The Pill That Makes Abortion Federal

I f you think abortion is no longer a federal issue, think again.

Thanks to intrepid work by researchers and analysts from great pro-life think tanks, the evidence is stacking up against mifepristone and in favor of a massive overhaul of the FDA’s regulations on the abortion pill. Despite those rising safety concerns, however, mifepristone continues to be shipped across state lines into states that ban abortion, which undercuts states’ ability to regulate the practice.

If President Trump truly wants to extricate the federal government from the abortion wars and empower states, his administration or Congress must take steps to restrict the abortion pill, the drug that transforms abortion from a state question into a federal question.

Reams of evidence are coming out demonstrating that the abortion pill is far less safe than the FDA has known or reported. The Ethics and Public Policy Center performed an exhaustive review of insurance claims from over 860,000 women who had mifepristone abortions from 2017–2023. It found that nearly 11 percent of them suffered a serious adverse reaction. The FDA-approved labeling on the abortion pill, based on older studies reviewing smaller samples of women under prior, stricter safety standards, only admits to a .5 percent rate of serious complications.

Not only is the abortion pill more dangerous than previously thought, but there is also evidence of systematic under-reporting of mifepristone complications. Another study from the Charlotte Lozier Institute concluded that 83 percent of mifepristone-related emergency room complications are miscoded as miscarriage complications.

This naturally follows from how Planned Parenthood and other abortion providers not-so-subtly encourage women experiencing complications not to disclose mifepristone usage to emergency room staff. This is despite the fact that no abortion-restricting state penalizes emergency room care for women who have had an abortion.

New research has also exploded one of the most commonly repeated and untrue slogans surrounding the abortion pill: that it is “as safe as taking Tylenol,” or other common medications like ibuprofen, aspirin, penicillin, or sildenafil (Viagra). Another Charlotte Lozier Institute study shows that these are apples-to-oranges comparisons focusing only on deaths or death rates. There are no rigorous head-to-head studies comparing mifepristone with these drugs, as would ordinarily be expected for ethical comparative claims of pharmaceutical risks. Further, boiling “safety” down to “deaths” is reductive, ignoring other legitimate, serious risks and ignoring how infections and other adverse events from mifepristone can be difficult to detect. The pro-abortion side has “use[d] death counts or death rates from different studies, at different times, and in vastly different populations” chiefly to make political and public relations arguments for mifepristone.  

Mifepristone is the chief driver of abortion in America today. Its deregulation under President Biden led abortions to increase from 900,000 to 1 million per year. We cannot meaningfully restrict abortion unless we restrict the abortion pill by at least restoring its pre-Obama FDA safeguards (requiring three in-person clinic visits instead of a mere telemedicine appointment, restricting its use to the first seven weeks instead of the first ten weeks of pregnancy, requiring in-clinic administration only), if not outright banning it. The emerging safety information only increases that urgency.

But the other area where these new safety concerns increase the urgency for action is in mifepristone’s illegal interstate transport. President Trump has repeatedly stated his support for abortion being regulated at the state level, which the Dobbs decision clearly permits. However, if the federal government does not restrict interstate shipping of the abortion pill, states will be powerless to regulate abortion, which will then remain a federal problem.

According to The Economist, the portability of the abortion pill along with abortion “shield” laws allow providers in abortion-legal blue states to ship abortion pills into abortion-restricting red states with no repercussions. Shield laws basically state that (e.g.) California will not cooperate with (e.g.) Texas authorities attempting to bring criminal or civil actions against California persons or corporations for any violations of Texas law restricting abortion.

Women in Texas can get the abortion pill illegally shipped to them, and Texas (which penalizes providers, not mothers, for abortion) is powerless to stop it. The federal government could restrict interstate and international transport of abortifacients via the Comstock Act, an on-the-books law signed by Ulysses Grant that outlaws interstate shipment of abortifacients. Trump has chosen not to do so.

As The Economist concluded, the combination of these factors has resulted in abortion numbers staying largely flat in abortion-restrictive states. Illegal abortions via mail-order mifepristone have made up for the drop in legal abortions.

Aid Access is one of the leading entities that ships abortion pills into abortion-restricting states. Like Planned Parenthood and ineedana.com, it also encourages women facing mifepristone complications not to admit that they had an abortion. It presents state-specific webpages giving instructions for how to get abortion pills mailed conveniently to a woman’s house within five days, even in abortion-restricting states like Alabama. States can do nothing to stop doctors and organizations based in blue states or overseas so long as mifepristone is unregulated (giving cover against malpractice claims), the Comstock Act remains unenforced, and the legal dispute between states over shield laws remains unresolved.

FDA Commissioner Marty Makary has committed to a thorough review of mifepristone, which is urgently necessary. Hundreds of thousands of women are taking a drug that is far more dangerous than previously disclosed, are doing so away from in-person physician oversight, and are getting it from shady suppliers who encourage them to mislead health-care providers in the event of complications. But it is up to President Trump, ultimately, to take the necessary actions to empower states to regulate abortion meaningfully. If he does not, abortion numbers will continue to grow, regardless of how many states ban it.