EXECUTIVE SUMMARY
Self-managed abortion care does not need to be difficult or expensive, but restrictive state laws make it challenging for clinicians and patients.
- The Food and Drug Administration could make it easier to obtain medication abortion pills once it updates the Risk Evaluation and Mitigation Strategy for mifepristone.
- Some large employers are offering travel benefits to help staff access abortion clinics out of state, if needed.
- Another tactic involves risk reduction policies or laws that would permit clinicians to help women find safe ways to manage their own abortions.
Self-managed abortion care could be far cheaper and easier to obtain than it is now in the United States, where legal barriers such as state laws banning mail-order abortion pills and the federal rule that still prevents pharmacies from selling mifepristone and misoprostol.
The Food and Drug Administration is expected to update its Risk Evaluation and Mitigation Strategy for mifepristone. The change should allow pharmacists to dispense the drug through pharmacies.1
“At the moment, mifepristone is not available to brick-and-mortar pharmacies,” says Elizabeth Raymond, MD, MPH, senior medical associate at Gynuity Health Project in Tacoma, WA. “But because we’re still in the pandemic public health emergency, it is available through online pharmacies, and physicians can send prescriptions to those pharmacies.”
This would enable a patient who lives in an abortion-ban state to travel to a state where abortion is legal, and meet in-person or remotely with a certified prescriber. Then, the provider could send the prescription to a pharmacy in the legal state for the patient to pick up.
“We had a small number of cases where people who lived in a restrictive state would travel to another state and stay with a friend or relative,” Raymond says. “They would have pills mailed to the house where the patient was staying, and that could be really helpful for some people.”
But the cost of medication abortion pills is likely to remain too high for many low-income people, unless they receive assistance from grants or insurers.
“Mifepristone is an expensive medication — close to $50 for a tablet — and misoprostol is much less expensive,” says Daniel Grossman, MD, FACOG, a professor and the director of Advancing New Standards in Reproductive Health at the University of California, San Francisco. To put the cost in perspective, a typical medication abortion regimen consists of one 200 mg mifepristone tablet and four 200 mcg misoprostol tablets.2
Self-managed abortion and advance provision of medication abortion would eliminate the need for in-person visits with providers and eliminate all physical screening methods, such as ultrasound and pelvic examination, making this a cheaper option than the current system.
“These medications are much less costly in countries like India. One question is whether the cost could potentially come down, and would advance provision also be covered by insurance,” Grossman says.
There is some evidence that employers are willing to help women meet the high cost of obtaining an out-of-state abortion, which means they also might be open to funding a self-managed abortion. For instance, in March, Citigroup announced to its shareholders that it would provide employees with travel benefits to facilitate access to abortion clinics. The policy would cover employees’ expenses for plane tickets and hotels.3 Travel costs and reproductive care benefits also are offered by Apple, Bumble, Levi Strauss, and Hewlett Packard Enterprise. Match Group, based in Dallas, offers employees a toll-free number for Planned Parenthood Los Angeles to arrange travel and lodging paid by a fund created by the company’s chief executive officer.4
Alloy, a New York-based startup company, is offering to pay up to $1,500 toward travel expenses for employees or their partners who need to travel out of state for abortions. The company also offered to cover half of any legal costs up to $5,000 for any issues related to anti-abortion laws in the employee’s state.3
While employer-based abortion care plans are helpful, they target a limited group. Most women who seek an abortion do not have access to insurance or employer plans that can help mitigate the cost.
“It’s important to think about the cost and look for ways to bring down the cost,” Grossman says.
Although many state legislatures are pushing for restrictive anti-abortion laws, it is possible that policymakers will learn from the experience of Latin American countries and develop harm reduction approaches to abortion care.
“There’s a lot that can be learned from Latin American countries where abortion has been restricted for a long time, and now there is a trend to liberalize the laws,” Grossman explains. “Uruguay has developed a harm reduction approach. While they cannot provide a legal abortion, if a patient comes in and says they’re self-managing their abortion, they could examine the patient, see how far along they were, and tell them how to self-manage their abortion safely.” Providers can ask patients to return for evaluation and provide contraception if the patient is interested.
That is a different legal framework than what some states are using, which includes criminalizing providers for even talking to their patients.
“But as providers, we need to stand firm in our responsibility to do no harm, and we should counsel patients about what’s best for their health,” Grossman says.
REFERENCES
- Muscat J. Upcoming changes to the mifepristone REMS program: Implications for pharmacy practice. Birth Control Pharmacist. Jan. 24, 2022.
- Nippita S, Paul M. Abortion. Contraceptive Technology 21st Edition. New York: Ayer Company Publishers, 2008.
- Goldman D. Citi’s response to abortion bans: We’ll pay for workers to travel. CNN Business. March 16, 2022.
- Butler K. How big U.S. companies are creating a brand new abortion benefit. Bloomberg. March 24, 2022.
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