Since the Dobbs decisions, there has been a significant increase in the number of medication abortions. In 2019, only 45% of abortions were initiated using medication compared to 63% of abortions in 2023. This increase is largely due to a 2023 REMS policy change that removed the in-person dispensing requirement of mifepristone, allowing mifepristone to be dispensed through the mail. One outstanding question was whether this increasing proportionality of medication abortions represented a change in the practice patterns of those already providing abortion, and if this represented a new group of abortion providers expanding their scope of practice. A new study attempts to answer these questions by investigating the volume of mifepristone prescriptions, where patients received their prescriptions from, and the different types of prescribing providers.
Researchers analyzed insurance data from a multi-source database (IQVIA). They used ICD-10 diagnosis codes to distinguish between prescriptions for early pregnancy loss and termination of pregnancy (since the treatments are the same). They used the National Provider Identifier (NPI) to determine the type of provider prescribing the medication. The findings were stark–they showed that from 2022 to 2023 while there was actually an increase in in-person dispensing of mifepristone, this increase paled in comparison to the increase in mailed prescriptions during that same time period.
The researchers also found a change in the composition of medication abortion prescribers. Between 2022 and 2023, while the number of OBGYNs prescribing medication abortion went up, the total number of prescriptions from OBYNS actually decreased. Family medicine providers, nurse practitioners, and physician assistants each wrote significantly more prescriptions in 2023 than in 2022, such that the overall proportion of OBGYNs responsible for medication abortions in 2023 was less than that in 2022.
This data tells us several important things about medication abortion access in the post-Dobbs world. First, it is not just OBGYNs that are prescribing mifepristone. As we continue to explore implementation of medication abortion from primary care practices, urgent care centers, and emergency departments this is important information, showing that communities losing local OBGYNs, do not have to lose access to abortion as well.
This study also identifies a gap in access. The same policy provision allowing mifepristone to be dispensed by mail also allowed it to be dispensed by certified retail pharmacies (ex: CVS or Walgreens). Despite this provision, less than 1% of total prescriptions from 2022 and 2023 were dispensed at a retail pharmacy. This is likely due to barriers with stocking mifepristone, insurance, or even pharmacist discomfort among community and retail pharmacies. This is an important gap and worth further investment if retail pharmacies are to become a reliable dispensing point of mifepristone.
The findings in this paper suggest that medication abortion access in a post-Dobbs world is expanding and becoming less dependent on any single-provider type or dispensing pathway. As access to mifepristone remains concentrated in states that have not made abortion illegal, it is important that patients have as many opportunities to receive the medication as possible. This paper supports making investments in training and supporting APPs, primary care providers, urgent care clinicians, and the emergency medicine workforce to prescribe and dispense medication abortion to fill this gap.
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