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What is mifepristone and why is it under fire?

Orange boxes of mifepristone lie on a wooden surface.
Robin Marty
The Republican-controlled Missouri legislature banned abortions in the state in 2022. But the outcome of a U.S. Supreme Court case could affect the availability of the abortion drug mifepristone in the Metro East, where patients throughout the St. Louis region and the Midwest are traveling to obtain abortions.

Updated at 5:30 p.m. April 14

Access to mifepristone, a pill commonly used in medication-assisted abortions in the United States, has been restricted nationwide asdueling federal court decisionsfrom two states play out on the national stage.

The Republican-controlled Missouri legislature banned abortions in the state in 2022. But theoutcome of the cases could affect the availability of the drug in the Metro East, where patients throughout the St. Louis region and the Midwest are traveling to get the abortions.

The U.S. Supreme Court could resolve the cases soon. The Biden administration on Friday filed an emergency application to the high court asking justices to pause parts of an appeals court ruling that limited availability of the pill, which also is used to treat miscarriages. Late Friday afternoon, Justice Samuel Alito put a hold on an order by a federal court in Texas that led to the appeals court ruling. That means mifepristone remains accessible at least until late Wednesday. 

Mifepristone is a pill that often is used in tandem with another pill, misoprostol, to end early-stage abortions. The federal Food and Drug Administration has approved the use of the pill to end pregnancies that are up to 10 weeks gestation.

A medication abortion usually occurs earlier in pregnancies than a procedural (or surgical) abortion, a more intensive inpatient procedure. More than half of abortions in the United States are medication abortions, according to the Guttmacher Institute, a research organization that supports abortion rights.

The federal judge in Texas last week reversed the FDA’s 2000 approval of the mifepristone, siding with anti-abortion plaintiffs who claimed the agency approved the drug too quickly.

An appeals court’s review of the Texas decision maintained some access to mifepristone while the case played out but placed limits on its use. Those limits included prohibiting using it after seven weeks of pregnancy and banning it from being sent through the mail.

However, Illinois Attorney General Kwame Raoul said a decision issued last week from another federal court in Washington preserves existing access to mifepristone in Illinois.

Is mifepristone still an option for patients in Missouri and Illinois?

Mifepristone is still available to some patients seeking abortions, but how accessible it is depends on where you live.

Missouri lawmakers outlawed abortion after the Supreme Court overturned Roe v. Wade in 2022. Because abortion is illegal in Missouri, the Texas ruling does not immediately affect residents in the state.

In Illinois, abortion is still legal, and state officials there have passed laws and brought court cases to preserve access to the procedure, including availability of mifepristone.

Earlier this year, Raoul and officials from 17 other states filed a lawsuit in Washington state seeking to preserve access to mifepristone. The federal judge in the Washington case ruled in their favor. That same day, a Texas judge ruled in the mifepristone case there.

Raoul said Thursday the rulings in the Texas case do not apply to providers in Illinois because of the Washington ruling.

“Regardless of recent orders from federal courts in Texas, the order out of Washington supersedes, and mifepristone will continue to be available in the 18 states participating in the pending litigation,” the Attorney General said in a statement. “Because my office did not hesitate to join the federal lawsuit in Washington, mifepristone is available in Illinois and will continue to be available in Illinois without the restrictions Texas courts have attempted to reinstate.”

Alito’s Friday decision temporarily restores access to the drug nationwide in states where abortion is still legal. It applies to states governed by either of the competing rulings.

What do the court decisions mean for abortion providers in the St. Louis region?

In the Metro East, which has become a destination for abortion seekers in the Midwest, clinics have spent the last week trying to make sense of the rulings.

“We are kind of all waiting on pins and needles, making sure that we don't miss any important information that comes down and to make sure that we are staying in full compliance,” said Michele Landeau, the chief operating officer at the Hope Clinic in Granite City, one of the two abortion providers in the St. Louis region. “But while we are also at the same time trying to offer our patients the highest quality, compassionate and medically accurate care that we can, it's been challenging.”

Landeau said the clinic has multiple contingency plans in place but declined to go into specifics about them.

Planned Parenthood’s clinic in Fairview Heights is continuing to offer mifepristone to its patients, said Dr. Colleen McNicholas, chief medical officer at the Planned Parenthood of the St. Louis Region and Southwest Missouri.

McNicholas said the providers have confidence the Washington decision protects their ability to dispense the medication. Additionally, she said, Illinois has been historically supportive of abortion rights, and the state allows medical providers to use medicine in an off-label manner based on scientific literature.

“So the combination of those three things really makes us feel safe and secure that we can legally continue to provide mifepristone and misoprostol to eleven weeks in pregnancy, in the way that we have been providing it for years now,” McNicholas said.

What’s could happen in the next few weeks?

The Supreme Court’s decision on the Texas appeal could restore access to mifepristone. It also could rescind the drug’s FDA approval and keep it from being used.

Dr. Michael Sinha, a doctor and law professor who specializes in health law at St. Louis University, on Friday said the Supreme Court will likely issue a ruling on the Texas judge’s decision before the stay expires Wednesday. That ruling will apply to all states, he said. 

“[We] have no clue what SCOTUS will decide at this point, but it will override both Texas and Washington,” he said.

“SCOTUS has been defying historical norms lately so it’s hard to predict what’s going to happen,” he said.

A Planned Parenthood spokeswoman said the organization's lawyers do not think the decision would immediately apply to Illinois and other states that were involved in the Washington state lawsuit. 

Mifepristone isn’t the only drug that can be used for a medication abortion. Misoprostol, the other prescription in the common two-part regimen, can be used on its own, doctors said. However, misoprostol abortions require more pills and could cause more side effects, they said.

Any restrictions on medication abortions ultimately make access more difficult in parts of the state where the procedure remains legal, McNicholas said.

“Much like we have seen since the Dobbs decision, this will push people to later parts in pregnancy, as the wait times at clinics — for example, in Illinois — get longer and longer,” she said. “And so we will have some unintended consequences again, of pushing people to later in pregnancy not being able to access medication abortion at all.”

Sarah Fentem is the health reporter at St. Louis Public Radio.