What to know about mifepristone, misoprostol access in Indiana — and how it could change
After the Supreme Court overturned Roe v. Wade in a groundbreaking decision on June 24, Indiana will likely see changes to abortion laws in the state.
One such conversation has centered around mifepristone and misoprostol, two drugs that together are used to induce an abortion. The same combination of drugs can also be used to treat a miscarriage — in situations where a person's body cannot on its own expel the tissue, such treatment is required to avoid potential infection or other complications.
Here's what to know about mifepristone and misoprostol and how access to the medication could change following the Indiana General Assembly's special session at the end of the month.
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How does mifepristone end a pregnancy?
Mifepristone is taken in conjunction with misoprostol, and together they are effective in ending a pregnancy in its early stages, Dr. Katie McHugh, an obstetrician-gynecologist and abortion provider in Indiana, said.
"The two medications together are the most effective in the treatment of both abortion and miscarriage," McHugh said. "So both of those conditions are treated most effectively when you use both medications."
Mifepristone, also known by its brand name Mifeprex or "mife," is an anti-progesterone that blocks the hormone that is needed for the pregnancy to develop.
"It is used as the first treatment in either miscarriage or in a medication abortion to stop the progression of pregnancy," McHugh said.
Then, 24 to 48 hours after the patient takes mifepristone, they will then take misoprostol, or "miso." The brand name is Cytotec. This will induce the uterus to "contract or to push out the pregnancy tissue," McHugh said.
"Effectively, you are inducing a miscarriage with the use of these medications," McHugh said.
It's important that you're able to have a heavy period, safely, to be able to take the medication, McHugh said.
"That excludes people who are already very anemic or sometimes, people who have a bleeding disorder or other problem that would make it unsafe for them to have a heavy, heavy period," she said.
McHugh said the patient must also be able to take a follow-up pregnancy test to ensure the medication worked. In addition, it's important to ensure that the pregnancy is inside the uterus and not ectopic.
Early ectopic pregnancy is often treated with a different drug, methotrexate. The condition can also be treated with laparoscopic procedures or emergency surgery, according to the Mayo Clinic.
How are mifepristone and misoprostol prescribed?
Mifepristone can only be prescribed by a certified doctor or pharmacy, McHugh said, as it carries additional requirements from the FDA.
Misoprostol, which has many other uses, including ulcer prevention, is less closely regulated, though still monitored due to its role in medication abortions, according to McHugh.
In Indiana, the patient must take the mifepristone in the same room as a physician. They will then receive a misoprostol prescription, which can be taken a day or two later at home.
How effective is medication abortion?
The medication varies in effectiveness depending on when in the pregnancy it is taken.
According to Planned Parenthood, here are the effectiveness rates for medication abortion as it relates to length of pregnancy:
For 8 weeks or less: Effective about 94 to 98 out of 100 times
For 8-9 weeks: Effective about 94 to 96 out of 100 times
For 9-10 weeks: Effective about 91 to 93 out of 100 times. With an extra dose of medicine, it's effective about 99 out of 100 times.
For 10-11 weeks: Effective about 87 out of 100 times. With an extra dose of medicine, it's effective about 98 out of 100 times.
How is medication abortion legal in Indiana?
Abortions can only be performed in Indiana within the first 20 weeks "postfertilization," according to Indiana law, which is about 22 weeks after the person's last menstrual cycle.
There are restrictions placed on medication abortion in Indiana currently, though. Indiana law specifies that medication abortion can only be administered within eight weeks "postfertilization" age, or about 10 weeks of pregnancy.
In December 2021, the FDA removed the "in-person dispensing requirement" for mifepristone, which had previously been temporarily allowed due to COVID-19, meaning patients can receive the abortion pills by mail from a certified physician or pharmacy, generally after a telemedicine appointment with a doctor.
Indiana had previously made telehealth consultations for abortion illegal. Though the restriction was originally deemed unconstitutional by a district court judge, that ruling was overturned and eventually upheld by a federal appeals court in September 2021.
Gov. Eric Holcomb confirmed in a statement following the overturn of Roe v. Wade that the Indiana General Assembly would address abortion in the special session, now scheduled to begin July 25.
"I have been clear in stating I am pro-life," he said. "We have an opportunity to make progress in protecting the sanctity of life, and that’s exactly what we will do."
