Primary care overlooked in medication-abortion debate

The U.S. Food and Drug Administration should make it easier for doctors to prescribe the abortion medication mifepristone via commercial pharmacies, according to a commentary published in JAMA Internal Medicine. The essay also said that primary-care doctors, especially in rural areas, have been overlooked in providing access to medication abortions. 

“I think the main takeaway is that obtaining mifepristone via the mail has been shown to be a feasible and safe delivery method, and that primary care has been needlessly underused or overlooked,” said the main author, Dr. Emily Godfrey, a UW Medicine family physician and OB-GYN.  She penned the commentary with Dr. Ying Zhang, a UW Medicine family physician, and Dr. Debra Stulberg of the University of Chicago Pritzker School of Medicine.

Their commentary accompanied a paper in the same journal reporting that patients found it practical and acceptable to obtain prescribed abortion pills by mail. The two-year study, conducted across 11 clinics in seven states, included five abortion clinics and six primary-care sites.

The authors noted that four of the six primary-care clinics had not previously provided medication abortion, suggesting that this care protocol is easy to learn. 

“This is especially important now,” Godfrey said. “Given the restrictions on abortion access, primary care needs to step up in states where it is legal to care for their own patients, especially as abortion facilities in those states could see an influx of patients arriving from other states.” 

“Primary care clinicians are a critical, untapped resource poised to take on the U.S.' abortion care crisis by offering medication abortion to patients in their clinics," particularly in rural areas, where telehealth is "especially important," noted Godfrey and her co-authors.

While the 540 patients enrolled in the study were assessed in person, the two abortion drugs, mifepristone and misoprostol, were dispensed via mail-order pharmacy. The patients’ average age was 27; 38% self-identified as Black, 17% as Hispanic, 28% as white and 9% selected multiracial or “other.”  

Twice during the study, patients were surveyed, and 91.2% expressed satisfaction with receiving their medication through the mail. The abortion was successful for about 98% of the participants, without need for a uterine aspiration procedure, and only three patients required hospital care. 

The commentary stressed that the FDA needs to make it easier for commercial pharmacies to offer pills for medication abortion.  Currently, commercial pharmacies and the doctors who prescribe abortion pills at those pharmacies must acquire an FDA certification. 

“That is irrational compared to (the prescribing of) more dangerous drugs for which no certifications are required,” the authors note. 

Although many headlines have reported commercial pharmacies’ ability to dispense abortion pills, Godfrey said media coverage has overlooked the overwhelming volume of paperwork required for individual pharmacies and for doctors who prescribe the medication. 

“In rural communities, where there is no assurance that clinicians who register will remain confidential, the paperwork can deter healthcare providers who don’t want their name on a list that may make them susceptible to harassment,” she said. 

Since the Supreme Court’s 2022 Dobbs decision, medication abortion has become increasingly popular, rising from 53% in 2020 to 63% of all abortions in 2023, according to the Guttmacher Institute. 

Now that 21 states severely restrict or ban abortions, it is more critical that the FDA roll back the certification process for pharmacies and clinicians, the authors wrote.

"By recognizing that half of all pregnancies occurring in the U.S. are unintended, that abortion is common, and that providing first-trimester abortion services using prescription medicines is within the scope of primary care, primary-care clinicians who offer medication abortion services can dramatically increase patient access earlier in the pregnancy, which is a critical part of reducing the U.S.' comparatively poor record of pregnancy-related complications and death,” authors wrote.

Currently, the U.S. Supreme Court is considering whether mifepristone should remain legal, and if so, whether mail-order prescriptions of abortion pills should be allowed. The Court is expected to decide in June. 

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