By Carrie Baker for Ms. Magazine.
Broadcast version by Roz Brown for Texas News Service reporting for the Ms. Magazine-Public News Service Collaboration

Over half of clinician-supervised abortions in the U.S. in 2020 were done with a combination of two medications: mifepristone and misoprostol. A Trump-appointed judge in Texas will soon decide a lawsuit brought by anti-abortion extremists asking him to force mifepristone off the market in all 50 states. If he does, as anticipated, reproductive rights advocates are ready to offer a safe and effective alternative to end pregnancy through three months: a higher dosage of misoprostol taken alone.

Misoprostol is a widely available ulcer medication that can induce a miscarriage by causing contractions of the uterus to expel a pregnancy. In the 1980s, Brazilian women began using misoprostol to end their pregnancies because abortion was unavailable through the medical system. Self-managed abortion with misoprostol resulted in precipitous declines in infection, hemorrhaging and death from unsafe abortion.

Today in countries where abortion is legally restricted, misoprostol is often used alone for self-managed abortion because it is inexpensive and widely available, often over the counter, unlike mifepristone.

Many studies from around the world have found that self-managed abortion with misoprostol alone is 93 to 99 percent effective and very safe. Because of the widespread availability of mifepristone in the United States, the use of the misoprostol alone for abortion had not been studied here, until recently.

On Feb. 6, researchers at the University of Texas at Austin published peer-reviewed research on the use of misoprostol alone for abortion. The research found that misoprostol alone was over 88 percent effective, with few incidents of serious adverse events or signs of potential abortion complications.

"This is the first U.S.-based study on misoprostol alone for self-managed abortion and it's coming at this critical time where we don't know what's going to happen with access to mifepristone," said the study's lead author, Dana M. Johnson, a Ph.D. candidate in public policy and demography at the University of Texas at Austin and a senior associate research scientist at Ibis Reproductive Health. "Our contribution with this study is to add to the broad evidence base we have from the international space on how safe and effective misoprostol is."

The research was based on data from the Vienna-based telemedicine abortion provider Aid Access, which provides telemedicine abortion services with pills in all 50 states in the U.S. Due to pandemic-related challenges shipping mifepristone, Aid Access prescribed misoprostol alone to over one thousand U.S.-based patients in June of 2020. Aid Access physicians either mailed misoprostol directly to patients or sent prescriptions to local pharmacies for pick-up.

"We took a very conservative approach by including just the people who had a totally confirmed, complete abortion at four weeks and didn't get a surgical intervention," said Johnson. "That is why our finding is 88 percent effectiveness, which is much lower than the SAFE Study from Ibis, which showed 98 percent effectiveness."

Published in November of 2021, the SAFE Study-which stands for Studying Accompaniment Feasibility and Effectiveness-showed that 98.8 percent of those who used the misoprostol-alone regimen had a complete abortion without surgical intervention. "SMA with misoprostol only is highly effective, and warrants renewed attention," it concludes, calling it "no longer a second-tier method, but one that offers similar effectiveness, and often greater accessibility, than the mifepristone and misoprostol regimen."

While this research shows misoprostol alone is a little less effective than the combination of mifepristone and misoprostol, extra doses of misoprostol can increase efficacy.

"We did take this conservative approach, but our findings were really, really good. There were very few people who had a serious adverse event. There were very few people who had any kind of treatment for that or a symptom of a potential complication," added Johnson.

Johnson is now conducting follow-up interviews with the research participants to understand their experiences of using misoprostol alone, which can be more difficult than the combination of mifepristone and misoprostol because the misoprostol-alone regimen calls for multiple doses of the medication, as opposed to one dose if combined with mifepristone. Those who use misoprostol alone may experience stronger cramping. Side effects from misoprostol can include nausea, fever, chills, vomiting and diarrhea, which can be more severe when taking misoprostol alone because of the higher dosage.

Johnson is finding in her research that women's experiences of using misoprostol are shaped by their mindset and how prepared they felt. Many found information on Reddit.com. The abortion Subreddit is curated by OARS (Online Abortion Resource Squad) with trained, expert volunteers who "ensure that every Reddit post asking for abortion-related help gets a quality, accurate, compassionate answer and referral to resources."

