‘The Pill That Changes Everything’: The Ms. Q&A With Carrie N. Baker, Author of ‘Abortion Pills: U.S. History and Politics’

Abortion pills now account for the majority of U.S. abortions, transforming reproductive healthcare. Carrie N. Baker explores their history, politics and the ongoing fight for access in her groundbreaking new book.

Research shows that abortion pills are as safe as Tylenol and easy to use,” Baker told Ms. “They should be available over the counter—as at long last, we are beginning to see with ordinary birth control.”

In recent years, the use of abortion pills has skyrocketed and now accounts for an estimated 63 percent of all abortions performed in medical settings, including through both brick-and-mortar clinics and telehealth providers. In addition, many abortion seekers obtain these medications through alternative avenues, including websites selling pills and community networks mailing them for free to people living in states banning abortion. Telehealth abortion has become especially important in states that have banned or restricted abortion since the U.S. Supreme Court  overturned constitutional protections for abortion in Dobbs v. Jackson Women’s Health Clinic in June 2022. 

Carrie N. Baker’s fascinating new book, Abortion Pills: U.S. History and Politics, tells the story of a decades-long struggle for acceptance of this safe, secure, and private method of ending an early pregnancy. It’s also a story of antiabortion attempts to suppress abortion pills.


Ellen Chesler: Carrie, tell us how this revolution using two medications, mifepristone and misoprostol, came to the U. S., and what role the women’s movement played.

Carrie Baker: The abortion pill now known as mifepristone was developed in France in the 1970s by a group of researchers affiliated with the French pharmaceutical company Roussel Uclaf. The medication was patented in 1980 as RU486 and approved for use in France eight years later. Pro-choice advocates in the United States quickly got wind of this development and organized to bring it here. At the same time, the National Right to Life Committee threatened to boycott any drug company who tried to bring the medication to the U.S.

Fearing controversy and even violence, Roussel Uclaf declined to market the pills in the U.S. This motivated Ellie Smeal, of the Feminist Majority Foundation, which now publishes Ms., along with Lawrence Lader, who was a founder of NARAL and head of Abortion Rights Mobilization, to pressure the French company to release the medication for development by others. Lader staged a major press event at Kennedy Airport by setting up the arrest of an American woman bringing mifepristone from France. Feminist Majority activists collected over 700,000 petitions, boxed them up, flew them over to France, and later went to Germany, where Roussel Uclaf’s parent company was headquartered. They met company officials in both places. Eventually in 1993, Rousell Uclaf granted the right to conduct clinical trials of RU 486 to the Population Council, a well-established U.S. non-profit.

The World Health Organization recommends two regimens for medication abortion: misoprostol alone, or combined with another medication, mifepristone. (Hendrik Schmidt / Getty Images)

Chesler: Can you locate these developments in the politics of the day? 

Baker: From 1988 to 1992, George H.W. Bush was president. He imposed an import ban on RU 486—effectively a barrier to research and clinical trials needed to bring the medication to market here. 

Chesler: Bill Clinton was the first pro-choice president elected in this country in 1992. His administration, including Donna Shalala, then Secretary of Health and Human Services, played a critical role in mifepristone approval. How did things change politically when Clinton came into office?

Baker: Clinton pledged to work for FDA approval of RU 486, but the process nevertheless took eight years. The environment was so tense. Officials at the FDA were concerned about political attacks by antiabortion members of Congress and they were fearful for their own safety. Let’s remember this was the 1990s when extreme antiabortion activists were blockading and even bombing abortion clinics and tragically shooting at doctors and clinic personnel.

Young people with signs depicting the abortion pill RU 486 participates in the transfeminist movement Non Una di Meno protest in front of the Ministry of Health for safe and free abortion on Sept. 28, 2024, in Rome, Italy. (Simona Granati / Corbis via Getty Images)

Chesler: Ultimately, though, this is a story about the effectiveness and integrity of the FDA, which approved the medication based on rigorous scientific evidence of its efficacy and safety, quite independent of politics. It’s such an important tale today, as this continues to be contested. The FDA back then made sure that the clinical trials on mifepristone were beyond reproach. 

Baker: Absolutely.

Chesler: Can you talk about another wrinkle from this period—the resistance that came from the feminist health movement, not from the right but from the left, so to speak?

Baker: Let’s remember that in the early 1960s, the birth control pill had first been approved at a dosage ten times what we use today, and many women had negative health reactions, including strokes. The FDA was accused of ignoring their complaints. The Dalkon Shield IUD also turned out to be harmful, even as other devices proved to be very safe. As a result, some feminist health advocates were skeptical about mifepristone. 

