Mifepristone Reaches a Milestone Amid a Hostile Environment

Twenty-five years ago, as September 2000 drew to a close, the FDA made a controversial announcement: A French medication that had been developed in the 1980s, then called RU-486 but now more commonly known as mifepristone, would finally be legally available in the U.S. Depending on your point of view, that FDA approval was either a major feminist breakthrough or the beginning of society’s rapid decline into immorality and chaos.

And yet despite its initial hype cycle — which included official statements from George W. Bush and Al Gore, who were running for president at the time — RU-486 was not an immediate disruptor. Thanks to the work of anti-abortion regulators, mifepristone was initially saddled with a collection of burdensome limitations that dramatically limited its transformative potential. 

Advocates had dreamed of a world where people could get abortion pill prescriptions from their primary care provider or gynecologist and pick up the pills at their local pharmacy, but the reality was vastly more limited. Mifepristone could only be legally dispensed in a clinic, doctor’s office, or hospital. The worst part: In order to prescribe and provide the medication, a doctor had to be officially certified and included on a government registry, an unappealing prospect in a world where abortion providers were routinely targeted for violence, harassment, and even death by anti-abortion extremists. 

Not surprisingly, the primary health providers willing to go through all that hassle were the ones who were already offering abortion services. Rather than opening up a whole new world of abortion access, mifepristone’s approval mostly just gave existing abortion clinics one more option to offer patients who weren’t thrilled about the usual abortion procedures, like undergoing vacuum aspiration or a D&E (dilation and evacuation). But abortion pill patients still had to physically travel to an abortion clinic to meet with a doctor, which often meant dealing with harassment from protesters — all barriers that were supposed to be eliminated by mifepristone’s approval. Combine that with the anxiety that accompanies any new medical breakthrough, and it’s not a shock to learn that in 2001, only 6% of abortions were induced with medication.

But a quarter of a century after its initial FDA approval, the American relationship to mifepristone looks significantly different. This year, the FDA approved a second generic version of mifepristone, further solidifying the medication’s presence in the U.S. canon of prescription drugs. It makes sense that pharmaceutical companies would want mifepristone in their company catalog: In 2023, a full 63% of abortions were done with pills. And that number is likely an undercount given that it does not include abortions performed outside the official medical system or patients who obtained abortion pills while living in a state where abortion is illegal — two increasingly common occurrences in the post-Dobbs world.

Some of this increase in popularity is doubtless due to a growing familiarity with abortion pills as an option. The Guttmacher Institute documented a steady increase in American abortion pill usage over the first two decades since it became available, growing to a 39% share of all abortions in 2017. But the biggest jump in abortion pill use — and the first time that more than half of American abortions were induced with pills — happened in 2020, when the restrictions of the early pandemic forced us all to reconceive medical care and introduced many of us to the idea of telemedicine. The mifepristone use that’s cropped up in COVID’s wake looks a lot more like what those early RU-486 advocates once envisioned — even, ironically, in the years following the death of Roe v. Wade.

If someone wants an abortion in 2025, there’s a good chance they won’t need to drive to an abortion clinic, or navigate a throng of angry protesters, or even step foot in a doctor’s office. In some cases, they don’t even need to have a face-to-face conversation with a medical provider. With the advent of telemedicine and loosened regulations, abortion pills can be easily ordered on the internet and taken in the comfort of one’s home. And while they’re not an appropriate method for everyone, abortion seekers who are able to use pills can choose the timing of their own abortion, rather than relying on a doctor’s limited — and potentially inconvenient — schedule.

And for some people who live in states where abortion is illegal, mifepristone has been a literal lifeline. For decades, feminists have warned that the overturning of Roe v. Wade would mean a return to the “coat hanger abortion” — a slang term for abortions performed in unsanitary conditions using dangerous tools (in some cases, literally a straightened coat hanger). And yet over the past few years of increasingly restricted abortion access, that hasn’t quite come to pass. In replacing a medical procedure with a pill, mifepristone has eliminated so many of the dangerous elements of underground abortions. People no longer need a sterile environment, or a knowledgeable provider, or access to proper abortion tools. They only need access to genuine abortion pills — which, thanks to websites like Aid Access and Plan C, is far easier than finding a safe underground abortion was in the pre-Roe era.

Fundamentally, mifepristone has enabled a radical rethinking of reproductive health and rights. Rather than forcing us to seek outside expertise to manage our fertility, mifepristone has made it possible for anyone who wants to to reclaim their bodily autonomy on their own terms; to safely terminate a pregnancy whenever and wherever they choose. It may not have transformed the world into a feminist utopia. And it certainly hasn’t ushered in some debauched era where abortion pills are popped like vitamins and all sexual mores are tossed out the window. But even as the hopes and fears put forth by pundits and politicians back in 2000 didn’t really come to pass, mifepristone has still managed to achieve something pretty monumental: It has removed at least some of the fear that’s long surrounded abortion safety, changing it from a procedure that should be “safe, legal, and rare” to one advocates proudly declare should be free and on demand. 

In an earlier era, that would have been unthinkable. And while it probably wasn’t the shift that French researchers — or American FDA officials — were planning on all those decades ago, it’s one for which we should all be eternally grateful. Because even as the Trump administration spreads misinformation about mifepristone, going so far as to launch an investigation into its well-documented safety record, the knowledge of what it means for people to be able to have abortions on their own terms, with minimal gatekeeping, has already transformed how about we talk about reproductive health in this country. And that’s something no government can legislate away.