Will At-Home Therapeutic Miscarriage Make Abortion Clinics Obsolete?

At the turn of the millennium, the FDA approved a pill that could replace most abortions with early at-home therapeutic miscarriage.  When will that potential be realized? 

Fifteen years ago, in September of the year 2000, the FDA approved a French pill known at the time as RU-486 that offered women a safe, inexpensive alternative to clinic-based abortion. Better known by the name mifepristone or mife (rhymes with spiffy), the pill triggers the body’s natural process for rejecting an ill-conceived pregnancy.

When a woman’s reproductive system is working normally, most fertilized eggs either fail to implant or spontaneously abort—a process designed to cull pregnancies that are unlikely to produce healthy babies. This natural process of spontaneous abortion (the medical term for miscarriage) is imperfect, but it stacks the odds in favor of thriving children and families. Therapeutic miscarriage, which has the same goal, makes the process voluntary, allowing rational decision-making to enter the equation.

After mife blocks the hormone progesterone, the lining of a woman’s uterus releases any attached embryonic sac and begins a shedding cycle. Coupled with a second medication, misoprostol, mife provides the most effective means of ending a pregnancy prior to seven weeks and it works well throughout the first trimester. For most women, the experience is like a very bad menstrual period—the kind with cramps, clots, heavy bleeding, nausea and so forth—definitely unpleasant but within the range of normal.  (True fact: Many times when a woman experiences unusually heavy period cramps and bleeding she is going through an early, spontaneous abortion.)

Dire Predictions and High Hopes

At the time mife came on the market, conservative Christians warned that it would increase the number of abortions.  It hasn’t. Health advocates predicted that it would replace clinic-based abortion with early, at-home therapeutic miscarriage. That hasn’t happened either. Today, mife is used for a third of U.S. abortions up to nine weeks, with most women still relying on clinic-based procedures. But medical experts believe that the potential of mife is largely unrealized—that many of today’s abortion procedures could be replaced by earlier, less intrusive, and less expensive at-home therapeutic miscarriage.

Safety not the Barrier 

To date, more than two million American women have used mife to end an unwanted pregnancy. The drug was approved in France in 1988 and is now used globally for early pregnancy termination; a quarter century of data show that it is highly safe and effective. In about two percent of cases the medication fails to cause a complete abortion and the woman requires an aspiration procedure—as can happen with spontaneous miscarriage as well.  About 4 in 1000 women will experience a serious infection or blood loss that requires hospital treatment, a rate that is much lower than comparable risk associated with full-term pregnancy.

Improvement in Clinic-based Abortion  

One reason that many women prefer to simply schedule an abortion is that abortion procedures themselves have improved significantly in the last generation. A retired Seattle doctor tells the story of a young woman decades ago who asked partway through her abortion, “Where are the whirring blades?” The doctor marveled at the patient’s courage and determination—she had scheduled and gone through with the procedure despite thinking that “whirring blades” were somehow involved—but assured her that the then-standard D&C required no such thing.

Today the D&C itself isn’t required for a first trimester abortion, which typically extracts an egg sac smaller and softer than a cherry.  An early abortion procedure can be completed with a small disposable hand-held aspirator, not quite as simple or cheap as a turkey baster, but operating on the same principle. In contrast to an induced miscarriage, which takes place over the course of several days, the aspiration procedure can be as short as ten minutes. That makes it an important option for women who, once their minds are made up, simply prefer to get the procedure done.

Obstruction and Unnecessary Restrictions 

Some women may always prefer a quick clinic-based procedure over an at-home process that takes several days, however private and convenient the latter may be.  But the main reason many choose clinic-based abortion procedures today is that conservative politicians have erected a barricade of “health regulations” that have nothing to do with health and everything to do with obstructing access to misoprostol.  These regulations take what should be a simple prescription—take 1 pill this afternoon and 4 tomorrow and call if you have any concerns—and turn it into a regimen that is complicated, expensive, and difficult to access. That is their purpose. They also cause women to delay abortions past the window in which at-home therapeutic miscarriage would be safe and effective, forcing them to seek later, clinic-based procedures.

