If the Main Abortion Pill Is Banned This Week, Providers Are Prepared to Go Off-Label

Update, March 14: Federal Judge Matthew Kacsmaryk scheduled a hearing in this highly consequential abortion pill case for Wednesday at 10 a.m. Eastern. He could issue a ruling on mifepristone any time after the hearing concludes. Over the weekend, Kacsmaryk tried to keep the date of the hearing from appearing on the public docket.

Original story from February 7 follows:

A Trump-appointed judge could revoke Food and Drug Administration approval of a common abortion drug as soon as this Friday, February 10—yes, even in blue states where abortion is still legal. Earlier this month, I suggested that people order abortion pills before they’re pregnant, because it could soon be harder to get the gold standard for medication abortion, and clinics could be inundated with appointments for procedures.

Now, eight abortion providers have confirmed to Jezebel that if the judge bans mifepristone—the first of the two drugs involved in the FDA-approved protocol for a medication abortion—they are prepared to prescribe misoprostol-only abortions as a workaround. (People will still be able to order both pills via international services like Aid Access.) Planned Parenthood, Abortion on Demand, Aid Access, Carafem, Choix, Forward Midwifery, Hey Jane, and Just the Pill told me they’re ready with the back-up plan and that the single-drug regimen is safe and effective—though, of course, people who have abortions deserve better than political interference at all.

Danika Severino Wynn, certified nurse midwife and vice president of abortion access at Planned Parenthood, said in a statement to Jezebel: “No matter the case outcome, Planned Parenthood health centers will remain committed to doing whatever possible to ensure patients can choose the method of abortion that is best for their circumstances, including medication abortion.”

A misoprostol-only regimen is not FDA-approved for abortion and would therefore be an off-label use of the drug, but it’s extremely well studied and supported by the World Health Organization. In fact, on Monday, researchers published the first study to examine misoprostol abortions in the United States and found that the drug was 88 percent effective at ending a pregnancy. Studies in other countries have found efficacy rates between 95 and 99 percent, on par with results for the two-drug combo. Yes, medication abortion with both drugs is slightly more effective than using just misoprostol only, but only slightly.

Even the National Abortion Federation’s clinical practice guidelines for abortion providers note that “where mifepristone is either not legally available or inaccessible, misoprostol-alone regimens may be offered.”

Christie Pitney, certified nurse midwife of Forward Midwifery and co-founder of the Abortion Freedom Fund, emphasized that drugs are used off-label all the time. Misoprostol itself is an ulcer drug that’s prescribed off-label to prep for IUD insertions, induce labor, and prevent postpartum hemorrhages, and more. “It’s not like abortion is the exception and everything else is only used in the way that is FDA-approved,” she told Jezebel. Pitney, who’s also an Aid Access provider, said “if mifepristone gets blocked—I mean, it’s shitty and we don’t want any sort of abortion restrictions—but it’s not like medication abortion will vanish.”

Rebecca Gomperts, the founder of telehealth service Aid Access, told Jezebel via email that they were still working out the details on pricing and whether miso-only would be an option in all 24 states where they operate.

Leah Coplon, director of clinical operations at Abortion on Demand, which offers telehealth in 22 states, told Jezebel that U.S. providers hadn’t been very interested in offering misoprostol abortions when a more effective option existed. But that’s changed with this lawsuit, and now AOD is actively making plans to switch.

What’s the practical difference between the two-drug abortion and the miso-only?

Abortion pills were used in over half of abortions in clinical settings and telehealth in 2020, and other people use them to self-manage abortions at home. When U.S. advocates and journalists say “the abortion pill” or “medication abortion,” they’re usually referring to a combination of mifepristone (mife for short) and misoprostol (miso). The FDA-approved regimen through 10 weeks of pregnancy is to take one mifepristone, which blocks a hormone necessary for the pregnancy to develop, then wait 24-48 hours before taking four misoprostol, which causes uterine contractions that expel the pregnancy, just like a miscarriage.

You can use the pills together, or you can use misoprostol on its own. As health science professor Angel Foster told The Atlantic last year, “it’s really the misoprostol that’s doing the lion’s share of the work.” If someone does an abortion with just miso, they would put four pills between their cheek and gum and let them dissolve, then wait three hours and repeat, and repeat that a final time for a total of 12 pills. That’s the World Health Organization protocol for people in the first 12 weeks of their pregnancy.

Since miso is the drug that causes contractions, “it can be a bit more of a painful process” to take it alone instead of the FDA protocol of mife plus miso, because a higher dose is involved, Pitney said. She said people may experience more diarrhea, nausea, and mild fever.

Melissa Grant, the chief operations officer at Carafem—which has clinics in four states and provides telemedicine abortion in 16 states—said the two-drug medication abortion experience varies from person to person, with some finding it annoying but not bad to others who are “absolutely miserable.” Her providers counsel patients that using ibuprofen and heat can significantly help with the painful cramping that misoprostol brings, either without mifepristone or without it.

Grant said Carafem has been offering misoprostol-only abortions as an option during appointments since 2020 under the Trump administration. Grant told Jezebel that less than 20 percent of their clients choose misoprostol abortions, but if they make the switch, all patients would talk with their provider about effectiveness rates and pros and cons before they choose between misoprostol or a procedural abortion.

Pitney said she expects anti-abortion activists to engage in bad-faith fearmongering over heightened side effects possible from misoprostol abortions. “The anti-abortion movement is causing the additional symptoms, because if someone had access to the FDA protocol, they wouldn’t have this enhanced discomfort.” And for some people who don’t want or can’t access a procedural abortion, “they would rather have the extra side effects from the misoprostol than a continuing pregnancy, which can lead to a range of medical complications in and of itself, aside from just an unwanted pregnancy,” she said.

Among states where abortion is still legal, unfortunately, the off-label strategy would be unavailable in Ohio, due to a 2011 law mandating providers follow the exact FDA protocol for medication abortion. People in states with abortion bans could still get the two-drug combination via Aid Access (the pills ship from India) or from community support networks like Red State Access. Anyone self-managing their abortions outside the U.S. medical system may face legal risks, so if they are going to buy pills, they should first read this guide on minimizing your risks and digital footprint.

The takeaway is that matter what happens in this court case, medication abortion will still be available in the U.S.—it just might look a little different than people are used to.