How medication abortion works and what the end of Roe v. Wade could mean for it

Roe v. Wade could soon be overturned — meaning abortion is "certain or likely" to be banned in 26 states, according to the Guttmacher Institute, a research group that supports abortion rights. If clinics that provide abortion shut down, women who can't travel to other states may turn to telehealth prescriptions or underground networks to obtain abortion pills, making that method of ending a pregnancy even more common.

Here's what to know about the pills and how they work.

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?

Medication abortions now account for more than half of all U.S. abortions. 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 Food and Drug Administration 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," says Aguilar. 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.

If Roe is overturned, the math could shift for people who would have to drive long distances to reach a surgical clinic — especially if the state they are traveling to has a long waiting period.

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 says.

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," says Aguilar. "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 in 19 states telemedicine appointments for medication abortion remain banned.

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.

What happens if Roe v. Wade is overturned?

In the states where abortion is expected to be banned if Roe is overturned, medication abortion will become illegal. But access to abortion pills will still be available for those who are able to travel to states with abortion protections.

Some may attempt to acquire the medications from out-of-state providers through the mail. A growing number of states have moved to make this approach illegal, but experts say that in practice, it's difficult to police.

Others may decide to order the medications from overseas pharmacies, though 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. [Copyright 2022 NPR]