What happens when every patient is a suspect

Restrictions on abortions in Texas are interfering with the ability of women to get essential treatment for miscarriages. 

SB4, a Texas law passed last year, restricts “drug-induced abortion procedures, providers, and facilities.” The law lists “several medications as abortion-inducing drugs and largely bars their use for abortion after the seventh week of pregnancy.” But two of the banned drugs, misoprostol and mifepristone, “are the only drugs recommended in the American College of Obstetricians and Gynecologists guidelines for treating a patient after an early pregnancy loss.”

The law specifies that it does not ban misoprostol and mifepristone when the drugs are "prescribed, dispensed, or administered" for other medical reasons. According to NPR, however, some pharmacies are refusing to fill misoprostol and mifepristone prescriptions for miscarriages, arguing that they can’t be certain that patients aren’t going to use the drugs for “the purposes of abortion.” 

Earlier this month, a Texas resident allegedly could not pick up her prescription for misoprostol while experiencing a miscarriage, despite being prescribed the drug by a doctor who “spen[t] 30 minutes explaining to a Walgreens pharmacist that she wasn’t having an abortion.” 

The woman was ultimately told by the pharmacist that they had “talked to colleagues and the corporate office, and have decided not to fill it” since they could not prove that she “isn’t using it for an abortion.” The woman's doctor reportedly chose to not send the prescription to CVS as it “likely wouldn’t get filled.” The woman was eventually able to get the prescription filled at another pharmacy. 

Popular Information contacted Walgreens to ask if the company was aware of the most recent incident and if it has issued any internal guidance for pharmacists regarding misoprostol and mifepristone in states with abortion bans. The company did not respond. 

Some of the issues could be traced to another abortion law passed in Texas last year, SB8, that bans abortions after six weeks — before many women know they are pregnant. SB8 specifies that private citizens can sue anyone who “aids or abets” an abortion in Texas after six weeks. The fear of litigation could discourage pharmacists from filling prescriptions for these drugs.

Denying women experiencing miscarriages the right to proper treatment can be dangerous. According to Mayo Clinic, around “10 to 20 percent of known pregnancies end in miscarriage.” While not all miscarriages require medication or additional care, some require treatment "to stop bleeding and make sure no pregnancy tissue remains, as a guard against infection.” 

The other option for a miscarriage treatment is a “surgical uterine evacuation to remove the pregnancy tissue.” But this procedure is the “same approach as for an abortion” and could potentially face similar obstacles, making it even more difficult for women to safely recover from miscarriages. 

Women in Texas have reportedly also been having difficulty obtaining the proper medications to treat ectopic pregnancies, which occurs when a “fertilized egg embeds in a fallopian tube or somewhere other than the uterus.” Ectopic pregnancies can result in severe bleeding or even death of the mother. The drug used to treat ectopic pregnancies, methotrexate, is also listed as a banned drug in SB4. 

The Supreme Court is expected to issue an opinion on Dobbs v. Jackson Women’s Health Organization in the coming weeks, a decision that will likely overturn Roe v. Wade and Planned Parenthood v. Casey, eliminating the constitutional right to abortion. Twenty-two states already have abortion bans on the books that will immediately be imposed when the Supreme Court overturns Roe. With more abortion bans in place across the country, restrictions on medical care for miscarriages, including prescription drugs, could become even more common.

Pharmacies reportedly withhold life-saving prescriptions, stay mum on corporate policies

Vaguely written abortion bans coupled with a lack of guidance from management appears to be  deterring some pharmacists from filling out life-saving prescriptions. As one Austin-based OB-GYN and fertility doctor recently told Slate “that pharmacists in her area ‘do not want to fill’ prescriptions for misoprostol.”

Another Texas provider told Kaiser Health News this month that they no longer send misoprostol prescriptions to the local Walmart after the pharmacy “a handful of times declined to provide the medication, citing the new law" even though the prescription specified it was for a miscarriage. Walmart “did not respond to multiple requests for comment,” the piece notes. 

A professor at University of Texas College of Pharmacy told Slate that pharmacists at H-E-B, a grocery store chain in Texas, are worried “they might be held liable for dispensing the medication if it were used for an illicit abortion.” For prescriptions sent without a diagnosis code, these pharmacists are calling doctors to document the diagnosis “both for insurance purposes and as a kind of protection against possible lawsuits.” Similarly, at CVS, pharmacy employees are reportedly required “​​to speak directly to the prescriber on the phone before filling a misoprostol prescription.” But this extra step “can obstruct timely care for a patient going through a miscarriage.” 

Blake Rocap, an Austin-based lawyer who specializes in reproductive rights, told Popular Information that pharmacists should not be deciding if medication prescribed by a medical professional complies with regulation. According to Rocap, pharmacists who turn down prescription requests are second-guessing the intent of the physician and assuming unlawful conduct. 

Rocap also added that corporations have a responsibility to read the law and provide proper guidance to employees to avoid confusion, and prevent situations where pharmacy employees end up “playing lawyer.”

“If corporations are going to continue to support anti-abortion politicans and invite this healthcare regulation and refuse to speak out against it, they need to do a better job of making sure a patient is not denied care that was prescribed by a doctor,” Rocap told Popular Information. “They’re not the gate-keepers of healthcare.”

Popular Information contacted CVS, Walmart, Rite Aid, Kroger, Albertsons, Publix, McKesson, and Costco and asked how they were advising pharmacists to dispense mifepristone and misoprostol in states like Texas. None of the companies responded. 

U.S. consumers seek abortion pills from overseas

With new abortion bans restricting access to abortion pills, women have been turning to the internet to obtain medications such as misoprostol and mifepristone from international telehealth services.

Among them is Aid Access, “a telehealth service with headquarters in Austria” that was founded in 2018. Aid Access provides women in the United States access to abortion pils by “work[ing] with doctors in Europe who prescribe the pills for patients via a mail-order pharmacy in India.”

According to Reuters, the “number of women requesting prescriptions for abortion pills, or information about their use” through Aid Access’ website “tripled” after Politico leaked the draft opinion to overturn Roe. On the day after the opinion was published, “the Aid Access website had 38,530 visitors,” which is nearly a “2,900% increase” from the day before. 

While this practice is not legal, U.S. authorities “have acknowledged that they have no effective way of policing orders from foreign doctors and pharmacies.” In 2019, the FDA issued Aid Access a “warning letter” that “ordered it to cease mailing pills from abroad.” The FDA argued that the “specific brand of mifepristone and misoprostol being sent to Aid Access patients has not been FDA approved.” 

In 2019, Dr. Rebecca Gomperts, the founder of Aid Access, told NBC News that she “would not comply with the FDA warning.” Gomperts said, “I will not cease to help women that need my help.” Gomperts’ lawyer argued in a letter to the FDA that “because abortion is restricted in the U.S., ‘women have been forced to attempt to exercise their right to a medical abortion by way of the internet.’”