On October 1, 2024, at 4:45 p.m., I frantically called my gynecologist’s office. It was only 15 minutes before they closed, but I desperately needed to speak to someone because the medication I needed to soften my cervix for Intrauterine device (IUD) insertion the next day had not been ordered. By 5:00 p.m. the prescription for my medication had been sent to the pharmacy, and by 5:45 p.m. I had picked up the medication, paid my $1.30 copayment and was headed home. The medication I needed was misoprostol – a prescription drug used in the most popular medication abortion regimen. Despite the rushed timeline, my experience receiving misoprostol was seamless. As an advocate who works in reproductive rights, I couldn’t help but think critically about how my experience would compare to someone in a state with less protection for reproductive health care than mine, especially as threats to medication abortion continue to grow.
There is so much wrong with the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, which overruled Roe v. Wade and held that the Constitution does not guarantee a right to abortion. But one of the most egregious is that the Court attempts to isolate abortion from other rights and explain why access to abortion can be restricted, falsely claiming that doing so would not impact other rights or other forms of health care.This practice of treating abortion differently is called abortion exceptionalism.
Abortion exceptionalism is the singling out of abortion care for special treatment or regulation. Although Roe originally established abortion as a fundamental right, abortion has been severely restricted and stigmatized by government policy through the prohibition of federal funds being used for abortion care through the Hyde Amendment, over-regulation of abortion facilities using TRAP laws, and the creation of abortion bans. These policies unjustly treat abortion as unique and further abortion stigma, a belief that abortion is morally wrong or shameful.
Abortion exceptionalism and abortion stigma are harmful because when abortion care is treated as separate from essential health care it puts people’s lives at risk. For example, a study by Stanford University in 2020 found that over half of medical schools either did not have formal training on abortion, or only provided students a single lecture. Since Dobbs, medical education on abortion care has worsened as fewer residency programs – hands-on training programs future physicians must undergo in a particular specialty – are able to offer training on abortion due to state abortion bans.
As of October 2024, there are twenty-one states with abortion bans within the first eighteen weeks of pregnancy, and thirteen of those states have total abortion bans (with only very limited exceptions). In addition to these bans, some states have taken additional measures to prohibit access to prescription drugs that can be used in medication abortion. On October 1, 2024, Louisiana began enforcing a law, known as Act 246, that categorized both mifepristone and misoprostol (the two prescription drugs used in the most popular medication abortion regimen) as Schedule IV controlled substances. Typically, this classification is reserved for highly addictive drugs, or medications that have anesthetic or depressant effects. There is no scientific evidence that mifepristone or misoprostol have any of the increased risks associated with other Schedule IV substances. These are safe medications with a low risk of complications.
Louisiana’s move to classify them as Schedule IV controlled substances is clearly driven by a political desire to make abortion care inaccessible. It is an example of abortion exceptionalism and endangers the lives and reproductive health of all those able to give birth, including because both medications have important uses outside of medication abortion. Ahead of the October 1, 2024, implementation date for the new scheduling of the medications, doctors in Louisiana began running drills to see how quickly they could access misoprostol in an emergency to prevent catastrophe for maternity care patients.
Misoprostol in particular is essential in managing maternal health complications due to its effectiveness in treating postpartum bleeding. Physicians in Louisiana have voiced concerns about the new restrictions on misoprostol, particularly on behalf of their patients giving birth. Under the new scheduling guidelines, mifepristone and misoprostol must be stored in a substantially constructed and securely locked cabinet away from non-controlled substances. As some physicians have stated, since most carts used for the treatment of postpartum hemorrhage do not have locked compartments, misoprostol would need to be stored on separate floors in the hospital or in auto-dispensing machines with frequently changing passwords that delay access. But the reality is that these delays could be deadly to a patient experiencing excess bleeding after birth – and are a direct consequence of Louisiana’s abortion exceptionalism, of the choice to prioritize anti-abortion extremism over pregnant people’s lives.
Outside of the maternal health context, mifepristone and misoprostol serve other important medical benefits in treating chronic conditions. Mifepristone can be used to treat high blood glucose levels of those with Cushing Syndrome (a hormonal condition) and misoprostol can be used in a treatment regimen to relieve symptoms of rheumatoid arthritis and osteoarthritis. Additionally, misoprostol is often used to soften the cervix for biopsy procedures or IUD insertions, like the one I received.
The designation as a controlled substance for mifepristone and misoprostol and subsequent prescription tracking furthers stigma about these medications and creates a chilling effect on the use of these medications. This could turn out to be especially true for the use of misoprostol for IUD insertions, as there has been little consideration of pain management for the procedure until recently. When a state labels misoprostol as a controlled substance, providers may be less inclined to offer it for IUD insertions or other medically indicated use, leaving people to experience pain or to suffer needlessly.
The scheduling of mifepristone and misoprostol as controlled substances is an example of abortion exceptionalism and furthers abortion stigma that compromises the care of patients. We must work to end abortion exceptionalism and recognize abortion for what it – is essential health care. We must ensure that abortion procedures and the prescriptions used for medication abortion are available and accessible to all.
