Access to a key abortion drug is in legal limbo. Here's how medication abortion works

By Laurel Wamsley,

Kaitlyn Radde

Published May 13, 2022 at 5:30 AM EDT

Containers of mifepristone and misoprostol — medications used to end a pregnancy — sit on a table inside of a Planned Parenthood clinic in Fairview Heights, Ill.

Updated April 14, 2023 at 5:11 PM ET

Two federal judges hearing cases about mifepristone issued contradictory decisions last week, throwing the future of a drug used in nearly all U.S. medication abortions into question.

In Texas, U.S. District Judge Matthew Kacsmaryk ruled that the Food and Drug Administration's approval of mifepristone more than 20 years ago was improper. Kacsmaryk issued a nationwide injunction to pause the FDA's approval.

That would have taken effect on Saturday, but the Supreme Court has issued an administrative stay until next Wednesday to preserve the status quo while the court considers the Justice Department's request to block the decision.

Hours after the Texas ruling, U.S. District Judge Thomas O. Rice issued his decision in a separate case in Washington state, blocking the FDA from "altering the status quo and rights as it relates to the availability of Mifepristone."

Nothing has changed yet, and it's unclear which states would be covered by the Texas ruling if the Supreme Court declines to block it. It's possible that the 17 states and the District of Columbia, which are involved in the Washington lawsuit, wouldn't be covered.

Medication abortion access had increasingly become the focus of the legal fight over abortion rights in the U.S., even before the Supreme Court overturned Roe v. Wade in its Dobbs v. Jackson Women's Health Organization decision last June. And about half of the states have moved to ban or severely restrict abortion. That's in large part because medication abortion now accounts for more than half of U.S. abortions.

As the legal landscape continues to change, here's what to know about the medication and how it works.

What is a medication abortion?

Medication abortion, also known as medical abortion, typically uses a combination of two drugs to end a pregnancy. This method of abortion does not require a surgical procedure and can be done at home.

The first pill is mifepristone, which blocks a hormone known as progesterone that the body needs for a pregnancy to continue.

The second drug, misoprostol, is taken 24 to 48 hours later. This medication causes cramping and bleeding and empties the uterus.

The World Health Organization says that if mifepristone is not available, misoprostol can be used on its own. But the two drugs are more effective together.

Why might a person prefer a medication abortion?

The option to take pills (rather than undergo a procedure in a clinic) has become an increasingly common choice for those seeking abortions since mifepristone was approved by the FDA in 2000.

That may be because it feels more private and less invasive than a surgical procedure, says Dr. Gabriela Aguilar, a physician and clinical instructor at NYU Grossman School of Medicine.

"Many people prefer to end the pregnancy in the comfort of their own home, surrounded by their support system and loved ones ... versus having to go to a clinic or hospital for a procedure," Aguilar says. The medication route may also feel less invasive, she notes, "because there's no instrumentation with medication abortion."

The pills may make it easier to get an abortion if a clinical provider is too far away or difficult to access.

Many people still choose a surgical or procedural abortion, for several reasons. Surgical abortions — an office procedure that often takes just five or 10 minutes — are highly effective and rarely require repeat procedures. Patients may want the in-clinic option to get the process over with quickly, avoid the discomfort of the medication process or because it involves the presence of trained medical and support staff. Another reason for choosing the procedure is that a pregnancy may be too far along to use medication — the pills are most often recommended for pregnancies less than 10 or 11 weeks.

Is medication abortion different from Plan B?

Yes. Plan B is emergency contraception, not an abortion. Plan B and another drug called Ella work by delaying or preventing ovulation. Plan B is most effective if taken within three days after unprotected sex; Ella can be taken within five days. Both are more effective the sooner they are taken.

How effective is medication abortion?

Abortion pills are very effective. One study of more than 13,000 women found the efficacy of the two-drug regimen was 97.7% for pregnancies up to nine weeks.

The later in the pregnancy the pills are taken, the less effective they are.

Dr. Aileen Gariepy, a professor of obstetrics and gynecology at Weill Cornell Medicine, says the medication route is more effective for abortion than for miscarriage management — another reason the pills are sometimes prescribed. For miscarriages, she says the pills are most effective when someone already has the symptoms of a miscarriage, like bleeding and cramping.

Why are abortion pills used in the case of miscarriage?

The same pill regimen used for abortion can be used for miscarriage management, depending on how far along the pregnancy is.

