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The medical abortion works — so why aren't more women using it?

The medical abortion works — so why aren't more women using it?


And why aren't doctors more vocal about it?

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I found out I was pregnant during a routine gynecological exam after I mentioned my period was a few days late. My doctor told me she’d need to collect a urine sample anyway, so they’d test it just to be sure. I wasn’t worried. I’d only been off hormonal birth control for a little over a month after staying on it for many years, and I’d read it sometimes takes months to resume regular ovulation. My boyfriend and I had one slip up, but that single incident seemed like a long shot. So when the doctor came back into the room with a upbeat "yup, you’re pregnant," I was (perhaps stupidly) shocked.

"Yup, you're pregnant."I immediately asked if her office performed abortions. I was 26, working in the sex industry, and involved with a man I knew wasn’t right for me in the long term. I was pretty sure I didn’t want to have children at all — but particularly not now, not like this.

The doctor recoiled as if I’d struck her. "We don’t do that here," she said. "You’re not even going to think about keeping it?" I affirmed with complete certainty that I was not, and asked if she could recommend a facility that would help. "You can Google it," she said as she opened the door to the examination room, indicating very clearly that I should leave.

My best friend, a nurse, urged me to get an abortion shot. (A what? I thought.) She swore it would be the easiest and quickest option, and told me where I could find it. She even accompanied me on the visit — though I wasn’t required to bring a second party for the procedure, which was a simple injection in the hip.

The subsequent abortion felt mercifully easyThe subsequent abortion felt mercifully easy. It was quick and entailed almost no pain. Giddy with relief, I hugged the doctor on my follow-up visit, when successful termination was confirmed.

I’ve been passionate about reproductive health for the entirety of my adult life, and surrounded myself with similarly engaged and educated women — how had I not heard of an abortion shot? Even today, when I talk to other women about terminating with an injection, they’re entirely unfamiliar with this option. I wanted to know why it wasn’t available and known to more women.

Why wasn't this available and known to more women?Well, it was; in Canada, anyway. Methotrexate, the chemotherapy drug used for my abortion, is one of three approved drug-based methods to end pregnancy, and an important one in environments without better alternatives; namely, countries with extremely restrictive abortion laws in which mifepristone ("the abortion pill") is difficult to obtain. Methotrexate works by stopping fetal cell duplication as well as the ongoing implantation process. Though my experience was mild and physically undemanding — I had no downtime, nausea, or heavy bleeding — the drug itself is regarded as extremely toxic and can have a host of ugly side effects.

So the current preference among health experts around the world is for the superior abortifacient mifepristone, often called RU486 or the abortion pill, which was approved by the FDA in 2000. (Misoprostol, the third abortion medication, causes contractions of the uterus and is effective in inducing abortion 90 percent of the time. Though it can be taken alone, it's more commonly used in combination with either methotrexate or mifepristone.) Some American clinics still offer methotrexate abortions — and methotrexate can be taken orally instead of administered by injection — but since the FDA approved mifepristone in 2000, most provide that instead. Mifepristone has a higher rate of success and carries less risk of side effects.

Medical abortion constitutes the majority of cases in many parts of EuropeMedical abortion — meaning any abortion induced by drugs as opposed to achieved through surgery — constitutes the majority of abortions in many parts of Europe: 70 percent in Switzerland, 83 percent in Sweden, and 94 percent in Finland. And for the majority of human history, ingestibles and herbs have been a highly common method for inducing abortion. The ancient equivalent of medical abortion even receives mention in the Bible. When the abortion pill became available in the States, the public response anticipated an abortion revolution. Time put the pill on their print issue’s cover, and The New York Times’ headline suggested it would "reshape debate." Gloria Feldt, president of Planned Parenthood at the time, called it "the most significant technological advance in women’s reproductive health care since the birth control pill."

abortion protest (flickr)

An anti-choice protester (Daveynin)

But the abortion pill amounts to only 36 percent of domestic abortions within the first nine weeks of pregnancy, at least in 2011, the most recent statistic available. That same year brought a slew of restrictive regulation which impacted medical abortion availability — and, consequently, its use. "The dream of Mifeprex was that all doctors are going to prescribe it, and that would greatly reduce stigma because it’s going to be available everywhere," says Tammi Kromenaker, MS, of Red River Women’s Clinic in North Dakota. But it proved to be a technological advancement that didn’t fulfill the invested parties’ anticipations of widespread change — at least, not here in the US.

Theoretically, medical practitioners could dispense a pill in private without calling attention to themselves Reproductive rights activists hoped that abortion medications would appeal to doctors who didn’t want anti-abortion protesters at their clinic doors, but who did want to help patients obtain abortions. Theoretically, medical practitioners could now dispense a pill in private without calling attention to themselves and inviting the inevitable cascade of protest, harassment, and threats. But stigma is not so easily sidestepped. As the Guttmacher Institute’s Rachel Jones points out, "if you’re [a doctor] in a fundamentalist, born-again community and you offer a patient an abortion option, it could be the death of your practice." That fear among practitioners places an onus on patients to ask for options they might not even know exist — and from someone who may not be sympathetic to the idea at that. As Jones says, "If you’re not advertising [that you offer medical abortion], how do patients know?" There’s always the possibility that if you venture a request for help, you might be told to "Google it," and shown the door.

Furthermore, the abortion pill is not available in pharmacies; doctors willing to provide it must work with the manufacturer directly to be personally approved. If a woman approaches her general practitioner with a request for medication and the doctor agrees, it’s possible too much time may pass before she can actually obtain the drugs. (Danco Laboratories, maker of Mifeprex, the only FDA abortion pill, did not reply to a request regarding how long the average application process takes.)

