Yes, some medication abortion patients go to the ER — but it may not be for what you think

Next Tuesday, the U.S. Supreme Court will finally hear a case about mifepristone — the first drug used in a medication abortion. 

A ruling in favor of the plaintiffs, Alliance for Hippocratic Medicine — an organization of anti-abortion activists backed by the Christian right-wing lobbying group Alliance Defending Freedom — could severely limit access to mifepristone across the country. As women’s health specialists and doctors have told Salon before, the effects of such restrictions will be "devastating,” and have far-reaching consequences beyond impacting reproductive health.

Numerous amicus briefs signed by organizations representing the country's leading researchers and physicians have emphasized there is ample scientific evidence to support widespread use and availability of mifepristone, which the FDA approved in 2000 and has a well-established safety profile. But a lawsuit filed in November 2022 called this decades-long credibility into question by alleging that its longstanding approval was based on incomplete data and put women’s health at risk.

The case is based on what many have called “junk science,” some of which has been retracted for presenting misleading data. But that hasn't stopped some from citing it anyway. Specifically, in one of the retracted studies cited in U.S. District Judge Matthew Kacsmaryk’s ruling, the authors claimed that mifepristone increased the risk of women going to the emergency room following a medication abortion compared to surgical abortions. The study claimed that ER visits after medication abortion increased between 1999 and 2015. Legal experts anticipate this study, despite being retracted, will still be a big part of oral arguments next week.

“Most of the case is based on the handful of poorly done studies that claim that abortion care is harmful, either in terms of mental health or in terms of adverse events,” Dr. Ushma Upadhyay, a public health scientist at Advancing New Standards in Reproductive Health (ANSIRH), based at the University of California-San Francisco, said at a press briefing. “We do know that a small proportion of patients do visit emergency rooms after an abortion.”

But it’s not necessarily because of an emergency situation, or because mifepristone is unsafe. Instead, Upadhyay said, it’s usually for a variety of other reasons that aren’t related to the pill’s safety profile.

“Oftentimes, the entire abortion is taking place at home, they live far from an abortion provider or a clinician who they can just walk into or visit if they have any questions about the side effects they're experiencing,” Upadhyay said, hence the emergency room is their only option. “Sometimes it's a lot of bleeding and they have questions about whether this amount of bleeding is normal.” 

Dr. Kara Cadwallader, who is a family medicine physician in Idaho, told Salon in a phone interview that bleeding is a common reason for people to go to the emergency room after taking abortion pills, in addition to pain. And the patient might be seeking out additional options for pain management as passing the fetal tissue can be quite painful. 

“We give ibuprofen and use heat and ways to manage that pain, but both bleeding and pain should decrease,” once the tissue has passed, Cadwallader said. “We tell folks if you’re soaking through a maxi pad, two, in an hour to two hours, they should seek help.” 

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Frequently, Upadhyay said, medication abortion patients will actually go to the emergency department to seek clinical care and make sure that the medication worked. That’s because a pregnancy test won’t be accurate for at least four to five weeks after a medication abortion, because the pregnancy hormones need time to leave the person’s system.

“There are many reasons that patients go to an emergency room,” Upadhyay said. “And the plaintiffs are relying on that to say that abortion is dangerous, but they don't actually look at the reasons for the visits whether the patient precedes any treatment.”

Cadwallader said emergency room visits aren’t a reflection of the safety of mifepristone, stating that there are risks with other outpatient procedures such as a colonoscopy, in which a person is more likely to have an unplanned hospital visit after the procedure.

“Use of the emergency room does not equate to lack of safety,” Cadwallader said. “Just because someone chooses to go to the ER for management of symptoms, medical attention doesn't equate to lack of safety.”

Upadhyay co-authored a paper published in BMC Medicine in 2018 on abortion-related emergency room visits in the United States. Her retrospective analysis of emergency room visits by women between the ages of 15 and 49 using data from the Nationwide Emergency Department Sample, from 2009 to 2013, which totaled more than 189 million visits. In her study, the researchers found that 0.01 percent of emergency room visits in this age group were actually related to abortions. And an estimated 51 percent of abortion-related visits received “observation care only,” meaning they didn’t result in treatment or a diagnosis. 

“What they're trying to do is obfuscate and bring a lot of attention to this need for care after an abortion,” Upadhyay said. “It's not based on science.”

It’s not the first time this has happened. In fact, this is a popular talking point among anti-abortion advocates that has infiltrated politics. Previously, South Dakota Gov. Kristi Noem, defended her state’s ban on prescriptions via telemedicine by claiming that “a woman is five times more likely to end up in an emergency room if they’re utilizing this kind of method for an abortion.” This claim stemmed from the same retracted study in the mifepristone case. As FactCheck.org found, not only did Noem’s press office fail to cite the study correctly, but researchers warned not to assume that a higher rate of emergency room visits means that there’s a concern with the safety of the medication. 

Statistically, medication abortions are very common in the United States. They account for a majority of all abortions in the U.S., according to the Guttmacher Institute. Medication abortions typically occur by taking the brand name drug Mifeprex, which contains mifepristone. In the two-step process, a pregnant person first takes a mifepristone pill, then 24 to 48 hours later, a second pill containing another drug known as misoprostol.

The two-step process works up to 70 days after the first day of a person's last period, which corresponds to week 10 of a pregnancy. But if the SCOTUS ruling restricts access to mifepristone, it would also shorten the timeframe that it could be used from 10 weeks to 7 weeks, among other restrictions. For instance, it would take away the ability to prescribe it by telehealth and by mail — options that many people are relying on in states where abortion access is nearly totally restricted. Mifepristone is also a key part of miscarriage management.   

Ashley Jeanlus, an OBGYN and assistant professor in the department of Obstetrics, Gynecology and Reproductive Sciences at UCSF, elaborated during the press briefing that mifepristone is safe, and that there are many reasons why someone chooses a medication abortion over a surgical abortion. For instance, it can keep potential patients from having a pelvic exam and instrument intervention, which might be a preference of younger patients who haven’t had one before or victims of sexual assault and domestic violence. It also gives people the option to manage their abortions in the privacy of their own homes, instead of going to a clinic in which there could be protesters. 

“Medication abortion is safe and effective, and having options for how to end a pregnancy in a clinic or at home really empowers a person to end a pregnancy on their own terms,” Jeanlus said. “Restrictions on medication abortion do nothing to make abortion care safer, but they do make it more costly and less available to the patients in our communities.”