"People asked a lot of questions and that brought a sense of comfort because if you know that you can prep your hot water bottle or your ibuprofen or your chamomile tea, you're going into it with a little bit more of a mindset that you can manage this pain," said Johnson.

Research from other countries has shown that patients can have positive abortion experiences with misoprostol alone when they have access to the information they need, feel prepared for what they will experience and are supported through the process.

If the Texas court imposes a nationwide ban on mifepristone, women and pregnant people can still access the highly effective and medically safe method to end an early pregnancy with misoprostol alone. And unlike mifepristone, misoprostol is inexpensive and widely available by prescription for different indications in pharmacies throughout the U.S.

While the FDA has not labeled misoprostol for abortion, U.S.-based providers can prescribe the medication off label for this use to patients in states where abortion remains legal. Many telemedicine abortion providers have already pledged to offer misoprostol off label to their patients if mifepristone is removed from the market, including Abortion on Demand, Aid Access, carafem, Choix, Forward Midwifery, Hey Jane and Just the Pill. Planned Parenthood has also said they will offer this service.

National Abortion Federation's clinical practice guidelines suggest offering misoprostol alone where mifepristone combination is not accessible. The World Health Organization also has guidelines for misoprostol alone as a safe and effective options for abortion care. According to these guidelines, women in the first 12 weeks of pregnancy dissolve four 200 mg of misoprostol between their gum and cheek, three times at three-hour intervals.

"With clinical options for abortion severely limited post-Dobbs, these guidelines are important in affirming self-managed abortion as a safe and essential practice that can be empowering for those seeking to end a pregnancy," concluded the U.T. Austin study authors. "There is potential for its use in the U.S. as a method of ensuring reproductive autonomy, especially for populations who have been systematically cut off from safe, affordable and non-coercive reproductive healthcare services."

A recent poll shows widespread concern among Missourians about the future of birth control access.

The survey from the Right Time Initiative reveals almost 40% fear birth control will become harder or even impossible to obtain. Some medical industry experts believe the uncertainty is fueled by a lack of access to future Title X funds, which provide affordable family planning services to thousands in the Show Me State.

In an unprecedented move, the U.S. Department of Health and Human Services has withheld funding from several grantees.

Michelle Trupiano, executive director of the Missouri Family Health Council, said her organization is one of them.

"I think this polling shows what Missourians already know," Trupiano asserted. "Both the state and the federal government are doing everything they can to make it harder for people to access care."

Missouri Family Health Council has led the Title X program in the state since 1981 and in Oklahoma since 2023, serving nearly 44,000 people in 2024. Both states are set to lose more than $8 million in Title X funding.

Trupiano noted her organization is always communicating with policymakers to ensure they are aligned with what voters and constituents want and argued the survey shows the will of the people, across party lines.

"What this polling shows is that an overwhelming percentage of Missourians, over 80%, believe that birth control is something that everybody should have access to," Trupiano pointed out. "They want their lawmakers to actually do more to support access."

Although a total restriction on birth control is not widely supported, there is stronger opposition to methods like Plan B and IUDs, compared to more common methods such as condoms or regular birth control pills.

Today marks the last day of Black Maternal Health Week, a nationally and internationally recognized observance that serves to build community collaboration around addressing the maternal health statistics for Black women.

Black women in the U.S. are more than three times more likely to die of a pregnancy-related cause than white women and are more than two times more likely to experience complications that negatively impact their health. The majority of them are preventable.

The weeklong campaign that serves to highlight these disparities was founded in 2018 by the Black Mamas Matter Alliance. Its executive director, Angela Aina, said while there have been great strides since the launch, more attention needs to be paid to the root causes of maternal morbidity and mortality.

"It really does point to how pervasive and how systemic and structural gendered racism and obstetric violence is very, very much seeped in our systems," she explained.

The rate of adverse outcomes for Black women in Wisconsin have increased significantly in the past decade. Across the state, they are more than 1.5 times more likely to experience adverse outcomes, and more than twice as likely to experience a pregnancy-related death.

In 2023, the overall maternal mortality rate in the U.S. decreased while rates for Black women slightly increased. The outcomes also impact infant health, with babies born to Black, American Indian and Alaska Native and Native Hawaiian and Pacific Islander women experiencing an increased mortality rates than those born to white people.

