Abortion Pills, Take Two

WNYC Studios is supported by Apple Card. You'll love Apple Card, it's everything a credit card should be and more. Earn up to 3 daily cash back on every purchase, which can automatically earn interest. When you open a high-yield savings account through Apple Card, apply for Apple Card in the Wallet app.

Oh, wait, you're listening, okay?

All right.

Okay, all right, you're listening to RadioLab.

Radiolab from.

WNYC State.

State, Yep.

Hey, this is Radiolab, I'm Latif Nasser.

I'm Lulu Miller.

And we find ourselves, as sometimes we do, in a moment where we're thinking back to an old episode. We did because the topic we covered is sparking all over the news right now.

Yeah, and that topic is the quote-unquote abortion pills, yeah. And on April 7th, 2023, which for us is also known as. Last Friday. A federal judge in Texas ruled that the F.DA's approval of one of those drugs, Mifepristone, was invalid. According to him, it should have never been approved.

And later that day, an hour or so later, in an entirely separate case in Washington state, a federal judge ruled seemingly the opposite. That the F.D.A. must continue to make Mifepristone available in certain states, that same drug. And then on top of that, there have been multiple motions to appeal that first Texas ruling we talked about.

Very chaotic, a lot going on. For the time being, Mifepristone is still available. But this all means that these cases will likely work their way up the federal court system. And we will eventually see rulings that could have real staying power and real consequences.

And so, given that there is suddenly so much attention on this pill, we wanted to share with you a story we did back in the fall of 2022, last fall about these very pills. And actually, in particular, because this Texas judge, in his ruling, made an explicit argument about the safety of this drug and the approval process. And actually, that's exactly what we cover in this episode.

Yeah, you can think of it sort of as a profile of these pills. These pills are sort of characters. And we really go into the science of them, their origin story, how they interact with the human body, and what their real risks are or aren't. It came to us originally from our senior correspondent, Molly Webster, and contributing editor and, e.r. doctor Avir Mitra, so we'll start it off with them.

I don't know, I was just gonna say, Avir, you start.

I love an Avir story.

All right, cool.

And we should say, before we get rolling. This story talks about abortion and has some kind of graphic descriptions. So if you don't wanna hear that today, this is a good one to skip.

Right, so, I guess this one started because, okay, for me. Growing up, my mom, she's a ob-gyn, and I just remember her telling me about stories of her performing abortions back in her day. This would have been like the late 70s.

Wait, wait, wait, wait, wait. I'm just picturing like Muppet baby Avir. Like even before you were a doctor, your mom would tell you doctor stories.

Yeah, I just grew up around so many medical stories. Both my parents are doctors that we talk about things at the dinner table that a normal family would be horrified. They would be actively vomiting, and I'm just like, Oh, yeah, pass the salt, please. So, basically, when she would talk to me about these procedures, they were pretty invasive. It was not a small deal, if that makes sense, right?

Yeah.

So basically, now at my job, I have to occasionally organize conferences to teach E.R. residents things. And so I ended up hosting this. OB. Doctor named Laura Macisaac, where I work, who for many years has been running the division in my hospital that deals with the abortions that we do now. What I was anticipating was sort of like this high drama, er, type of lecture of, like, all right? When a patient comes in with a coat hanger abortion, these are the things you gotta think about. It's gonna be sepsis. Here's how you evacuate. Or uncontrolled bleeding.

I'm so glad that it was more interesting than you expected.

And basically, she told us, while we've all been arguing about the politics, the legality and the morality of abortion, the actual practice of it has been really on its own trajectory.

Since I've been doing this work, it's changed probably more than any other thing I can think of.

For the majority of abortions happening today, we're not talking about surgeries.

No, it's with the medications to induce abortion pills.

And while I knew that you can take pills to induce an abortion, I hadn't really thought about how much. This really does change everything about what it means to get an abortion. And how much of that has really just happened in the past few years since Covid, and in a weird way.

Okay, so the story starts back in the 80s, Roe v. Wade just happened. And you have greater access to abortions, and the way that we did abortions was surgically right. So it was like the woman is put on a table, she's given anesthesia.