The rules now regulating misoprostol have turned what should be an evaluation, followed by at-home pill-swallowing and self-monitoring, into a process that is every bit as cumbersome as outpatient surgery. Depending on state rules:

• A woman may be required to make multiple clinic visits days apart.
• She may be required to actually swallow the pills in the presence of a physician.
• A doctor may be forced to prescribe more medication than is necessary, based on an outdated procedure with more side effects.
• Advanced practice clinicians like physician’s assistants and nurse practitioners may be barred from assessing pregnancy status or administering mife and misoprostol, even though World Health Organization guidelines and research indicate that they are perfectly qualified to do so.
• The office in which the medications are given may be required to have an operating suite and halls in which two gurneys can pass, even though no surgery is being performed there.
• The doctor may be required to watch the patient swallow the pills in the operating theater.
• Telemedicine prescribing of mife may be specifically prohibited by law, even though this has been shown to be a safe and effective option for women in rural and underserved communities and to drop the number of second trimester abortions.

In sum, women don’t opt for early at-home therapeutic miscarriage because it is not available to them as an option.

Looking to the Future

Would more women choose at-home miscarriage over clinic-based abortion procedures if obstructions were removed? Certainly religious conservatives think so, or they would not have introduced hundreds of obstructive laws in recent years with the goal of forcing women to undergo more appointments and procedures in order to end a pregnancy. Self-proclaimed abortion foes who publicly talk about viability and fetal pain show little interest in helping women transition from later to earlier terminations, those that take place at the embryonic “lentil” or “bean” stage, long before pain or viability becomes a question.

Nor do they show any interest in preventing the unwanted pregnancies that lead to abortion. Today’s top tier contraceptives drop the abortion rate by over ninety percent. In a St. Louis study of nearly 10,000 women, the percentage drop in abortions almost perfectly matched the percentage of women who switched to long-acting “set and forget” contraceptives. I have written elsewhere about what a serious anti-abortion movement would look like—and how it would leverage advances in pregnancy prevention. But given a choice between clinic-based abortion and pregnancy prevention, self-proclaimed abortion foes choose more abortion every time. The recent attempt to defund everything that Planned Parenthood does except abortion care speaks for itself.

One great irony of the culture wars is that the most staunch defenders and providers of abortion care are also those doing the most to make abortion need dwindle into history, while the most staunch critics disdain and discredit family planning technologies and undermine access—driving demand for clinic-based abortion in an all-or-nothing bid to control female sexuality. But despite the obstructions, word has gotten out that women have options; and despite obstacles, women seek them out—determined to live the lives of their choosing and to stack the odds in favor of their children, their families, and our world. Despite—not because of— conservative obstructionism, both unintended births and abortions are declining as reproductive empowerment grows.

Dr. Daniel Grossman of Advancing New Standards in Reproductive Health, a research program at the University of California, San Francisco, is a tireless advocate for options including over-the-counter birth control pills, emergency contraception, “set and forget” IUDs and implants, and—when all else fails—abortion care.  He shares one opinion in common with his conservative opponents:  If obstacles are removed, more women will choose the privacy and convenience of at-home therapeutic miscarriage over clinic-based abortion. “What is the ideal ‘perfect’ proportion of medication abortion?” Grossman asks. He goes on to say, “We don’t know.  I think if women are given a true choice, at least half of eligible abortions would be medication abortion.”

One pill the first day, four to follow, have someone pamper you, pay attention to how you feel, call me. 

Will that put abortion clinics out of business? Not in the near term.

But in the long run, the men and women now providing abortion care may find themselves increasingly able to devote their energy to pregnancy planning and prenatal services. Clinic-based abortion procedures likely will dwindle as more women have access to at-home therapeutic miscarriage. Add that to the fact that abortions of all kinds will plummet as young women switch over to IUDs and implants—and by 2030, the familiar 1-in-3 statistic and the stand-alone abortion clinic may be a distant memory.