How a Texas ruling on abortion pills would affect Washington

If mifepristone is taken off the market, abortion providers in Washington will still have options, and they’re prepared to pivot to misoprostol-only protocols or even a third regimen, meaning medication abortion will remain available in the state regardless of the Texas case’s outcome.

Telemedicine abortion services will also still be available. That’s because misoprostol is not subject to the same stringent regulations as mifepristone, which was unavailable by mail until 2021, when the Food and Drug Administration lifted a restriction limiting its distribution to specific providers and hospitals. The pills only recently became available in retail pharmacies.

Still, providers have other concerns about how the Texas case might disrupt patient care, sow confusion, exacerbate side effects, and impose additional logistical barriers on patients who travel to Washington from states with active abortion bans. “This will mean longer wait times that especially impact patients who are traveling since more doses will be required, especially if patients are farther along in their pregnancy,” said Paul Dillon, vice president of public affairs for Planned Parenthood of Greater Washington and North Idaho.

Currently, said Dillon, if a patient crosses the Idaho state line for treatment in Washington and has a pregnancy of under 12 weeks’ gestation, clinicians can administer doses of both mifepristone and misoprostol for the patient in-clinic, allowing them to head back over the border and complete their abortion in the privacy and comfort of their own home.

Without mifepristone, that regimen will likely be replaced by three doses of misoprostol, taken three hours apart, with an additional dose in some cases, a process that could take up to 16 hours — just to take the pills. Completing the abortion could take even longer, which would mean longer trips into Washington for out-of-state patients, a development that could disincentivize pregnant people from seeking legal abortion options with clinician involvement. Dillon said Planned Parenthood was preparing to shore up funding and resources like lodging to accommodate patients through the longer wait times required for misoprostol-only protocols.

While more cumbersome, misoprostol-only protocols are safe and effective. According to a 2021 report from Ibis Reproductive Health analyzing data on self-managed abortion using misoprostol on its own, “The two regimens may result in different abortion experiences when it comes to duration of bleeding and side effects, but data from studies of self-managed medication abortion suggest that the safety and effectiveness of misoprostol-alone regimens is likely comparable to that of the combined regimen.”

But misoprostol-only protocols are slightly less effective — about 85%-95%, compared to 87%-99%, said Smith — and they can cause more side effects, said Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington. If mifepristone is taken off the market, she said UW abortion providers would “pivot immediately to misoprostol-only regimens” or even protocols involving a third drug, letrozole. “But neither of those is ideal,” she said.

Because misoprostol requires more doses without mifepristone, she said, patients could experience more side effects when they take it, including nausea, vomiting, fever and significantly increased cramping and pain. An alternative protocol using a different drug, letrozole – three days of letrozole followed by misoprostol on the fourth day – lengthens the time a medication abortion takes, said Prager, and is used infrequently. “This feels like just another way to punish pregnancy-capable people for having an abortion, as the ruling will likely not prevent a single abortion,” she said.

But the change could lead more patients to seek surgical procedures, said Prager, a development that could increase demand on clinics offering those services, which have already been coping with more patients since the reversal of Roe v. Wade. In January, Planned Parenthood reported an increase of 25% in abortion visits compared to the previous year and a 75% increase in patients from Idaho, said Dillon. There was a 36% increase in demand for surgical abortion procedures and a 90% increase in demand for medication abortion.

“This means there might end up being surges in clinics that can offer aspiration abortion, and this could delay care for everyone. Ultimately, our pregnant patients are all going to suffer, one way or another, due to this,” Prager said.

Accommodating an increase in patients seeking surgical procedures “will also be [a] challenge,” said Dillon, “since three sites – Spokane, Yakima, Kennewick – provide procedural abortion care.”

Dillon said he was also concerned about the lawsuit’s implications beyond abortion care and its potential impact on access to other medications. It  also could confuse patients about their rights, especially amid headlines announcing that the case could ban “abortion pills” nationwide, giving the impression that medication abortion would no longer be an option at all. It could add to existing confusion about the legal status of medication abortion. Earlier in February, a poll from the Kaiser Family Foundation found that almost half of American adults don’t know if medication abortion is legal where they live.

That confusion is a problem, said Dillon, and one Planned Parenthood is used to encountering when abortion hits the news cycle: When Planned Parenthood lost its Title X funding under the Trump administration’s domestic gag rule, he said, patients thought the organization had been defunded or even shuttered altogether, when in fact state dollars had filled the gap. “We need to be very clear that we will be there for patients and are able to clarify any questions,” he said.