And that's just sort of the way it was. Until two things start happening on opposite sides of the world, the first one is in Brazil. So in Brazil, abortion was illegal, and Brazilian women when they would have an unwanted pregnancy, they would go into a pharmacy. And they saw on these ulcer drugs that there was like a little sign that says, like, don't take this in pregnancy.

Oh, interesting.

So they started taking it and, surprisingly, it worked. It would cause an abortion.

And how does that work? How does it do that?

Well, so that drug, it's called misoprostol. Misoprostol is a prostaglandin. And prostaglandin is something that we make in our body, and it does a bunch of different things all over the body. One of them is healing ulcers, but another one in the uterus. It causes it to basically contract, that's it.

So it just basically physically ejects it.

And so it induced abortions. But no one really knew, like, how much to take and stuff. And it was like, do I take it in my mouth? Should I shove it up my vagina and, like, get it near my cervix or my uterus? No one knows. So really, what they were seeing is that sometimes it didn't work.

Right, so that's misoprostol, which works some of the time.

Okay, right? So, meanwhile, while all this is happening in France, you have a Dr. Etienne-Emile Beaulieu. And his whole idea was like, well, in the early stages of pregnancy and throughout pregnancy, we really need progesterone.

Right, because progesterone helps the uterus build up a thick layer of like bloody tissue that can support a possible pregnancy, and the embryo needs to implant into that tissue.

And so he was like, Well, if we know that, the body has to amp up progesterone in order to facilitate a pregnancy, what if I did something that, like, interrupted that? And so he and his research team develop this drug, called RU-486, otherwise known as mifepristone.

So mifepristone is basically a progesterone blocker, and so when you take Mifepristone, that layer can't grow, and essentially that signals the body to shed that layer. Then essentially, you're just saying, like, you just say nope.

No place for you to implant here. Yeah, move along.

So that's mifepristone.

There's one problem, though, which is that. Mifepristone will cause the uterus to be an unfriendly place for the embryo, but it won't then actually expel that embryo. And so you need to combine something with mifepristone to make it flush out the uterus. So then the doctors in France are like, wait a second, we're hearing about this ulcer drug in Brazil. That's kind of doing what we need. And so what if we take that and combine the two?

Oh, that's very vivid and clear. Okay, yeah, yeah.

And then when they combine these two, what they see is like a 95 success rate and it's very safe. Et voila, they created the abortion pill, okay, so in 2000, the Mifemiso pill combo comes to the market in the United States.

Oh wow, so that's like, that's years later.

Yeah, so basically, like there was like scientific testing we had to do in the states. But then there was also all this politics. Because it is like an abortion drug. But eventually they get approved, though. Even then, there were still all these hoops that doctors were jumping through to get it to patients.

Yeah, like, what? Like? For example, doctors would run all of these tests.

You had to check a blood count.

This is Laura Macisaac again.

So you'd have to draw blood.

To make sure is this person anemic?

We used to do a blood type.

Check their liver function.

Do an ultrasound and make sure that it was not an ectopic pregnancy.

Every once in a while, a pregnancy will implant somewhere outside of the uterus, if it's in a fallopian tube, that, as it grows, it will rupture the mom's fallopian tube.

And these pills do work for that or don't work for that.

No, it wouldn't work for that.

It would not, yeah.

No, because you are flushing out the uterus, but if the embryo is not in the uterus, it's just gonna keep growing, right? And so that's like a super dangerous situation that this situation can happen in any pregnancy, but it can also happen in this type of scenario, right? And I should say that you didn't have to do all these tests.

Like, literally watch them ingest the pills in their mouth.

Yeah, exactly.

Is this all in one visit, or are we at multiple visits at this point to get all of that done?

Yeah, it initially could take two visits.

Wait, so why all the regulations and the testing? Was it because of politics or because of science, safety stuff?

Well, there was a little bit, some of it was politics. But then you also have to remember, like the day before these pills came out, the abortion was a surgery.

You know, we can't forget that reproductive events, abortion, miscarriage, childbirth can be fatal, right?

I mean, Laura was like, Don't get me wrong, most of the time, these things go fine.

Totally. But when it doesn't, it is scary and you have to act fast and the light bulbs have to go on and say something's not right here. Why does she have a fever? She might be septic. I'm not gonna leave her side till I figure this out. So it's not like bad shit never happens.

