Beyond the Bench: The Battle for Medication Abortion Access
By: Alexandra Soos & Ishita Shukla
The U.S. is one of only four countries in the last 25 years to roll back abortion rights, having made the decision to overturn Roe v. Wade in 2022. Alongside Mexico, who decriminalized abortion nationally in late 2023, the U.S. is the only other country with state-specific laws. By dismantling federal protections, pregnant individuals and healthcare providers across the country face serious consequences trying to interpret state restrictions. Pregnant individuals like Jaci Statton in Oklahoma, a state where abortion is only allowed to save a pregnant person’s life, have been turned away from hospitals for fear of litigation.
In Statton’s case, she had experienced a partial molar pregnancy where the fetus was non viable and the pregnancy carried the risk of life-threatening bleeding and cancer but was told by providers “we cannot touch you unless you are crashing in front of us or your blood pressure goes so high that you are fixing to have a heart attack.” In a report last year, researchers called 34 hospitals in Oklahoma inquiring about hospital abortion protocol and 65% of these hospitals were unable to define procedures or policies around emergency obstetric care. Only two hospitals offered legal support for clinicians forced to determine life-threatening circumstances.
While states continue to interpret and codify their own abortion laws, the Supreme Court will soon weigh in on FDA v. Alliance for Hippocratic Medicine (AHM), which seeks to severely restrict access to mifepristone, a medication deemed “essential” by the World Health Organization (WHO) for its use in abortions and miscarriages. Nationally, medication-induced abortion constitutes 54% of all abortion. Until this decision, access to safe and effective abortion services is particularly constrained by maternity care provider shortages and wide variation in insurance coverage.
Despite being on the market for over 20 years across 96 countries, mifepristone’s future in the U.S. remains unclear. Self-managed medicated abortions have been shown to be a safe alternative to in-clinic abortions, which is notable given the access and affordability limitations stated above. Additionally, self-managed abortion may be a viable option globally for refugees in cases of statelessness or in low and middle income countries where 97% of all unsafe abortions take place. Unsafe abortions, as defined by the WHO, are those done “either by people lacking the necessary skills, or in an environment lacking minimal medical standards, or both.” In India, medication abortion stands as a primary method for terminating pregnancies. Given the taboo and stigma surrounding abortion in Indian society, the use of abortion pills affords individuals the dignity of undergoing the procedure in the privacy and comfort of their homes.
Just this year Argentina, Japan, and Niger have added mifepristone to their approved list of abortion management.13 This reflects a broader global trend recognizing the pivotal role this drug plays in safely terminating unintended pregnancies. Almost universally, rural compared to urban settings result in worse abortion outcomes given limited access to trained professionals and regions like Sub-Saharan Africa are especially vulnerable given that 60% of individuals reside in rural areas. For this reason, it is important to consider alternatives to provider-delivered abortion care like the self-managed abortions discussed above or “no-test” abortions where pelvic exams or ultrasounds are not utilized. A systematic review encompassing over 10,000 patients who received “no-test” medication abortions revealed that 96.4% cases ended in a terminated pregnancy and only 4.4% of individuals necessitated surgical intervention.
Abortion policies and laws without any scientific basis reduce accessibility to necessary reproductive care in the United States and have implications for abortion and miscarriage-related research, policy, and funding internationally. The Hyde Amendment and the Global Gag Rule prevent federal funds from being used for abortion services in the U.S. and abroad, respectively. These federal restrictions exacerbate racial oppression and threaten bodily autonomy in a country with a history of forced population control. While in office, former President Trump further expanded Gag Rule restrictions on family planning funds, which subsequently increased the rate of abortions and unintended pregnancies.
During this time, restricted funds grew from $575 million to $9.5 billion, affecting PEPFAR funds that support HIV and STI prevention and treatment. Given the grim reality of global maternal health outcomes where 45% of all abortions globally are unsafe, the Dobbs decision and anticipated AHM ruling pose a credible threat to restrict reproductive rights and establish grounds for a socially conservative agenda that is like to further constrain national and international budgets. These rulings will impact generations to come, contributing to a reduction in U.S-trained providers as medical residents in restricted states struggle to gain necessary experience.
Abortion rights are fundamentally tied to human rights. As Americans, we need to care about the implications our policy changes have, not only for ourselves, but also in the larger global context. Mifepristone is a pharmaceutical product, and its regulatory status in the U.S. influences how other countries’ health agencies and regulatory bodies approach the regulation of this medication. Topics like pharmacometrics, which include medication dosing and side effect monitoring, are discussed quarterly among regulatory bodies in the U.S., Canada, and Europe. If the U.S. takes a restrictive stance on mifepristone, this could embolden anti-abortion advocacy worldwide. In fact, policy makers in Nigeria and Kenya “began self-censoring” discussion of abortion care in national policy due to the “anticipation of the Global Gag Rule coming back into place.”
In anticipation of the Supreme Court ruling on mifepristone, the fate of reproductive rights hangs in the balance not only for Americans but for individuals globally. The decisions made by the U.S. have far-reaching implications, influencing how other countries navigate the regulation of crucial medications like mifepristone. As we stand on the precipice of change, let us not forget that abortion rights are inseparable from human rights. To safeguard the future of reproductive justice, it is incumbent upon us to actively engage in advocacy. Donations can uphold organizations informing policymakers, as well as marginalized communities such as Black, indigenous, and undocumented individuals who are disproportionately affected by obstetrical violence.
In a digital generation, narrative and the collective power have significant opportunities to champion these causes and ensure that the voice of reason prevails. It is essential to continue discussing openly with friends and family about upcoming legislation, particularly as midterms and national elections are fast approaching. There are several letter and email templates available to send to elected officials in order to continue prioritizing reproductive freedom and the protection of personhood. For in our collective actions today, we carve the path for a future where bodily autonomy and reproductive freedom are cherished and protected, transcending borders and resonating with generations yet to come.
Biography of Authors
Alexandra Soos and Ishita Shukla are both Masters’ students at the School of Public Health.
Edited By: Allison Hanley, MPP 2024 // Eneida Hysi, MPP 2024