In response, two reproductive health advocates, Marie Bass and Joanne Howes created the Reproductive Health Technologies Project to research the medication and its safety They, in turn, gathered a wide range of women to meet with doctors and scientists involved in the testing of the medication. This was very effective since, actually, there was a lot of research already showing that the medication was not only safe and effective, but also acceptable and appealing to users.

Chesler: And also preferable, because it allows women to have more private control. 

Baker: Many women say that taking abortions pill feels more natural than a procedure. In fact, the pill brings on an early miscarriage. Spontaneous miscarriages are actually quite commonplace—they happen in approximately one out of every four pregnancies.

Chesler: My biography of Margaret Sanger was published in 1992, and I was asked to write and speak about the new abortion pill. Etienne Baulieu, the French scientist, who helped develop RU 486 wanted to market the medication as what he called a “contragestive”, because it interfered with gestation before fetal development not as an abortifacient, which the right wing had so successfully stigmatized. For most people, early interventions are actually medically and morally less complicated than later procedures, but these actual and semantic distinctions have never really taken hold.

Baker: I found an interesting quote from John Willke of the National Right to Life Committee, who said, early on, “If what [abortions] destroy in there doesn’t look human, then it will make our job more difficult.” The organization understood that support for early abortion was higher, and was very worried about the fact that abortion pills could expand access to early abortion.

Chesler: Your book is a classic study of the complications of making public policy, especially if there is controversy. Let’s now talk about the 25 years since FDA approval and the fight to expand access to the two-pill regimen.

Baker: Initially there was great hope that abortion pills would, as one TIME magazine cover said, “change everything”—that the pill would increase access to abortion, enabling gynecologists and even primary care doctors to prescribe abortion medications in the privacy and anonymity of their offices rather than only in stand-alone abortion clinics that are easily targeted by protesters.  This hope was not achieved for many years, however, because the FDA approved the mifepristone pill with many restrictions, or as one commentator put it, with ‘belts and suspenders.’

Only certified physicians who were willing to sign up with the manufacturer could purchase, prescribe, and administer it. Pharmacies were not allowed to stock and dispense it. Doctors had to dispense the medication in person and patients had to make three visits to the clinic. As a result, abortion pills were largely prescribed by doctors who were already performing procedural abortions in clinical settings. Advocates worked hard to broaden access, but the FDA’s restrictive approval of mifepristone did not in fact significantly expand the number of clinicians providing abortion. And many abortion clinics preferred to do procedural abortions.

Between 2000 and about 2016, the percentage of U.S. abortions performed with medication rose gradually, but much more slowly than in Europe. By 2014, the abortion pill only accounted for about thirty percent of the total.

Chesler: There was resistance, as well, from Danco, then the sole manufacturer of mifepristone in the U.S, which at the start preferred the ease of working with a limited number of doctors in clinics.  The FDA routinely establishes what amounts to a twelve-year monopoly for new drugs in order to compensate pharmaceutical companies for the high cost of research, clinical trials, and complicated approval processes. The market is then opened to competition. 

Tell us what happened when the first generic manufacturer entered the abortion pill field and how the COVID-19 epidemic accelerated this?  

Baker: First, in 2016, the FDA finally removed many of its initial restrictions. 

The FDA replaced the term “physician” with “healthcare provider” in their regulations, opening the door for nurses, nurse midwives, and physician’s assistants to dispense the medication. They dropped the requirement that patients make three appointments to obtain the medication. The FDA also lowered the recommended dosage and  approved use of the medication through ten weeks gestation, rather than just seven, the original limit. Finally, a TelAbortion study was authorized to investigate the efficacy and safety of telehealth abortion. 

In 2019, the FDA approved a generic mifepristone product developed by GenBioPro, a company that received initial funding from the Packard Foundation, and more recent investment from the Open Society Foundation and other donors. Danco, for the first time, had a competitor and, as a result, the price of mifepristone dropped from $100 dollars to about half that cost. 

Once the pandemic hit in 2020, the Trump administration lifted restrictions on in-person dispensing for many medications, but, no surprise, not for mifepristone. The American College of Obstetricians and Gynecologists (ACOG) and the advocacy group Sister Song then jointly filed and won a lawsuit arguing that the in-person dispensing requirement imposed a substantial unconstitutional burden on women due to potential exposure to COVID-19. The FDA was forced to lift the requirement. 

Clinicians immediately created virtual, “telehealth” abortion clinics that screened patients via video-conferencing or online forms, then mailed pills to them. Honeybee Health, a mail-order pharmacy, formed to dispense generic mifepristone and misoprostol at significant discounts. Cutting out the middleman enabled these providers to charge much less. The cost of an abortion dropped significantly from a nationwide average of $550.00 at brick-and-mortar clinics to $150 to $250 via telehealth. Beyond the low cost, the convenience, privacy, and reliability of these services has made them very popular.   

