After Roe, after the intensification of abortion restrictions in the United States, it is more important than ever that scholars and activists both critically reflect on the gravity of this moment and effectively organize to turn it into a catalyst for change. We can harness the energy of this anticipated, yet shocking, moment to build new relations, to amplify our voices, and to wield our institutions as academic and feminist collectives. This moment also provides the impetus to radically reconfigure the pathways to reproductive agency and to reimagine what reproductive freedom could mean in the post-Roe era.

One way of doing so is by expanding the medical indication for the abortion pill mifepristone to cover the full reproductive cycle. Mifepristone, in combination with misoprostol, is 99 percent effective at ending an early pregnancy, but clinical trials suggest it can also function as a new, weekly, on-demand contraceptive. With this new indication, mifepristone can provide a singular, convenient means to enhance women’s reproductive freedom to both avoid and end an unwanted pregnancy.

The availability of abortion pills (i.e., medication abortion) is one of the key differences between the post-Roe moment and the pre-Roe situation. The combination of mifepristone and misoprostol is highly effective, safe, and approved for use by the US Food and Drug Administration (FDA) and endorsed by major health organizations such as the World Health Organization (WHO). In contexts where abortion is not legal or accessible, the use of telemedical abortion services, as well as underground reproductive justice networks, also offer the possibility of dodging forced pregnancy regulations. Organizations such as Women on Web (global) and Aid Access (US) provide physician-led consultations and prescriptions to women and pregnant people who need an abortion in contexts where it is illegal or otherwise inaccessible.

Four years ago, Dr. Rebecca Gomperts founded Aid Access specifically to help women in the United States who could not access safe abortion care. Since the Supreme Court opinion leak in May 2022, Aid Access has seen a spike in requests. After Roe was overturned, the group received approximately 4,000 requests a day, up from 600–700 before. Given that there are an estimated 77,513 abortions nationwide each month, Aid Access and its telemedical approach will play an even more significant role in the post-Roe US reproductive landscape.[1]

One of the challenges of telemedical abortion is to get the pills to those who need them in a timely fashion, which aids peace of mind and allows women to use the pills earlier in the pregnancy. To circumvent potential delays caused by postal services and federal officials enforcing legal restrictions, and to meet women’s need for fast access to abortion medication, Aid Access now also offers advanced provision medical abortions. Women can order and receive abortion pills when they are not pregnant but anticipate they could face an unwanted pregnancy at some point in the future.

This move towards advanced provision separates the diagnosis of pregnancy from the need to access abortion pills. Rather than representing a treatment relevant only to people who are pregnant, advanced provision materializes and normalizes the potential need for abortion care among the much larger group of people who may become pregnant. Although anti-abortion regulations purport to approach pregnancy as a discrete state that requires restrictions on medical freedom, they in fact function as a means of control over anyone who could potentially become pregnant.

Beyond advanced provision, mifepristone has the potential to shift the post-Roe paradigm more fundamentally. Several clinical trials suggest that this medication—at a smaller dosage—is effective at safely preventing pregnancy and can be used as a new, more flexible contraceptive. Unlike the familiar oral contraceptive (OC), mifepristone would require only one pill a week to prevent pregnancy. Moreover, it could be used as an on-demand drug, taken only in those weeks when sexual activity of the kind that could lead to a pregnancy is anticipated. Importantly, mifepristone does not have the estrogen-related side effects of other hormonal contraceptive options. For those with contraindication to the combined oral contraceptive pill—such as women who have or are at increased risk of breast or endometrial cancer, heart disease, hypertension, and deep vein thromboembolism—mifepristone could provide an alternative. As a generic drug, mifepristone is cheap to produce and would be an affordable contraceptive to individuals and health systems across the globe.

However, precisely because mifepristone is not patented and is cheap to manufacture, there has not been much interest in research investments from pharmaceutical companies. While early trials are promising and suggest this medication is indeed safe and effective, a larger trial is required to register mifepristone with the major drug agencies. Women on Web is currently preparing to undertake this research and has taken advice from the European Medicine Agency (EMA) to design a trial that would meet the requirements to register mifepristone as a contraceptive in Europe. All the necessary permissions and collaborators are in place; funding applications as well as crowdfunding are underway. If the required funding can be found and the study results are as favorable as in the smaller trials, the registration of mifepristone as a contraceptive could be a reality within several years.

Importantly, beyond providing a new contraceptive option, this use of mifepristone could usher in a more fundamental paradigmatic shift in reproductive freedom. Women could control their reproductive function both before and after sexual encounters using the same pill. When the management of fertility by women who do not wish to have (additional) children makes use of the same medication both before and after sex, mifepristone can reconfigure the way in which people conceptualize and approach their reproductive potential. When, as in the post-Roe moment in the United States, the criminalization of abortion puts women under increased scrutiny after a pregnancy test, the proposed use of mifepristone may destabilize the politicised distinction between pregnant and non-pregnant states. Because mifepristone enables a situation in which women could use the same pill whether or not they are pregnant, it presents a means of critically responding to the laws that rely on this distinction to control women’s reproductive agency.

The potential of mifepristone to place firmly in the hands of women the power to avoid or to end a pregnancy is especially powerful at a time of tightening restrictions, waning privacy, and intensifying surveillance. In the face of restrictive laws, structural reconfigurations of both the distribution and the conceptualization of the means of reproductive control are within reach. Our hands hold a more hopeful future for the generations to come.

Notes

[1] According to the Guttmacher Institute, 930,160 abortions were overseen by a clinician in the United States in 2020. These numbers reflect an estimation based on a census among all known US facilities providing abortion services, but do not account for self-managed abortions.