In a recent statement, U.S. Attorney General Merrick Garland said states could not ban mifepristone based on disagreement with the FDA's safety and efficacy recommendations.
"We stand ready to work with other arms of the federal government that seek to use their lawful authorities to protect and preserve access to reproductive care," Garland said.
How could medication abortion access change in Indiana?
McHugh said it is her "absolute expectation" that medication abortion will be banned when the Indiana state legislature convenes starting July 25.
In the short term, McHugh and others are urging legislators to take into account exceptions for rape, incest and life and health of the pregnant person.
However, there are still options. Abortion by mail is still legal in Indiana, not from a domestic provider but by ordering abortion pills from an international provider through organizations such as Aid Access.
Still, McHugh said she thinks "that is a loophole that will be closed at some point."
All the Indiana legislature would have to do is pass a law saying that "you can't get drugs from any source," said Jody Madeira, professor at the Indiana University Maurer School of Law. Still, enforcement would be tricky.
"Their ability to shut down the international manufacturers and suppliers is nil," she said. "And good luck enforcing it, because a lot of the times these pills arrive in these ... non-flashy, brown envelopes. And are you going to start opening every package that every woman receives?"
Because it's difficult to prosecute clinicians and pharmacists that operate out of the country, "if they're going to take steps to punish someone, it's going to have to be the woman herself," Madeira said.
Marion County Prosecutor Ryan Mears said June 24 that his office will not prosecute cases related to abortion if Republicans in the state legislature try to criminalize the procedure.
However, clinics like Planned Parenthood will not be able to prescribe the medication in-state if abortion is banned or very limited, as some advocates expect.
"Planned Parenthood complies with all laws and regulations when delivering health care," Nicole Erwin, spokesperson for Planned Parenthood Alliance Advocates, said. "If medication abortion is banned in the state of Indiana, it will not be legally accessible."
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Aid Access has been facilitating prescriptions of abortion medication internationally for patients in states where telemedicine abortion is illegal.
The patients can obtain abortion medications from international doctors and pharmacies, receive them in the U.S. and perform a self-managed abortion at home.
"(Self-managed abortion) is very safe and evidence-based and very effective," McHugh said. "So it has the potential to be a huge benefit to many patients."
This technically does not break any Indiana laws that are currently on the books. International physicians are not bound by the Indiana law that prohibits telemedicine abortion, Madeira said, and the United States' control over those entities only goes so far.
"The United States has no control, much less individual states, over these individuals who are dispensing from outside the United States," Madeira said.
An option for the federal government, if they plan to challenge restrictive state abortion laws in regards to mifepristone and misoprostol, is to make a preemption argument, which means that the state must cede to the federal government regarding access to abortion pills, Madeira said.
"My guess is that there might be a preemption argument that is used to challenge state laws that restrict use of the components of mifepristone or misoprostol to earlier in pregnancy than 10 weeks, that forbade individuals to get this through the mail, that kind of thing," Madeira said.
In terms of medication abortion, Madeira said, there are several different options, including driving to Illinois to take the pills there, getting a shipment of pills in Indiana or setting up a mail forwarding address in a state like Illinois, where abortion will remain legal, to receive the pills, then having that mail forwarded to Indiana.
There's a lot of legal ambiguity as to whether these processes are illegal, will be made illegal or how they will be regulated.
"It's a scale," she said. "Along the line you have different questions, and a lot of these issues have yet to really be litigated."
Once the pills are taken, the symptoms are the same as a miscarriage, McHugh said, meaning that patients don't necessarily have to disclose that they have pursued self-managed abortion if they need to go to the hospital or seek additional medical care for any reason.
"That can be a measure of safety for patients especially as states are moving forward with criminalization of pregnancy, especially around pregnancy termination," she said.
The fact that abortion rights will differ so widely will likely cause confusion and create legal complications, if a fetus is considered a person in some states and not others, and if people have different rights regarding reproductive healthcare from state to state, Madeira said.
"It's gonna be a mess," Madeira said.
Contact IndyStar trending reporter Claire Rafford at crafford@gannett.com or on Twitter @clairerafford.
This article originally appeared on Indianapolis Star: Indiana abortion laws: What to know about mifepristone, misoprostol