Some people learn that their pregnancy is not viable at a prenatal medical appointment — for instance, because the embryo has stopped developing but is still in the uterus. A medication abortion or a surgical abortion may be used to help empty the uterus completely, so that there is no risk of excess bleeding or infection.

How far into a pregnancy can medication abortion be used?

The FDA has approved the two-drug regimen for pregnancies up to 10 weeks. The World Health Organization says medication abortions can be safely performed at home up to 12 weeks.

Gariepy says patients seeking abortions are generally steered toward the surgical option after 11 weeks. "That's not because [medication abortion] is unsafe; it's just not as effective as the pregnancy gets beyond 11 weeks," she says.

Since Roe was overturned, increasing numbers of people have had to drive long distances to reach a surgical clinic in states where abortion remains legal and clinics in those states are struggling to serve many more patients than before Dobbs.

In the case of a pregnancy that is say, 11 weeks and 3 days, "it might be better to try and see if the medication abortion will work," Gariepy told NPR last spring, before the Dobbs decision.

Is medication abortion safe?

Yes. The American College of Obstetricians and Gynecologists assures that medication abortion is a safe and effective way of providing abortion. And the regimen is also FDA approved.

But it can be uncomfortable. Cramping and bleeding can occur for several hours after taking the second drug, misoprostol.

"I tell most people that it feels like very strong menstrual cramping," Aguilar says. "I've had patients tell me that they felt nothing — they felt just a little bit of cramping or 'It was not as bad as my period.' And then I've had other patients tell me that it was the worst experience that they've ever had. So I think there's a wide range of experiences, probably more related to what a person's baseline pain experience and tolerance is like."

A follow-up consultation with a doctor — either in person or via telehealth — is important to make sure the patient is healing and is no longer pregnant, Gariepy says.

Who can prescribe abortion pills?

Mifepristone, the first drug in the sequence, is more tightly regulated by the FDA than many other drugs. Due to the FDA's requirements, mifepristone can only be prescribed by a certified health care provider who meets certain qualifications, and the pharmacies that dispense mifepristone must also be certified.

In December 2021, the FDA dropped the requirement that mifepristone could only be dispensed at in-person settings, but as of January 2023, 18 states had banned telemedicine appointments for medication abortion.

In January, the FDA updated the drug's labeling to allow more retail pharmacies to dispense the pills, potentially expanding access at both in-person and online pharmacies that complete the certification process.

Some Republican attorneys general, including states where abortion remains legal, threatened to sue pharmacies that dispense the pill in their states.

Some patients have gotten the medications from out-of-state and even overseas providers. A growing number of states have moved to make this approach illegal, but experts say that in practice, it's difficult to police. This carries the risk of getting products that are not FDA approved and patients not getting the appropriate care before and after taking the medication.

Does insurance cover abortion pills?

Insurance coverage will vary depending on whether the patient has public or private insurance, and in which state they live.

The Hyde Amendment blocks federal funds like Medicaid from being used to pay for abortions except in cases of rape or incest, or if the pregnancy would endanger the woman's life. However, a 2019 study by the Government Accountability Office found that 14 states' Medicaid programs don't cover mifepristone even in those cases.

The Kaiser Family Foundation found that in 2020, 33 states had no plans available on the Affordable Care Act Marketplace that offered abortion coverage. Six states — California, Illinois, Maine, New York, Oregon and Washington — require state-regulated private health plans to cover abortion, including ACA Marketplace plans, according to Kaiser.

Some insurance plans cover surgical abortion but not medication abortion.

So-called "self-insured" plans — which aren't regulated by state insurance laws — may cover abortion because federal law neither bans nor requires such coverage in self-insured plans, Kaiser notes.

According to Planned Parenthood, the cost of a medication abortion can be up to $750, but is often less. Abortion funds around the U.S. may be able to help with the cost of an abortion if a person's insurance doesn't cover it.

Are there certain people who should not take the pills?

Medication abortions are not a good option for those whose pregnancy has progressed too far.

Others who should not use abortion pills, says Gariepy, are people who have a rare disorder called porphyria, are on chronic steroids, have had a previous allergy to mifepristone, or are severely anemic.

The Cleveland Clinic also notes that medication abortions are not safe for those who have a blood clotting disorder, chronic kidney failure or have an IUD (intrauterine device).

They're also not a good choice to treat an ectopic pregnancy (a pregnancy outside the uterus), or for those who don't have access to emergency medical care or can't do a follow-up consultation, the clinic says.