Roe v Wade: Abortion pills a new front in culture wars

As a crowd assembled outside the United States Supreme Court, waiting for its landmark abortion ruling last month, Kristan Hawkins stood front and centre.

She held a microphone in her left hand and a sign in her right. "I am the post-Roe generation," it said, a signature of her group Students for Life of America - one of the largest anti-abortion organisations in the country.

Ms Hawkins read the court's decision in real time, shouting the words into her microphone: "The Constitution does not confer the right to abortion."

It was a generational victory for the anti-abortion movement - but for Ms Hawkins it was just a start.

"Our organisation was established as a post-Roe organisation," she told the BBC, referring to the 1973 Supreme Court decision overturned in June, which had guaranteed women's right to abortion nationwide.

The court's reversal has returned the decision over abortion to individual US states, paving the way for Ms Hawkins' ultimate goal.

"We want to see the states across America move to make abortion unavailable and unthinkable," she said.

Ms Hawkins and her allies already have a new target in their sights: abortion pills.

In the days since Roe was repealed, demand for the medication has exploded, setting the stage for the abortion war's new front.

The two-pill regimen was first approved by the US Food and Drug Administration (FDA) in 2000, for use up to 10 weeks of pregnancy.

Medication-induced abortions are now the most common method of ending pregnancies in the US.

The first drug, mifepristone, ends a pregnancy and the second, misoprostol, empties the uterus. Mifepristone is also used to treat women who have suffered miscarriages and Cushing syndrome, a hormone-related condition. Misoprostol has been available by prescription for decades as a treatment for stomach ulcers and to manage postpartum haemorrhaging.

Less expensive and less invasive than the surgical option, medication abortion, as it is known, has long been championed by pro-choice groups.

Throughout two decades of use, the FDA, the American College of Obstetrics and Gynaecologists (ACOG) and other mainstream medical organisations have maintained that both mifepristone and misoprostol are safe for use. US studies say medication abortion is about 95% effective in ending pregnancy and requires further medical follow-up less than 1% of the time.

But increasingly, anti-abortion campaigners have promoted claims that abortion medication - cast as "chemical abortion" - is ineffective and dangerous.

"These drugs have caused injury, infertility, death," Ms Hawkins said. "Every single abortion ends one life, but chemical abortion is going to start ending two lives and they [pro-choice campaigners] are going to be responsible for it."

The FDA has reported a total of 26 deaths associated with mifepristone since it was approved - a rate of about 0.65 deaths per 100,000 medication abortions. For comparison, the death rate associated with habitual aspirin use is about 15.3 deaths per 100,000 aspirin users. And a five day course of azithromycin, a common antibiotic used to treat bacterial infections like bronchitis and sore throats, there were 42 cardiovascular deaths (31.5 per 1 million courses) and 29 sudden cardiac deaths (21.8 per 1 million courses), according to a recent study.

When mifepristone was first approved by the FDA, it was placed in a programme for risky drugs because most of the safety data came from outside the US. And for years, mifepristone remained among the most heavily regulated drugs in the country, despite growing evidence demonstrating the drug was safe.

In April 2021, the FDA announced it would lift the in-person dispensing requirement for mifepristone for the duration of the Covid-19 pandemic. In December, the FDA permanently lifted that requirement, allowing the medication to be sent by mail. A spokeswoman at the time said the agency had conducted a "comprehensive review" of published safety data before making the change.

The decision, lauded by pro-choice activists and mainstream medical organisations, expanded access to those unable to travel to a clinic, often people of colour, low-income individuals and those in rural areas.

Even before the Supreme Court Roe reversal, anti-abortion groups targeted abortion pills with force. In the first five months of 2022, lawmakers proposed 117 restrictions across 22 states specifically on medication abortion, including outright bans.

"Abortion opponents are keenly aware that a pregnant person could access medication through an online provider," said Elizabeth Nash, a policy analyst with the Guttmacher Institute, a pro-choice research group. "They've seen this method grow, and be used more and more and so they're saying: 'OK, we need to limit access'".

Without federal abortion protection, more restrictions will follow.

• Mississippi's near-total ban to take hold

In recent days, abortion - including medication abortion - has been prohibited in at least 10 states, sometimes with exceptions for rape or incest. Nearly a dozen states are expected to follow. Some anti-abortion advocates have targeted the pills specifically, barring the use of telemedicine or the delivery of medication by mail.

"Our hands have been untied," said Carol Tobias, president of anti-abortion group National Right to Life, to the BBC. "Now we really get a chance to defend these babies."

But as bans have rolled in and abortion clinics have shuttered, demand for abortion pills has surged.

In the hours after the Supreme Court's decision, patient numbers doubled at telemedicine abortion clinic Hey Jane over the month before, while its website traffic grew tenfold. The organisation is now seeing four times as many patients than this time last year.

Plan C, an abortion pill advocacy group, had 311,000 visitors on its website in the single weekend after Roe was repealed, founder Amy Merrill told the BBC - well above its previous monthly average of 50,000.

"It was like a dam had broken," she said.

Indeed, pro-choice advocates say abortion medication will be a lifeline to women in states where the procedure is prohibited.

Abortion pills must be prescribed by providers where the procedure is legal, to a patient in that state. But pro-choice groups have already developed workarounds for states where it is banned.

Some are sending fleets of mobile clinics to the borders of abortion-restricted states. Others are developing plans for mailing pills to women in states with abortion bans anyway. One of these groups, Shout Your Abortion, sold out a line of T-shirts that say: "I will aid and abet an abortion."

"We believe abortion pills by mail will continue to be a reality in all 50 states, no matter what bans exist," said Ms Merrill.

Most anti-abortion activists have long said they want to see abortion providers punished, but not the mothers themselves.

"We would certainly go after abortion providers," said National Right to Life's Carol Tobias. "I would want to know who provided the pills."

But if a person receives abortion medication from outside her state - or the country - who is there to punish?

Democratic-led states have already started to help. California, New York and Connecticut have moved to shield doctors from penalties from other states for helping women in restrictive states obtain an abortion. And one major abortion pill provider - Aid Access - is based in Europe, falling outside the jurisdiction of law enforcement within the US.

In a world without Roe, Kristan Hawkins wants to make abortion "unthinkable"

Still, pro-choice advocates warned that anti-abortion campaigners will enforce their bans broadly.

"They talk about criminalising anybody who, quote unquote 'aids and abets' somebody seeking abortion care," said Dina Montemarano, research director at NARAL Pro-Choice America. "Is that the Uber driver who drives them to the airport to seek an abortion out of state? Is that their friend who helps them pay for that flight?"

​​"They have been dodging this question," she said.

State bans on abortion pills may also face legal hurdles. On Friday, President Joe Biden issued an executive order, directing his health secretary to "protect access to medication abortion". And last month, US Attorney General Merrick Garland said states could not ban the FDA-approved medication "based on disagreement with the FDA's expert judgement about its safety and efficacy".

Ms Hawkins called the FDA and Biden administration's support of mifepristone "absolutely hypocritical", repeating her claims that abortion pills were dangerous.

"This is what the abortion industry is trying to do, this is their post-Roe plan," she said.

GenBioPro Inc, a company that sells mifepristone, has already challenged Mississippi's restriction on the medication, saying they are "pre-empted" by the FDA - meaning federal law overrides state bans.

"This is not the end," Ms Merrill said. "If I have hope, it's that this is a situation in flux."

Clarification 22 August: This article was updated to include more detailed comparisons in the paragraph about the rates of death associated with mifepristone.