A medical abortion is a process, not an instant fix And then there are the side effects. A medical abortion is a process, not an instant fix, and it can entail heavy bleeding, intense cramping, and the passage of large clots. According to Kromenaker, pregnant women who intend to request abortion medications are sometimes dissuaded after finding out what the side effects entail.

This last point is crucial for understanding why abortion by pill didn’t sweep the nation in the way some media coverage suggested it would. Enthusiasm about abortion medication has less to do with its intrinsic advantages, which are highly subjective, and more to do with its ability to work around circumstantial limitations that make surgical abortions challenging to obtain. Its rise in popularity on the international stage, for instance, is the result of increasing abortion access for rural women with scant other options, rather than women with ready access to surgical options choosing medication instead. And while some European countries have policies favoring abortion through medication and may subsidize the cost entirely, the Hyde Amendment prevents US federal funding from playing a role in citizens’ abortions in any aspect. Twenty-five states have even passed laws prohibiting or inhibiting privately purchased insurance plans from covering it.

Here in the States, where many people are left to cover the cost themselves, surgical abortion can be the cheaper option — another mark in its favor. The Guttmacher Institute averages the cost of surgical abortion to be about $450, while medication is $483. Thirty dollars is not an insignificant amount to those for whom the procedure is already a considerable expense.

Rates of medical abortion have consistently risen every year since the pill's approval — even as abortion rates have dropped

Still, rates of medical abortion have consistently risen every year since the abortion pill’s approval 15 years ago, even as abortion rates themselves have gone down, and Dr. Beverly Winikoff of Gynuity, an organization that promotes expanding affordable reproductive options worldwide, expects that trend to continue. "I think [medical abortion] is amazingly popular here given how hard the government has made it to get," she says. Since awareness of and comfort with choosing the abortion pill rests largely on word of mouth — women telling friends what their personal experience with the drugs was like — any frustrations about its popularity are a reflection of "inflated expectations about how transitions between medical technologies happen without commercial involvement," as opposed to an accurate indication of the method’s appeal and usefulness.

bad surprise (flickr)

(Anthony Easton)

As Dr. Winikoff observes, state laws ultimately play such a large role in women’s ability to obtain abortions, medical or surgical, attempting to describe them as popular or unpopular indicates a level of personal preference most women simply can’t exercise. The same women who struggle to obtain a surgical abortion will most likely struggle to obtain a medical one as well, thanks to purposefully restrictive regulations.

17 states have banned telemedicine for medical abortion For instance, telemedicine, which allows physicians to consult with nurses and patients through video conferencing, keeps patients from driving long distances to obtain mifepristone and misoprostol. That time saved can mean the difference between choosing an early, medical abortion, or being left with no choice but surgical after the window for early action has closed. But 17 states have banned telemedicine for medical abortion — and only medical abortion — which effectively means those who’d benefit most from access to the pill (rural women without the time or financial resources for travel to the nearest surgical abortion clinic) are denied.

Other recent anti-choice legislation seized upon enforcing an outdated FDA-approved regimen for administering mifepristone, which requires patients make three or more office visits instead of only two. (Under the evidence-based alternative regimen, women can bring home the misoprostol they’re supposed to take two days after the mifepristone, while the FDA regimen requires an additional trip be made to take that misoprostol in front of a doctor.) In North Dakota, home to Kromenaker’s clinic, this law is in effect. "We had to switch back to the FDA regimen, and our medication abortion numbers plummeted," says Kromenaker. "Even for the most privileged of women, making four trips to a doctor’s office to terminate one pregnancy is a huge burden." Guttmacher Policy Review described this legal maneuver as "threaten(ing) US trend toward early abortion."

Women prefer surgical abortion to medicalDr. Winikoff is quick to point out that while only four states have passed laws requiring providers adhere to the FDA regimen, two of those states are Ohio and Texas. "Those are big states with a lot of people — and they’re almost entirely unable to provide medical abortion because conforming to the FDA approval document makes provision so cumbersome. Medical abortion is very popular in California and New York, which are also states with a lot of people, but with more supportive regulation."

In 2014, the American College of Obstetricians and Gynecologists found that while women are usually satisfied with whatever abortion method they choose, they prefer surgical abortion to medical. When presented with the breakdown of what each entails, it’s easy to understand why: surgical abortion is quicker, more effective, and often entails only light bleeding, so it may remain the more popular choice in the US for the foreseeable future even if restrictive laws are overturned. And that’s not a bad thing. In fact, it’s a testament to how tenaciously activists have fought to ensure access and options to the pregnant people who need them.

For supporters of reproductive rights and comprehensive health care, the goal is for everyone to have the option of both methods: no more instances in which women can’t obtain medication in time to avoid surgery, and no more instances in which women have to go with medical abortion (or else no abortion at all) because surgery is too costly an investment in terms of travel and time.

reproductive rights rally

A reproductive rights rally in Minnesota (Fibonacci Blue)

I'm not sure I would go with medication again if I needed an abortion and were given the option of surgery

Now that I know my medical abortion experience was somewhat anomalous, I’m not sure I would go with medication again if I needed an abortion and were given the option of surgery. I admit I’m daunted by the thought of intense cramps and heavy bleeding. But any number of circumstances could mean medical abortion would be the better method for me in the future, even if it isn’t right now. In a perfect world, I — and all of us — would always have the choice.