alone for abortion had not been studied here, until recently.

On Feb. 6, researchers at the University of Texas at Austin published peer-reviewed research on the use of misoprostol alone for abortion. The research found that misoprostol alone was over 88 percent effective, with few incidents of serious adverse events or signs of potential abortion complications.

"This is the first U.S.-based study on misoprostol alone for self-managed abortion and it's coming at this critical time where we don't know what's going to happen with access to mifepristone," said the study's lead author, Dana M. Johnson, a Ph.D. candidate in public policy and demography at the University of Texas at Austin and a senior associate research scientist at Ibis Reproductive Health. "Our contribution with this study is to add to the broad evidence base we have from the international space on how safe and effective misoprostol is."

The research was based on data from the Vienna-based telemedicine abortion provider Aid Access, which provides telemedicine abortion services with pills in all 50 states in the U.S. Due to pandemic-related challenges shipping mifepristone, Aid Access prescribed misoprostol alone to over one thousand U.S.-based patients in June of 2020. Aid Access physicians either mailed misoprostol directly to patients or sent prescriptions to local pharmacies for pick-up.

"We took a very conservative approach by including just the people who had a totally confirmed, complete abortion at four weeks and didn't get a surgical intervention," said Johnson. "That is why our finding is 88 percent effectiveness, which is much lower than the SAFE Study from Ibis, which showed 98 percent effectiveness."

Published in November of 2021, the SAFE Study-which stands for Studying Accompaniment Feasibility and Effectiveness-showed that 98.8 percent of those who used the misoprostol-alone regimen had a complete abortion without surgical intervention. "SMA with misoprostol only is highly effective, and warrants renewed attention," it concludes, calling it "no longer a second-tier method, but one that offers similar effectiveness, and often greater accessibility, than the mifepristone and misoprostol regimen."

While this research shows misoprostol alone is a little less effective than the combination of mifepristone and misoprostol, extra doses of misoprostol can increase efficacy.

"We did take this conservative approach, but our findings were really, really good. There were very few people who had a serious adverse event. There were very few people who had any kind of treatment for that or a symptom of a potential complication," added Johnson.

Johnson is now conducting follow-up interviews with the research participants to understand their experiences of using misoprostol alone, which can be more difficult than the combination of mifepristone and misoprostol because the misoprostol-alone regimen calls for multiple doses of the medication, as opposed to one dose if combined with mifepristone. Those who use misoprostol alone may experience stronger cramping. Side effects from misoprostol can include nausea, fever, chills, vomiting and diarrhea, which can be more severe when taking misoprostol alone because of the higher dosage.

Johnson is finding in her research that women's experiences of using misoprostol are shaped by their mindset and how prepared they felt. Many found information on Reddit.com. The abortion Subreddit is curated by OARS (Online Abortion Resource Squad) with trained, expert volunteers who "ensure that every Reddit post asking for abortion-related help gets a quality, accurate, compassionate answer and referral to resources."

"People asked a lot of questions and that brought a sense of comfort because if you know that you can prep your hot water bottle or your ibuprofen or your chamomile tea, you're going into it with a little bit more of a mindset that you can manage this pain," said Johnson.

Research from other countries has shown that patients can have positive abortion experiences with misoprostol alone when they have access to the information they need, feel prepared for what they will experience and are supported through the process.

If the Texas court imposes a nationwide ban on mifepristone, women and pregnant people can still access the highly effective and medically safe method to end an early pregnancy with misoprostol alone. And unlike mifepristone, misoprostol is inexpensive and widely available by prescription for different indications in pharmacies throughout the U.S.

While the FDA has not labeled misoprostol for abortion, U.S.-based providers can prescribe the medication off label for this use to patients in states where abortion remains legal. Many telemedicine abortion providers have already pledged to offer misoprostol off label to their patients if mifepristone is removed from the market, including Abortion on Demand, Aid Access, carafem, Choix, Forward Midwifery, Hey Jane and Just the Pill. Planned Parenthood has also said they will offer this service.

National Abortion Federation's clinical practice guidelines suggest offering misoprostol alone where mifepristone combination is not accessible. The World Health Organization also has guidelines for misoprostol alone as a safe and effective options for abortion care. According to these guidelines, women in the first 12 weeks of pregnancy dissolve four 200 mg of misoprostol between their gum and cheek, three times at three-hour intervals.

"With clinical options for abortion severely limited post-Dobbs, these guidelines are important in affirming self-managed abortion as a safe and essential practice that can be empowering for those seeking to end a pregnancy," concluded the U.T. Austin study authors. "There is potential for its use in the U.S. as a method of ensuring reproductive autonomy, especially for populations who have been systematically cut off from safe, affordable and non-coercive reproductive healthcare services."