Aina said while Black Maternal Health Week amplifies the lived experiences of Black women, it does not exclude others.

"We want to see a change for those most impacted, those most vulnerable, those most at risk of these issues and these challenges - and that when we address it, has a ripple and domino effect for everybody else," she insisted.

Aina said such structural issues as housing, economics and maternity-care 'deserts' all play a role, and emphasized the need to increase midwifery care, the number of birth centers, and funding to community-based organizations to positively affect Black maternal-health outcomes.

"To really understand and value the lives of Black people, and the lives of Black women in particular, the lives of us all," she explained, "and the fact that we are all deserving of quality, comprehensive maternal and reproductive health care."


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By Jade Prévost-Manuel for Yes! Media.
Broadcast version by Farah Siddiqi for Ohio News Connection reporting for the Yes! Media-Public News Service Collaboration

Taylor Young has never wanted to be a mom. From the time the now 27-year-old began dating, she experienced persistent anxiety around the thought of getting pregnant in Ohio, a Republican-controlled state where Young felt her right to abortion was tenuous.

In 2018, she discovered the childfree subreddit, an online forum on Reddit for people who do not have children and do not want them. In that forum, she learned about bilateral salpingectomy, a procedure that removes both fallopian tubes and permanently prevents pregnancy.

"I was 19 or 20, and I knew I probably wouldn't be able to get it," says Young, who didn't meet the minimum age requirement to have a Medicaid-funded sterilization procedure at the time. "But it was something that was kind of in my back pocket."

In 2022, when a document suggesting the U.S. Supreme Court was likely going to overturn Roe v. Wade was leaked, Young, who now met the minimum age requirement, immediately made an appointment with her gynecologist for a bilateral salpingectomy.

After observing the mandatory one-month waiting period, Young received the procedure. "[I had felt like] an animal in a trap," she says. "But when I woke up from that surgery, it was just ... indescribable peace."

Young is one of many people of reproductive age whose health care decisions have been influenced by the overturning of Roe v. Wade, the fundamental ruling protecting the right to abortion in the United States.

In the years since, the rate of permanent sterilization procedures for people between 18 and 30 has jumped, particularly among female-born people. During the 2024 election, abortion rights were a key ballot issue and several states, including Maryland and Colorado, enshrined the right to abortion into their state constitutions.

Political promises to legalize abortion-a critical issue, but one topic in the much larger ecosystem of reproductive health care-have overlooked some of the discussions the country must have to improve reproductive rights for the millions of reproducing people in America. When we take a closer look at the quality of reproductive health care that most people receive, it's clear that simply restoring Roe v. Wade isn't enough.

"The populations with the best reproductive health care outcomes ... have all of [their] basic and human life needs met," says Dr. Regina Davis Moss, president and CEO of In Our Own Voice: National Black Women's Reproductive Justice Agenda, a group that amplifies Black voices to advocate for reproductive equity. "That is why we have some of the worst outcomes when we compare ourselves to other industrialized countries."

Pregnant people in the United States are more likely to die during pregnancy, childbirth, or postpartum than any other high-income nation, even though more than 80% of maternal deaths are preventable. The maternal death rate is double for Black women, who statistically are less likely to have access to high-quality medical care. On average, giving birth in the U.S. can cost more than $18,500.

Cost is a leading prohibitive factor for those who most need to access birth control, abortion, and other reproductive health care. But there are legal barriers to subsidizing reproductive health care services-such as the Hyde Amendment, which bans the use of federal funds for abortion with few exceptions-and in many counties, no one to provide them. An estimated one-third of American counties, for example, do not have a single birthing facility or obstetric clinician to deliver maternal care.

So, what might reproductive health care look like in a reimagined America that puts equity first? There's already a framework for it: reproductive justice, a critical feminist framework that advocates for the right to have children, the right not to have them, and the right to raise children in a safe environment.

A Quest for Overall Well-Being

In 1994, a group of Black women activists coined the term "reproductive justice" to achieve, as Loretta J. Ross writes, "the complete physical, mental, spiritual, political, social, and economic well-being of women and girls, based on the full achievement and protection of women's human rights."

While reproductive justice promotes equitable reproductive health care for everyone, the idea was born out of the struggles that people of color-particularly Black women-have faced in the United States since slavery, when they were forced to bear children to work on plantations.