And honestly, even when everything's going right, there's like you're heavy bleeding, there's uterine contractions, there could be vomiting or diarrhea. It's a full body experience that can feel and be scary, even if it ends up being okay. And for folks where it's not okay, like they'd have to get themselves to a hospital or a doctor, or even get a surgical abortion to, like, complete the procedure. So I did find myself when I was talking to Laura, like saying, you know, as the person who could bleed from these pills? Like, I appreciate the guardrails because I have just a lot. I'm a person that has a lot of questions all the time.

How little do they have to be?

She's applying for the job, basically.

I know I was like, there's an opening, so I would be the happiest person, you know, so I understand. Like, knowledge, satiation.

Totally, totally.

The one thing with all these guardrails, though, is that guardrails do make it hard to get these pills to patients. Right? You're missing work for all of these visits, you know, all these tests are expensive.

Yeah, so to sort of, like, advance the story, right? This is the state of play in 2000 and the Mifemiso. Abortion is approved for up to seven weeks. Now. Over time, like the next couple of decades, doctors are starting to, and these are OBs specifically, right. They're starting to experiment and test the boundaries of clinical practice.

Someone tries an experiment, meaning a scientist.

Yeah, like a researcher doing a clinical trial, so the initial dose of mifepristone was 600, I think milligrams. They try, well, maybe we could. This is pretty high, let's try 400, same efficacy, then they cut it down to 200, same efficacy.

And I just wanna say a lot of this experimentation started in other countries. So it'd be like, Oh, the UK is doing it this way now, that's interesting. And then, you know, Sweden would do something, and then France would try something, right.

And then Covid happens, and almost overnight, everything about the way we use these pills changes in a huge way.

When we come back, the abortion pills and the pandemic face off, stick with us.

WNYC Studios is supported by Apple Card. You'll love Apple Card, it's everything a credit card should be, and more. Earn up to 3 daily cash back on every purchase, which can automatically earn interest. When you open a high yield savings account through Apple Card, apply for Apple Card in the Wallet app.

Lulu Latif.

Avir.

Molly.

Radiolab.

Okay, so now it's the beginning of 2020 and these pills are around, they're becoming more and more common.

Yeah, so nearly half of abortions in the United States are happening because of these pills.

And then Covid happens, everything changes. Women still need to have abortions, and the ACLU leads a lawsuit against the F.DA. Basically saying that forcing patients to come into the office to get these pills poses a huge medical risk to both the doctor and the patient.

Now, because of Covid.

Because of Covid.

Right, and they win. So now patients don't have to come in to the office to get these pills.

Yeah, and on top of that, doctors did away with ultrasounds and testing for all but the most high-risk patients.

So now, all of a sudden, the majority of abortions are happening over video chat, they're essentially becoming like, quote no touch.

No touch abortion.

That's Laura Macisaac again.

Was that like, for people who are doing this, was that a huge moment?

Huge when telehealth abortions first started.

I remember my first feeling was, Oh, some bad things are going to happen. We're going to miss some ectopic pregnancies, or patients are going to estimate their gestational age poorly. I'm just used to doing it with the patient in front of me.

In medicine, you know, it's like, we're super conservative, we don't want to rock the boat. One mistake makes us all feel terrible, even if 99 of the rest of the time it went fine. But it turns out-.

Telehealth abortion and in-person abortion have the same outcomes.

There's absolutely no difference.

Oh my gosh, really nothing, nothing.

Nothing, so the efficacy rate is the same, right? the failure rate is the same, the adverse event rate is the same.

That's wild, so it's like the worries may have been legit, but the worries were in vain.

Yes, yes, wow.

I'm kind of shocked, like I feel like, especially when Covid first hit. Like, there were all these stories of like, like. It's like people doing Zoom funerals and Zoom weddings, and those were all and then. But like, nobody was talking about Zoom abortions going on at the same time.

Yeah, exactly. And I mean, Laura's take on it is that, like, all of this happened precisely because, you know, there was so much else going on. And neither the pro-abortion movement or the anti-abortion movement even got the chance.

They were too distracted by Covid to be fighting these-.