Carrie Baker wrote this article for Ms. Magazine.



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Nevada health-care providers, patients and advocates are responding to the U.S. Supreme Court case that'll determine the future of the Emergency Medical Treatment and Labor Act.

The federal law mandates Medicare-funded hospitals provide patients with stabilizing care in emergency situations, which include abortions.

Dr. Christine Miyake is an emergency physician with the Valley Health System in Las Vegas, and said abortions are sometimes a necessary part of health care.

"I saw a patient who ruptured her membranes early and developed a severe uterine infection," said Miyake. "She was dying from that infection. If they were not able to provide the abortion, she surely would have died - as no amount of antibiotics would've helped her."

Miyake said abortion bans around the country have driven physicians out of their respective states - causing hospitals to shut down their labor-maternity wards, making it harder for women to access what she called "basic pregnancy care."

In Nevada the right to an abortion is protected though state law, but an initiative petition is working to enshrine abortion rights in the state's constitution.

Laura Campbell is the director of the National Organization for Women's Nevada Chapter, and said she received lifesaving care while she was pregnant - and contended that EMTALA is key to protecting the very care that saved her life.

But anti-abortion proponents argue that state laws that ban abortion access can coexist with the federal law. Campbell disagreed.

"With total bans on abortions in neighboring states like Arizona, Utah, and Idaho," said Campbell, "there is no question that Nevadans deserve to have their abortion rights protected in the state constitution to ensure that no judge or politician can strip away the right to make their own health-care choices."

Eighty-six percent of the public supports protecting access to abortion for patients experiencing pregnancy-related emergencies, according to a recent KFF poll.




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The Missouri Legislature has approved a law to stop its Medicaid program, known as MO HealthNet, from paying Planned Parenthood for medical services for Medicaid patients.

The decision follows a court ruling which found not reimbursing Planned Parenthood through Medicaid goes against Missouri's constitution.

Emily Wales, president and CEO of Planned Parenthood Great Plains, said they have joined forces with Planned Parenthood St. Louis Region and Southwest Missouri and stand behind providing health care to those who need it. She argued the Legislature is causing confusion despite a clear decision from the highest court.

"Despite the court's repeatedly ruling that 'defunding' Planned Parenthood health centers is unconstitutional, lawmakers continue to deny critical care like birth control, cancer screenings, wellness exams and STI testing and treatment from the patients who need it," Wales stressed.

According to the Missouri Family Health Council, Planned Parenthood health centers serve nearly half of patients who rely on family planning safety net providers in the state. Planned Parenthood Great Plains and St. Louis Region Southwest Missouri will continue serving patients and is looking for alternative solutions for funding.

The new law also blocks Planned Parenthood from being a recognized provider in the state's Medicaid program. Wales pointed out it could hurt health care for people who rely on the safety net.

"There are not enough other providers in the health care safety-net system to absorb Planned Parenthood's patients," Wales pointed out. "At Planned Parenthood, we'll continue to do everything we can to serve our patients, no matter what."

Planned Parenthood Great Plains provides health care to more than 30,000 people in 13 health centers across Missouri, Arkansas, Kansas and Oklahoma. The St. Louis Region and Southwest Missouri chapter has been serving for more than 90 years.

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The U.S. Supreme Court is set to hear oral arguments today in a case about whether patients have access to emergency room abortions in states banning the procedure.

Idaho v. United States could determine if providers can perform medically necessary abortions for women experiencing complications under decades-old rules known as the Emergency Medical Treatment and Labor Act.

Dr. Polly Wiltz, a second-year emergency medicine resident at University Hospitals in Cleveland, said she is worried about her ability to care for patients who need abortions, if protections end.

"We are putting ourselves at risk for allowing legislators -- allowing people who do not have medical training -- to pick and choose which procedures, which life-stabilizing treatments and medications can and cannot be applied in the emergency department," Wiltz pointed out. "It's infringing on patient rights."

The Center for American Progress said pregnant patients with severe complications who are denied abortions could develop severe sepsis requiring limb amputation, uncontrollable uterine hemorrhage requiring hysterectomy, kidney failure requiring lifelong dialysis, hypoxic brain injury and other severe conditions.

Wiltz added most of the patients with pregnancy complications coming into the hospital lack access to routine OBGYN-related care.

"Regarding pregnancy related complaints, I see first trimester pregnant patients every single day," Wiltz noted. "In my shift, I have caught ectopic pregnancies that have ruptured."

Hospitals made up 33% of the facilities providing abortions in 2020, according to data from the Pew Research Center. Last fall, a majority of Ohio voters chose to approve a constitutional amendment, "Issue 1," establishing a statewide right to abortion and reproductive care in the aftermath of the Roe versus Wade decision.


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