Many Women Can't Access Miscarriage Drug Due to Abortion Conflation
Many women can’t access a miscarriage drug because it’s also used for abortions. Despite its proven safety and efficacy, mifepristone remains tightly regulated at the federal and state level, and widely unavailable to patients experiencing pregnancy loss.
Patients like Lulu are, experts say, a little-recognized casualty of America’s fractious abortion wars. Lulu, who asked to be identified by her first name to protect her privacy, bled for six full weeks after her miscarriage and hasn’t had a normal menstrual cycle since. Such disruptions aren’t uncommon after miscarriage, which affects roughly 1 in 10 known pregnancies. But for Lulu, they’ve also served as a persistent reminder that she couldn’t access the drug mifepristone — her preferred method of care — to help her body pass the miscarriage. Instead, her doctor prescribed a drug called misoprostol, which on its own is less effective. “I recall clarifying with her about the kind of medication I would get,” Lulu said. “When she said misoprostol … I was really shocked. I made her repeat herself.”
Mifepristone and Misoprostol: Uses and Regulation
In other contexts, both mifepristone and misoprostol are used to voluntarily terminate pregnancies, and both medications are often called “abortion pills.” But while misoprostol is indicated for a wide range of medical uses, including labor induction and ulcer treatment, mifepristone is taken almost exclusively to induce abortions and manage miscarriages, the latter of which is an off-label use. The federal government regulates it tightly, as do most state governments. The drug remains widely unavailable to patients experiencing pregnancy loss — even in states that do not otherwise restrict abortion, for a variety of regulatory, cultural and political reasons.
“There’s been this conflation of abortion and miscarriage management,” said Dr. Elise Boos, an assistant professor of obstetrics and gynecology at Vanderbilt University and a practicing OB-GYN. “There’s so much stigma and worry about the optics — and as a result, patients get suboptimal care for miscarriage.”
Miscarriage Management Options
Miscarriage patients have three options for passing pregnancy tissue, which can cause hemorrhage or infection if not removed: medication, minor surgery or “expectant management” — waiting for the body to complete the process on its own.
Since 2018, the American College of Obstetricians and Gynecologists has recommended a two-drug protocol of mifepristone and misoprostol for patients who elect the medication route. Mifepristone is taken first, to “loosen” pregnancy tissue from the uterine wall. This is followed by misoprostol to expel the tissue.
Effectiveness of Treatment Protocols
A study published in July in the Journal of the American Medical Association found that between 2016 and 2020, just 1% of more than 22,000 patients nationwide who took medicine to help pass their miscarriages received the recommended two-drug protocol. That leaves tens of thousands of patients like Lulu to face longer miscarriage processes and potential medical complications, doctors say. While misoprostol also is a safe and effective treatment on its own, physicians stress, it is markedly less effective than the two-drug combination — requiring follow-up surgery to complete the miscarriage in roughly 1 in 4 cases.
“It felt like that was the reason my miscarriage was dragging on and the reason I bled for so long,” Lulu said in private messages with Stateline on the discussion site Reddit, where she has chronicled her experience with miscarriage. “Of course, [it’s] hard to know … but I’m convinced I would have healed much faster” with mifepristone.
Miscarriage Treatment Effectiveness Data (2016-2020)
| Treatment Protocol | Percentage of Patients | Outcome for Misoprostol Alone |
|---|---|---|
| Recommended two-drug protocol (mifepristone + misoprostol) | 1% | N/A |
| Misoprostol alone | 99% | Requires follow-up surgery in ~25% of cases |
Policy, Stigma, and Access Limitations
Doctors and reproductive health advocates blame a thicket of overlapping cultural, political and regulatory factors for limiting patient access to mifepristone. Decades of federal data show that the drug only rarely causes serious side effects and is responsible for fewer deaths than Tylenol. The two-drug combination is just as safe as misoprostol alone.
More than 90 countries have approved mifepristone since the late 1980s — including Canada, which since 2017 has permitted any physician or nurse practitioner to prescribe mifepristone and any pharmacist to dispense it. In the United States, however, mifepristone is typically only available at hospitals, health clinics and doctors’ offices that routinely provide abortions or that employ specialists in “complex family planning,” a branch of gynecology focused on abortion, contraception and miscarriage management.