As Minnesota abortion care providers ramp up for an expected influx of patients from across the Midwest following the end of Roe v. Wade, some doctors are pushing the state’s major health care systems to do more now — including improving access to a drug that’s also used for medication abortions.
Mifepristone is a best practice treatment for managing a miscarriage, doctors say. It’s also a key drug in medication abortions, and physicians say they must run through regulatory hurdles to obtain it, limiting its use and perpetuating an unwarranted stigma.
“We should be using it for miscarriage management. It’s much more effective and safer than dilation and curettage (removing tissue inside the uterus) for miscarriage that has not completed on its own,” said Dr. Siri Fiebiger, an OB-GYN in the Twin Cities.
“If people can then provide mifepristone in their own clinics, then we take off the burden of sending our own patients to clinics like Planned Parenthood or Whole Woman's Health, and just provide full scope of care wherever we are, as part of the full scope of practice of obstetrics and gynecology,” she said.
Some large health care systems, including M Health Fairview, HealthPartners and Allina Health, said their doctors have prescribed mifepristone. Others including Mayo Clinic and Hennepin Healthcare did not address in statements to MPR News how they use the drug, or if they use it. Physicians say it's not available in all organizations or clinics.
‘Why couldn't I have this in my usual clinic?’
Mifepristone is an anti-progestin, which stops the hormone progesterone from working and breaks down the lining of the uterus. In order to get the drug, providers must follow a “risk evaluation and mitigation strategy” laid out by the federal Food and Drug Administration.
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The agency requires the drug to be prescribed by or under the supervision of a qualified health care provider who has signed an agreement form. That provider must also obtain an agreement form from the patient “after counseling and prior to prescribing” the drug. Any pharmacy that dispenses the medication must be certified.
In late June, the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association asked the Biden administration to cut back the use rules. Fiebiger and others in the ACOG state chapter are pressing leaders in Minnesota’s large hospital systems now for wider access to mifepristone.
Dr. May, who works as a family medicine doctor and provides abortions at a clinic in the Twin Cities, recalled the distress of having to refer a patient to another clinic because the doctor’s family medicine practice didn’t provide abortions. MPR News agreed not to use her real name given her concerns about security.
May performed the abortion at the outside clinic but said she could still recall the woman’s pain as she asked, “‘My doctor, you're here. But why couldn't I have this in my usual clinic?’”
May said she’s not currently able to provide mifepristone for miscarriage management, in part because it would require approval from her health system.
“Because (mifepristone) is known often as the abortion pill, and has been surrounded by restrictions — fear, fear of being associated with providing abortion care — it has historically not been available in primary care clinics,” she said.
Conversely, she said, if she orders a patient misoprostol — the second drug commonly used in a medication abortion — they can pick it up at any pharmacy.
‘Won’t say the word’
Some of the hesitancy to adopt mifepristone at major institutions could stem from the fact that while hospitals and larger health care systems have always been able to provide abortion care, they’ve historically not adopted induced abortions as part of their regular practice.
The reasoning goes back to before Roe v. Wade, said Dr. Jennifer Kerns, associate professor of obstetrics, gynecology and reproductive science at the University of California San Francisco. At that point, she said, abortions were mainly done behind the scenes by some independent clinics and people in the community.
“It was, to some extent, a lot more empowering than being part of a large medical institution,” Kern said. “Places could function and sort of run and develop processes in ways that they really felt met the needs of patients.”
After the U.S. Supreme Court found a constitutional protection for abortion in the 1973 Roe case, Kern said there was little interest from hospital systems in changing that dynamic.
Some also noted that hospitals and big health care systems may not be ideal places for abortion care. For one, larger health institutions can be more expensive than smaller clinics, so the financial barriers can be greater. There can also be legal and regulatory hoops to jump through.
Additionally, because the pool of staff is much larger in these institutions, it can be more difficult to ensure that they will be supportive of patients seeking abortion care.
But considering the number of people expected to seek abortion care in Minnesota, increasing access to care of this kind at large institutions could have a disproportionate impact on the health of people of color, said Asha Hassan, a researcher with the University of Minnesota’s Center for Antiracism Research for Health Equity.
“A clear and obvious solution to this is to treat abortion like it is: health care, within our larger health care system,” said Hassan, noting that larger health care systems have the capacity and the experience. “It is a normal part of reproductive health.”
Still, some physicians say they are optimistic about how hospital officials are responding to bringing mifepristone in across their systems.
“Moving the wheel of big organizations of any kind is challenging, but I think people are feeling more pressured since June 24 to make actionable steps in a more expedient manner,” said Dr. Christy Boraas, an OB-GYN in Minneapolis. “Not without counsel and without consideration of lots of things, but in a way that I haven't experienced before.”
And most Minnesota health systems do provide abortion care to some degree, she noted.
“It all comes out of fear, I think, because big health systems don’t want that attention,” Boraas said. “And I think that is certainly a part of why we are in this landscape that we are now, with abortion access decimated in half of our country, because people in positions of power at the top of the chain of major health systems won't say the word abortion, and won't be out about it.”