What role will the abortion pill play if Roe v. Wade falls?

Demand for "abortion pills" rose sharply right after Politico published a leaked Supreme Court draft majority opinion that would unequivocally strike down Roe v. Wade and the constitutional right to obtain the procedure, according to organizations that provide access to or information about abortion medication. What is the abortion pill, and is it the future of pregnancy termination in a post-Roe America?

What is the abortion pill, and how does it work?

It's actually two different medications, mifepristone (sold under the brand name Mifeprex) and misoprostol, taken in tandem. Mifepristone blocks progesterone, a hormone required for a pregnancy to continue. Misoprostol, taken 24 to 48 hours after the mifepristone, causes contractions similar to what happens during a miscarriage, emptying out the uterus. There are generic versions of both drugs available.

Are the pills legal?

Yes, nationwide with a prescription and doctor consultation. The Food and Drug Administration approved mifepristone in 2000, and misoprostol has long been available for a variety of uses, including ulcer prevention and treating other stomach issues. The FDA allowed the drugs to be prescribed after a remote doctor's consultation during the pandemic, then got rid of the in-person requirement entirely in December. So far, 19 states have passed laws banning telemedicine abortion, and some conservative states are looking at ways to further restrict or ban access to the pills, especially after the Roe opinion was leaked.

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Are they safe?

Misoprostol is approved as safe and effective up through 10 weeks of pregnancy, though it is sometimes used "off label" after 10 weeks. "Research has shown that telemedicine medication abortion is of comparable quality to the in-person procedure, and adverse events occur less than 0.2 percent of the time," Politico reports.

But you wouldn't know that from how abortion is depicted in popular culture, Steph Herold, a researcher with Advancing New Standards In Reproductive Health (ANSIRH), tells NPR News. She described a 2021 episode of Law & Order in which a foster father forces a teen to get a medication abortion, and she suffers near-fatal consequences from the pills.

That's "extremely irresponsible because we know that abortion pills are very safe," Herold said, pointing to a more realistic and compassionate depiction from A Million Little Things in which the woman takes the pill on camera, sitting on her couch, "surrounded by pillows and blankets" and accompanied by the "guy she had sex with," who flew over "from the U.K. to be with her during the abortion."

What if your state bars medication abortion?

This is expected to be the next big legal battle if Roe is overturned, but most experts say states are facing an uphill climb. In 2020, most abortions in the U.S. — 54 percent — were medication abortions, according to the Guttmacher Institute.

"Given that most abortions are early and medication abortion is harder to trace and already kind of becoming the majority or preferred method, it's going to be a big deal," Mary Ziegler, a legal scholar who studies abortion rights, tells The New York Times. "It's going to generate a lot of forthcoming legal conflicts because it's just going to be a way that state borders are going to become less relevant."

"These laws that state legislators are trying to pass aren't going to stop abortion," Elisa Wells, co-founder of Plan C, a site that provides information and resources for people seeking to end a pregnancy, tells The Washington Post. "They are just going to change how people access abortion."

Can't states block access to the pills?

Many Republican legislatures have tried, but "some women have been able to circumvent the restrictions by getting their pills online from overseas pharmacies that can't be reached by U.S. laws," the Post reports. A five-day regimen arrives in the mail in a generic-looking package. "Mailed pills are hard to police," said Rachel Rebouche, interim dean of Temple Law School. "That has not stopped [states] from trying."

Doctors could also prescribe the pills and send them to the closest state where it is legal to take the drugs, requiring the woman to travel. "This is just not going to be stoppable," Gerald Rosenberg, a law professor emeritus at the University of Chicago Law School, tells the Post.

Some lawmakers trying to outlaw all abortions are aware of this issue. "If you make it harder on people to get an abortion, there will be less of them," but shooting for zero, "I don't think that's realistic," said Alabama state Rep. Andrew Sorrell (R). "Anything you make illegal there's going to be a black market for. There's a black market for drugs, there was a black market for alcohol during Prohibition."

Will this be the future of abortion?

That might depend on how states respond to the death of Roe. "The need for abortion will not go away," Abigail Aiken, a University of Texas associate professor whose research documented a big uptick in medication abortions after Texas banned most abortions last September, tells the Post. Restrictions lead to "an increase in self-managed abortion, outside the formal health-care setting. What we have seen is that every time states move to restrict abortion, there is an increase in self-managed abortions."

But the pills don't work for a very small number of women, and second-trimester pregnancies typically require more expensive and invasive surgical abortions. There's also a question of supply, and supply chains. "We are not ready for the surge," Julie Amaon, medical director of Just the Pill, tells Politico. "Nobody is, so that's the really scary part. ... So we are doing our best to be ready for that surge. But I am concerned no state is ready for what's about to happen."