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Preparing for a Post-Pill World

U.S. District Judge Matthew Kacsmaryk in Texas could very well issue an order this week that would ban the use of a drug called mifepristone nationwide. This case is not about the safety of those that can become pregnant. It is not about scientific fact or medical best-practices, but about the extremist ideologies held by a small but vocal and very well funded collection of anti-choice activists. This case was brought to the court by groups including the Alliance for Hippocratic Medicine, which incorporated in Amarillo three months before filing the case specifically to guarantee that it would go before Kacsmaryk, a man with a professional history of supporting anti-lgbtq+ discrimination and forced prayer in school.

These groups picked their judge, then did everything in their power to get their case before him, pulling it when it showed up on another judge’s docket. Kacsmaryk has already issued rulings on trans rights, immigration and birth control, that have been deemed radical and outside of legal precedent by many law experts. Due to this understanding of his previous rulings, the merits, or lack thereof, of this case don’t matter in how we should all be preparing. We cannot rely on logic or established law to protect us.

Though many know it as simply “The Pill,” mifepristone is currently part of a two-drug regimen used to terminate a pregnancy up to 11 weeks of gestation. Mifepristone (or mife) blocks the hormones needed to continue a pregnancy and has few noticeable side-effects. It has been prescribed widely and with an excellent safety record for over twenty years since its FDA approval in 2000. Mifepristone is used in conjunction with another drug called misoprostol. Misoprostol (or miso) causes the uterus to cramp and pass the pregnancy, engaging the same muscle groups that expel the uterine lining during menstruation. Miso is also used for gastro-intestinal issues and excessive bleeding in situations not involved with abortion. The two medications combined are an impressive 98% effective at terminating an early pregnancy, and while medication abortions utilizing mife and miso are not completely without risk, the risks associated with carrying a pregnancy to term are actually ten times higher than that of having an abortion. If the Texas case results in a nationwide ban of mifepristone, some of this will change.

Throughout much of the world, places where mife is too hard to come by or too expensive, misoprostol alone has been used for those seeking an abortion widely. Miso-only protocols involve taking multiple rounds of the medication to cause cramping and passage of the pregnancy over a longer period of time. The duration until completion of this process can take days or weeks, compared to the mife/miso combination, which generally is successful in the first day or two. With delayed follow-up, meaning a check-up around one-month after taking the initial misoprostol, the success rate for a miso-only abortion is around 95%. While that rate of completion is an encouraging one, having to plan for and experience a process that may take up to a month may be incredibly difficult in a country without universal sick-leave or paid time off, but is superior to having no option available to terminate an unwanted pregnancy. A study from the National Institutes of Health summarized their findings as such:

“Despite these limitations, currently available data suggest that misoprostol as a single agent is a reasonable option for women seeking abortion in the first trimester. This treatment is clearly less effective than standard regimens that also contain mifepristone, and thus enhanced vigilance should be recommended to detect potential failures. Nevertheless, misoprostol alone may be preferred by some women because it may be easier to obtain, less costly, or have other advantages.”

Currently, a medication abortion involves taking one 200 mg tablet of mifepristone by mouth, then taking four 200 mcg tablets (or 800 mcg) of misoprostol, by letting it dissolve either in between the cheeks and gums, under the tongue, or intra-vaginally. All of these methods for taking the miso are effective, though vaginal absorption has lower risk of nausea and vomiting associated with it, something no one wants to deal with and is especially troublesome for those already experiencing “morning sickness.” Additional 800 mcg doses may be given to those further along in pregnancy or those that have a medical history indicating that one dose may be insufficient. Most people taking this combination of drugs will pass the pregnancy within 24 hours, many will pass the pregnancy within the first 48. There are rare occurrences of it taking up to a week for completion. A follow-up call or in-person visit and ultrasound are usually scheduled 7-10 days from the initial appointment to take the first pill of mifepristone, and for the vast majority of people, that is the conclusion of necessary care. For added clarity, a pregnancy test can be taken 4-5 weeks out and should start to display a negative result as pregnancy-hormone levels drop. This timeline will change considerably with a mife ban, but it is unclear just how much.

While there are reams of data showing that misoprostol-only abortions are safe and effective, more information is going to be needed to know the optimal protocols for dosage, route of administration, and frequency. The standard regimen at the moment is an initial dose of 8oo mcg taken vaginally or sublingually (under the tongue) followed by two more additional doses taken every 3 to 12 hours. This process will likely lead to a longer length of time cramping and higher incidences of nausea and diarrhea. Strategies to prevent dehydration and minimize these effects should be put in place beforehand. Having anti-nausea medications and anti-diarrheals added to the medication plan for these “miso-only” abortions makes a lot of sense to provide quality care, as well as a wide variety of pain-management strategies as cramping time increases. In an ideal world, people undergoing this process would be able to rest at home or a safe place until the pregnancy is passed and symptoms have resolved, but ours is not an ideal world.

Though miso-only protocols for ending early pregnancy can work for most, a small but significant percent of people will need an in-clinic procedure for their abortion to be complete. This isn’t accessible in much of the U.S. right now after the fall of Roe vs Wade, and will disproportionately impact communities of color and those facing economic insecurity. Clinics in remaining safe-states will need to be prepared for this additional need for surgical follow-up should a mifepristone ban be put in place either permanently or temporarily due to the Texas case. Funds for procedures as well as travel and lodging and missed work are going to be necessary to mitigate the additional burdens placed on people with the capacity for pregnancy if Judge Kacsmaryk issues a ruling triggering removal of mife from medical use.

As a community, we can’t see all of the twists and turns brought by this looming case, or those brought by new challenges to mifepristone access, but we can continue to share resources, be that accurate information, rides, housing, funds, or time on phone lines. We can continue to march and make ourselves heard. We can call our representatives and choose where our dollars are spent, avoiding businesses with a history of discriminatory practices. A miso-only post-Roe world is not the world we want, but it may very well be the world we are all living in soon. If that’s the case, people will still have options, but our friends, loved ones and neighbors are going to need more time, more help and more care than ever.


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