In the first month of the coronavirus pandemic, when planes from India temporarily stopped flying, Rebecca Gomperts faced a problem. A Dutch physician and abortion specialist, she had spent the two years prior shipping the pills commonly used to end a pregnancy – mifepristone and misoprostol – to people in countries where they couldn’t access them. Now, mifepristone wasn’t available to her any more.
Gomperts is a doctor who has gone to extraordinary lengths to circumvent abortion restrictions around the world, including parking her boat in international waters outside of countries like Poland to administer abortions. So she pivoted. She trialled misoprostol-only abortions, as that drug was more easily available outside India. The results weren’t ideal, but they were much better than nothing.
Her experience has relevance to an upcoming ruling in a Texas lawsuit that could have national consequences. There, a judge is considering arguments from a Christian, ultra-conservative legal organization that is suing the Federal Drug Administration (FDA) over its approval of mifepristone more than two decades ago. If he rules in favor of the plaintiffs, the result will be a mifepristone ban – not just in Texas or other states where abortion is banned, but nationwide.
The potential for the case to end access to a life-saving drug in the US for the foreseeable future is significant: the Donald Trump-appointed judge, Matthew Kacsmaryk, previously worked for the First Liberty Institute, a conservative, Christian organization that brings litigation to promote religious liberty and restrict abortion and LGBTQ+ rights. As a district judge, he has ruled that teenagers in Texas must seek parental consent before accessing contraception.
And so in the meantime, providers and advocates have been scrambling to work out what the country will do if one half of its medication abortion regimen is no longer available in the US. To answer that question, many have been touting Gomperts’ own research on misoprostol-only abortions, published earlier this month, suggesting they will be a viable stand-in for the more effective, two-part regimen most commonly used in the US.
But while the research is promising, Gomperts is not so sure we should settle for a less effective option.
Misoprostol-only abortions are effective 88% of the time, the study found, compared to a 98% success rate for the two-step regimen. They are also more complicated: they are more likely to result in the need for surgical interventions; they bring a risk of foetal abnormalities if the pregnancy is not terminated effectively; they result in more bleeding, cramping and pain; and they come with the potential for very expensive aftercare – which matters in a privatized system like the US.
“You cannot just say it’s OK. It’s not,” says Gomperts, striking a tone commensurate with the “serene sort of audacity” that has been attributed to her, when we speak in a phone interview.
“As a doctor, you have to give the best treatment that’s available. And we know that the best treatment possible is the two drugs combined,” she says.
If Kacsmaryk bans mifepristone, it will be an attack on women’s health, not just on abortion, Gomperts says.
Mifepristone, combined with misoprostol, is the best miscarriage treatment, she explains. Mifepristone is shown to be beneficial for people with breast cancer. It works against myoma, a condition that causes heavy bleeding in women, and endometriosis, a condition where the endometrium is outside of the womb and can cause extreme pain. And it can be used as a birth control pill – Gomperts is currently crowdfunding for a clinical trial to test mifepristone’s safety and effectiveness as a weekly contraceptive.
“It really is a life-saving drug and is relevant to many conditions that women have,” says Gomperts.
“There shouldn’t be any gatekeepers here. There shouldn’t be a doctor, a pharmacy, nothing. These medicines have such a high safety profile. They’re so safe, they shouldn’t even be prescribed, they should be available over the counter. That is the goal. That is what we’re fighting for,” she says.
Of course, Gomperts recognizes that if misoprostol-only abortions are the only option, they should be used – that’s why she pivoted to them herself in 2020. But she thinks we should reject the premise that it’s all we’ve got – just because US courts seem to be having a dark-ages moment, that doesn’t mean we should roll back the rights we believe ourselves to be entitled to.
No matter what Kacsmaryk rules, Gomperts’ organization, Aid Access, and others like it will still be shipping mifepristone all over the US. “People should know we will continue to provide medication abortions this way, whatever the ruling is,” she says.
‘Get the medication now’
Gomperts’ conviction, in part, stems from her own experiences: her refusal to accept the status quo, whatever the restrictions. But it also stems from something she began to notice after the supreme court ended the constitutional right to abortion last year.
Before Roe v Wade was overturned, Gomperts said people in the US who were stymied by abortion restrictions felt robbed of an entitlement, and angry.
“They were outraged, and they were upset, and they wanted to talk about that,” she says. “They were saying, ‘Even though this is my constitutional right, I am not able to access it. That’s wrong’.”
But after 24 June, the mood changed: “People became much more fearful. They think they are doing something illegal. And that is really damaging. It means that when people need to look for care, they are delayed, because they’re afraid. And that is a situation that we see everywhere in the world where abortion is really strictly forbidden,” says Gomperts.
Gomperts is nonplussed by the idea of another ruling that will make abortion even harder to access in the US. It sounds like for her, the moment for shock has been and gone.
“I am so already so appalled by many things that are happening in the US,” says Gomperts.
“I would feel rather desperate, if I were a US citizen with this supreme court, knowing that everything ends up in this court, which you cannot trust, which is a fundamentalist court, which doesn’t have the best interest of the citizens. It doesn’t consider human rights as [something] they have to uphold. This court is going to last for a long time,” she says.
But she doesn’t suffer from a lack of hope. For all of the obstacles the last three years have presented, she believes the pandemic has also opened up care – making abortion medication much more widely understood, more readily available and cheaper. Before the pandemic, medication abortion accounted for about 39% of all abortions in the US – now, it accounts for more than half.
Gomperts is always encouraged by the ways people adapt to keep getting the care they need – no matter what judgments are handed down.
She points to people who have already turned to the internet to get abortion pills; people who have travelled out of state for abortion care; doctors who have referred patients to websites like hers for medication abortion.
“People are extremely resilient. And also innovative,” she says.
But in the meantime, she wants people to stock up on the drugs currently available to them, fast.
“Don’t wait for the decision. Just get the medication now, get it in your house, get it in your hands,” she says.
“If you’re in a war zone, and the war is coming, you also make sure you have enough food in your house. This is how it feels. It really is a war. It’s a war on women,” she says.