The legal battle to limit mifepristone access threatens equitable health access throughout the United States

Though it is 2023, the abortion debate rages. Abortion was not always the focus of hotly contested political debate. In the 1700s-1800s, it was provided for those in need as a common practice of family planning, often provided by women and black women. There is a racist history rooted deeply in the U.S. abortion tapestry. Since  abortions were being performed by women, half of whom were black women, the medical society was kept at a distance from this procedure. Male gynecologists and doctors forced these women out of the world of abortion providers in the early 1900s in an effort to “regulate” abortion practices. This set the tone for providers and politicians to exert bodily control over patients and women. 

I describe this to underscore that anti-choice and anti-abortion rhetoric has a long, confusing background that has not historically centered the woman, or individual with reproductive needs, as the patient. It works as a strategic machine disseminating misinformation and non-scientific recommendations to physicians, patients, and politicians. The most current example of these tactics at work is the Texas case court case Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration. One of the most damaging effects of this reality is who the strategy targets most; those most socially vulnerable and those historically medically underserved

The lawsuit in question requests that mifepristone, commonly known as the “abortion pill,” be taken off the market. The suit states that the FDA made errors in their original process of approval of the drug 2000 and it must be rectified with a preliminary injunction. On April 7th, Judge Matthew Kacsmaryk ruled in favor with a week to receive an appeal. The 5th circuit court of appeals upheld aspects of this ruling and denied others. Mifepristone can no longer be prescribed via telehealth or sent in the mail and it is only valid for use through seven weeks gestation, rather than 10 weeks as approved by FDA in 2016. As of April 13th, Attorney General Merrick Garland said the Department of Justice will take this 5th Circuit Court ruling and dispute over mifepristone to the Supreme court.

Mifepristone was first approved by the FDA in 2000 for the medical termination of a pregnancy through 10 weeks gestation. The FDA regards mifepristone as safe and effective when used as directed according to a certified provider. [To learn more about mifepristone follow this link.] Since the Supreme Court’s decision to overturn Roe v. Wade in June of 2022, ending the constitutional right to abortion, abortion is fully banned in 13 states. If this next ruling is upheld at the Supreme Court level, even more states will be impacted by extreme limits and/or full abortion bans.

This threat to medication abortion and self-managed abortion is a glaring attack on bodily autonomy and equitable access to healthcare and reproductive rights. For safety comparison, penicillin (a common antibiotic) has a four times greater risk of death than Mifepristone. Additionally, risk of death from Viagra (a common erectile dysfunction medication) is almost 10 times greater. Evidence that health and safety are not the priority in this legal battle. 

Medication abortion and self-managed abortion are critical options for care to those living in rural areas and communities with less access to healthcare providers and healthcare facilities like community health centers and federally qualified health centers. With 40% of the U.S.’s clinics – largely clinics in rural areas and small, less funded community health centers – offering only medication abortions, the people they serve will be more negatively impacted by medication abortion restrictions. Studies report that situations where there are legal restrictions on mifepristone were “associated with reduced access among women who were younger, of black race, less educated, and in lower socioeconomic groups.”

This threat of abortion restriction harkens back to the early 1900s use of abortion as a tool of oppression over women, black women and women of color, people in poverty, and people in rural areas. Abortion bans because of the Texas ruling will contribute to increased health complications in areas and communities already experiencing higher than average maternal mortality rates. The maternal mortality rate in the U.S. is ten times that of other high-income countries. This is especially true as women report more serious complications in carrying a pregnancy to term than undergoing an abortion. Despite the amount of money the U.S. spends on healthcare, the U.S. ranks almost 50thin the world for maternal safety. The maternal mortality rate in 2021 for Black women was 69.9 per 100,000, which is 2.6 times higher than their White counterparts, likely due to being more likely to live in a medically underserved area

The healthcare precarity that women in poverty, women of color, women who are uninsured and underinsured, and women in rural areas face in the U.S. abounds. Mifepristone is a strong example of how the health interests of those most medically underserved and ignored by the system are deprioritized. Regardless of opinions on the morality of the abortion pill, the data demonstrates a direct link between abortion restrictions and increased poverty, maternal and child mortality rates, adverse health effects, etc. In addition to contributing to worse health outcomes, banning medication abortions also contributes to worse financial outcomes for women of color and those with uteruses. Individuals that are denied abortions are more likely to experience increased household poverty lasting at least four years after pregnancy, compared to those that did receive an abortion. Similarly, those who are denied access to abortion are likely to experience a 78% increase in debt in the following 30 days, with an 81% increase in negative public records on their credit reports – leading to potential bankruptcies, evictions, etc. 

If the Texas decision is upheld, this will impact states where abortion was not previously affected by the Dobbs decision. As stated above, this will perpetuate existing negative health outcomes of the medically underserved, as well as perpetuate cycles of poverty. There is additional worry that the strain on abortion providers in states with legal abortion access will increase with the corresponding rising influx of patients in search of care. 

Medication and treatment options and recommendations must be based on data, science, and fact regardless of political atmosphere. If the Texas ruling in Alliance for Hippocratic Medicine v. U.S. Food and Drug Administrationstands, legal and political interest groups could be ready to take aim at many other safe, effective, approved medications and forms of treatment in the name of morality. The lawsuit claiming the FDA violated procedure in its original approval of mifepristone does not specify details as to how or why that occurred, setting the precedent that medication and treatment decisions may be up to federal judges and the legal community in the future. 

If we, as the public health and health policy community, are to center equitable access to healthcare as a primary goal, we must disseminate data-driven information to reinforce protections for all people’s reproductive healthcare and general healthcare. Mifepristone is safe and effective. Access to it supports better health outcomes for communities and the medically underserved. 

This is the moment for action against further healthcare inequity. Patients need sustained support for health equity at the community level and guaranteed protections under the law that their health outcomes are priority. Providers need to be able to provide research and data backed healthcare to all. Policymakers need to enact and protect policies that prioritize medically underserved communities, women, black and brown people, unhoused individuals, the uninsured or underinsured, those living in poverty, those in rural areas, etc. 

Those with reproductive needs have been on the defensive for too long. Health equity means providing women and people with uteruses and/or the capacity to get pregnant the full breadth of reproductive care with increased access. 

View Healthcare Ready’s statement on the Texas court’s mifepristone ruling and health equity here.

Resources for patients and providers

As the legal battles regarding medically induced abortion, here are a few resources for patients and physicians to help navigate the complex landscape. However, as these cases are still being decided, always make sure sources reflect the latest information and legal guidance. If unsure, check with a trusted provider. 

If you are a provider that is seeking legal compliance assistance and other resources to help you provide quality care to your patients, the Resources for Abortion Delivery organization may be able to provide pro-bono help.