The framework acknowledges that Black women face poorer reproductive health outcomes-and aims to do something about it. "The reproductive justice framework analyzes how the ability of any woman to determine her own reproductive destiny is linked directly to the conditions in her community-and these conditions are not just a matter of individual choice and access," Ross writes. "Reproductive justice addresses the social reality of inequality-specifically, the inequality of opportunities that we have to control our reproductive destiny."

There is a modern-day implicit bias in health care, says Davis Moss, that women as a whole can't be trusted to make their own decisions about their bodies. For example, Black women commonly report that health care providers are not offering them the full range of contraceptive options.

"The subjugation, the control, all that has happened ever since the country was born," says Davis Moss. "We've seen that happen over the years in our health care system, in segregated hospitals, all the way up to modern day in clinical care encounters."

Though Young's bilateral salpingectomy, which can cost thousands of dollars without insurance, was fully covered by Ohio Medicaid, cost remains a prohibitive factor for many people accessing reproductive health care in the United States.

Take contraception, for example. A 2022 KFF Women's Health Survey, which interviewed more than 5,000 female-born participants, looked at how cost influences contraceptive choice. Researchers found that a quarter of those surveyed with insurance had to pay at least part of their birth control costs out of pocket. "Any time you have to make a choice about day-to-day expenses and a copay... you know, living expenses, keeping food on the table... that is going to have an impact [on health]," says Davis Moss.

The survey also found that of those who were in their reproductive years, one in five women who were uninsured had to stop using a contraceptive method because they couldn't afford it. That data is supported by a Commonwealth Fund survey of women in several high-income nations, which found that women of reproductive age in the U.S. were the most likely to skip or delay necessary care due to cost.

Solutions for the Future

In 2023, In Our Own Voice and more than 50 other Black women's organizations published the Black Reproductive Policy Agenda, a playbook on how to improve reproductive justice for birthing people at the policy level.

The report makes more than a dozen policy recommendations that Davis Moss calls "proactive, comprehensive, and life-saving." Among them are making prescription birth control free, requiring states to provide maternity and newborn care for at least one year (the time frame in which most maternal deaths occur), and increasing access to doulas and midwives who advocate for patients.

Passing acts like the Equal Access to Abortion Coverage in Health Insurance Act would require the federal government to provide funding for abortion services. "That in and of itself directly impacts a large percentage of Black women of child-bearing age [who] are on Medicaid and Medicare," says Davis Moss.

For people struggling to pay for contraception, with or without health insurance, the cost of an in-person abortion-the median price is $600-is somewhat unthinkable. Medication abortion, however, can be cheaper and more accessible. Such is the promise of telehealth abortion, a virtual way to connect with a doctor, receive a prescription, and take abortion pills in a supportive environment.

Increasingly more women in the United States are finding themselves living in maternity care and reproductive health care deserts-areas where there is limited or nonexistent access to prenatal, postnatal, maternity, contraceptive, or abortion services. Telemedicine can provide a range of services for people living in these areas at a fraction of the cost-the median price of a telehealth medication abortion is $150.

"Telehealth does a lot to remove barriers to access to health care," says Dr. Ushma Upadhyay, a public health scientist at UC San Francisco who researches the impacts of telehealth abortion. "People who live in rural areas, young people, people who report facing food insecurity... in our research, they are the most likely to have said that telehealth enabled them to have an abortion."

But even with the advent of telehealth, both Upadhyay and Davis Moss say addressing racism is essential to establishing an equitable reproductive future. That's one of the reasons the Black Reproductive Policy Agenda recommends funding anti-Black racism programs as a part of its agenda.

"This is the reason those 12 Black women 30 years ago said 'You can't only focus on abortion,'" says Davis Moss. "It's impossible to have one without the other."

After getting a bilateral salpingectomy, Young feels relieved. Yet she still worries about what will happen with Medicaid and the Affordable Care Act-the resources she relies on to help her afford care for chronic health issues-under the Trump administration, and what that means for others seeking care.

"Thinking about if other women don't have access, that breaks my heart, and from the abortion side [...] it's too much to bear," she says, emotion tugging at her voice. "I feel relieved I got [the procedure] done when I did. I feel safe."


Jade Prévost-Manuel wrote this article for Yes! Media.


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