Fighting over how doctors should be doing these abortions, huh? Wow, yeah. But there's actually one more thing that Laura told us, something that almost feels like a signal of what abortions might look like in the future.

So this nonprofit, called Aid Access, has been providing women with mifepristone and misoprostol through the mail.

And Aid Access is the U.S. branch of this abortion provider that is literally mailing abortion pills all around the world. And it's run by this European doctor who has developed a company to practice essentially in other countries where access to abortion is really limited. What you do is you go online, you fill out a questionnaire and then a doctor on the other end would read it. And if they felt like you qualified to have a medical abortion, they would mail you the pills directly to your house.

In the first two years of the service, there were 57,506 requests from people in the United States, and they came from all 50 states.

This is Abigail Aiken, professor at the University of Texas, Austin.

Abigail and her team looked at data from almost 3,000 of those patients.

And we found that 96 of people were able to end their pregnancy without any intervention from a medical provider.

How does that compare to the same statistics for if this is done in a clinic setting?

Yeah, that's a great question. So these results in terms of effectiveness are really on par with what you would see in the clinical setting.

Yeah, again, same results, no greater adverse events, even when a doctor and a patient weren't speaking to each other at all. And can I just say also that there was this other result? That was very interesting.

There were actually several topics, not many, a handful, maybe five in one study, three in the other that were diagnosed by the service at the time of consultation. So the person would share symptoms of some kind and they would say, we think that's probably a topic. You should go get that checked out before you proceed with this. And they would actually get into care earlier than if they had waited until they had severe abdominal pain and vomiting.

So you mean, it's like, the form that they did sort of flagged them.

Yeah, exactly.

Wow, yeah.

So it's a crazy study. This is the idea that had been percolating, and aid access is definitely the vanguard. But it's this idea of the self-managed abortion, and I think of it like Molly's probably tired of me saying this same metaphor.

Never, never.

But Jenga, I just played it the other day, okay, I see this whole thing like a game of jenga, right? How? When the medicines come out, we have a perfect block of jenga, you know, like the whole structure's there.

It's, Can I just say? It's like, so funny to hear you both tell this story, because it's like we're so used to every story about abortion. It's all about the politics, it's like so politically drenched. It's like every single little detail about it is like a culture war. But what you're telling is like, the story. That seems like there's no politics in it really, or very little, which is kind of surprising to me.

That's what I think is so incredible, is like, science moves based on science, more or less. I mean, you know, obviously there's politics involved, but in this case, I'm seeing that these pills keep moving and moving and moving in the same direction. It's bigger than politics, it's bigger than the Supreme Court, it's bigger than all of that.

Contributing editor Avir Mitra and senior correspondent Molly Webster.

So that was the piece we played just a few months ago. At the time, it seemed to us at least like it really was mostly a science and medicine story. But obviously now the law and the politicians have caught up and nailed this pill, it's sort of in the crosshairs.

But we should say, for the moment, this pill, Mifepristone, is still available at pharmacies, and it doesn't seem to be affecting the work of aid access. The group we mentioned that sends patients abortion pills through the mail, so thanks for listening.

Stay tuned.

Radio Lab was created by Jad Abumrad and is edited by Soren Wheeler.

Lulu Miller and Latif Nasser are our co-hosts.

Susie Lechtenberg is our executive producer.

Dylan Keefe is our director of sound design. Our staff includes Simon Adler, Jeremy Bloom, Becca Bressler, Richard Cusick, Akedi Foster-Keyes, W. Harry Fortuna, David Gable, Maria Pascual-Tierrez.

Sindhu Nanasambandam, Matt Kielty, Annie McEwen.

Alex Neeson, Sarah Khari, Ana Rascuet-Paz.

Sarah Sandbach, Ariane Wack, Pat Walters and Molly Webster, with help from Andrew Vinales.

Our fact-checkers are Diane Kelly.

Emily Krieger and Natalie Middleton.

Hi, this is Tamara from Pasadena, California. Leadership support for Radio Lab's science programming.

Is provided by the Gordon and Betty Moore Foundation Science Sandbox, a Simons Foundation initiative.

And the John Templeton Foundation?

Foundational support for Radio Lab was provided by the Alfred P. Sloan Foundation.