‘By 2021, reliable data collection, research and analysis had been gathered to argue for dropping the in-person dispensing requirement permanently, which the FDA did in December 2021 with the encouragement of the Biden administration. Telehealth abortion has since blossomed. Today Massachusetts, where I live, has 16 telehealth abortion providers, which has more than doubled the number of abortion providers in the state.

Chesler: Identify some of the heroes in this process. It’s such an inspiring story about women taking control of their own lives and helping others to do so.

Baker:  Some of the biggest heroes are the medical providers who dove right in, invested their own resources, and created services when it was still legally iffy to do so—services like Just the Pill or Pills by Post or Abortion on Demand. In addition, we have the organization Plan C, which advocates for access to abortion pills free from all medical gatekeeping. Plan C worked with many of these early telehealth providers to create virtual abortion clinics and also encouraged a Dutch physician, Rebecca Gomperts, who has long provided abortion services online around the world, to create Aid Access, a service targeted to U.S. women. Once the Supreme Court overturned Roe, Aid Access relocated into states like New York and Massachusetts that passed telehealth provider shield laws to protect physicians mailing abortion pills into states banning abortion healthcare.

Telehealth provider shield laws permit clinicians to provide telehealth abortion to people in all 50 states. These state-based laws essentially provide protection from criminal and civil liability actions threatened from states with abortion bans. Doctors in places like New York or Massachusetts can serve women in Texas, for example, confident that their licenses, their insurance, their livelihoods are safe. An estimated 10,000 pills a month are being mailed into states with abortion bans, a critical access point post-Dobbs.

Chesler: The Society for Family Planning’s #WeCount report demonstrates that the number of U.S. abortions post Dobbs is actually greater than before restrictions were put in place.  

Baker: That’s right. And official numbers do not include many people obtaining abortion pills outside of the medical system—called self-managed abortion. My book documents how activists have developed community networks that share free abortion pills with people living in states with restrictions. There are also many services selling abortion pills online. Plan C lists these options on their website and several other organizations have developed to support people self-managing their abortions.

An organization called Miscarriage & Abortion Hotline provides free, confidential medical advice to anyone self-managing an abortion. Reprocare provides logistical and emotional support., A group called OARS provides vetted information and support at their abortion subreddit. There’s also a chatbot named Charley that guides people through their options depending on where they are located and how far along their pregnancy is. If/When/How has a legal helpline. No state currently criminalizes taking abortion pills, although some are threatening to do so. 

Chesler: There are so many lessons in this history.

First, advocacy matters. Courageous advocates in the feminist and health sectors have led the way. Second, funding matters. Private philanthropy has provided critical support for research and advocacy, along with mission-related investments to finance new products, when traditional venture capital markets would not do so. Third, elections matter. The FDA and private actors may try to follow the science, but who’s in charge in Washington and in the states also makes a critical difference 

What’s going to happen with the new administration? Where are we now? 

Baker: Opponents are now laser focused on rolling back telehealth abortion or even reversing FDA approval of mifepristone. A lawsuit brought by antiabortion clinicians in November 2022 in Amarillo, Texas, tried to do this, but on appeal the Supreme Court dismissed the case for lack of standing. Conservative state attorneys general are now trying to revive the lawsuit.

The Republican Project 2025 agenda calls ons Donald Trump to direct his FDA to reverse the availability of telehealth abortion and to pull mifepristone from the market completely. It also directs Trump to misuse the Comstock Act, a 19th century anti-obscenity statute, to criminally prosecute anyone mailing of abortion pills across state lines. We are at a critical juncture, but one thing I guarantee you: this will not stop the flow of abortion pills. Across the world where abortion is illegal, the practice does not disappear. Women find pills outside of the medical system, and that’s already happening in the U.S.

Chesler: I trust women, but I do worry that “speakeasy” abortion, so to speak, may not be as safe and reliable as pills provided with appropriate supervision and counseling.

Baker: Research shows that abortion pills are as safe as Tylenol and easy to use. They should be available over the counter—as at long last, we are beginning to see with ordinary birth control. Research on OTC mifepristone access is underway at the University of California at San Francisco.

About

Ellen Chesler, Ph.D, is author of Woman of Valor: Margaret Sanger and the Birth Control Movement in America. She was formerly a program director at the Open Society Foundations and is currently a visiting senior fellow at The Ralph Bunche Institute for International Studies of the City University of New York.