Access to Abortion Medications: Why Should Nurses Care?

She sat in my office, tissue in hand, tears rolling down her cheeks as she tried to process the news I’d just confirmed: she was pregnant, and really, really needed to not be. She was living in her brother’s small house, her seven-year-old son with her, sleeping on a sofa while trying to put her life back together after a divorce. She had chronic kidney disease, and had been told that another pregnancy could cause kidney failure.

She didn’t really believe abortion was a good thing to do, but also couldn’t imagine that God would want her to go on dialysis. For the most part I listened, asking a question here and there to help her clarify her own thoughts. Ultimately, she decided on an abortion, so I referred her to the closest clinic, several hours away from the rural town we met in.

Medication Abortion in the United States

Even before the Dobbs decision overturning Roe v. Wade, abortion was difficult to access for people living in many regions of the country. TRAP (targeted regulation of abortion providers) laws forced many clinics to close, making abortion access challenging if not impossible even though every American was legally, constitutionally permitted to make her own decision.

Last year, as the Dobbs ruling eradicated that right, medication abortion with mifepristone and misoprostol had just surpassed procedures as the most common method for first-trimester abortion. The medication combination was already well-established as a safe and effective protocol—so safe that the World Health Organization (WHO) guidelines recommended it for self-managed abortions, since the risks of incomplete abortion, hemorrhage, or infection are very low. Self-managed abortion allows use of medications in the privacy of the home, inducing miscarriage.  These drugs are also used to manage early pregnancy loss, making mifepristone a critical drug for patient care that helps people avoid unnecessary procedures.

Medication Abortion and the Rights and Duties of the Nurse

Despite its two-plus decades of safety data, the status of mifepristone is uncertain as we await the imminent decision of a judge who was strategically chosen in a case brought by plaintiffs who believe abortion is morally wrong. Of course, some nurses agree, and do not want to be involved in abortion-related care. Conscience clauses provide legal protections to nurses who wish to opt out of non-emergency situations.

Ironically, many nurses are now legally compelled to deny evidence-based care that the patient desires and the nurse may believe is ethically required to provide based on the ANA Code of Ethics. The Code supports patients’ rights to self-determination in health care based on the patient’s values and beliefs and compels the nurse to uphold patient autonomy even if the nurse disagrees. Many U.S. states now deny their citizens a legal avenue to access safe abortion care, and deny nurses the right to provide it. When activist judges, governors, and state legislatures keep evidence-based care from patients for ideological reasons, everyone loses.

Accessing Medication Abortion

So, what can nurses do if mifepristone becomes harder to obtain? There are several options to consider. First, protocols have been published using misoprostol alone for medical abortion. The WHO has found the regimen to be acceptable in terms of safety and efficacy both for clinician-supported and self-managed abortion.

Nurses may be prevented from directly assisting in mifepristone provision if the United States Food and Drug Administration (FDA) decides its hands are tied by an adverse ruling and removes approval of the medication. However, nurses retain the right of free speech under the First Amendment and may decide to refer their clients to a reliable website to obtain mifepristone and misoprostol by mail for self-managed abortion or telehealth abortions.

Some people may seek advance provision of abortion medications prior to pregnancy so that they will be immediately available to them in case of need. The medications have a shelf-life of about two years and are easily accessible online; however, state laws are evolving rapidly and the legality of this option may change over time in many states. If/When/How offers a legal help line for reproductive health to answer questions with up-to-date information, state by state. Buying clubs like those already established in Mexico may allow for extralegal access outside the formal health care system. Currently, patients may access in-person medication abortion by traveling to states where it is legally provided, and nurses may refer patients who need to travel to abortion funds to help cover costs.

Implications for the Future of Nursing

Regardless of our personal views on the ethics of abortion, nurses should be wary of political interference in evidence-based patient care. It is unacceptable that clinicians, including nurses, could face loss of license or criminal penalties for providing care that meets long-established professional standards and guidelines. This year, many state legislatures are actively restricting the rights of people to make decisions about their pregnancies (and about other areas such as gender identity), and have enacted laws in direct opposition to science and evidence. If this trend continues, nurses may experience new barriers to providing care that has been part of our profession for decades, including contraception, an essential element of health care that reduces the need for abortion.

Whatever our personal beliefs may be, we need to keep our eyes on the big picture. We must follow our ethics. We must work to ensure that patients receive evidence-based care, while honoring our core principle of patient autonomy. Nursing ethics demand that care is based on scientific evidence, paired with the values and religious beliefs of the person receiving the care, not those of their care provider or state legislature. When we encounter barriers, nurses must find ways to continue to provide ethical patient care. This will take creativity and resilience. We must stay true to what drew us to nursing in the first place: meeting patients where they are and helping people reach their health and life goals.          

Laura Manns-James, PhD, CNM, WHNP-BC, CNE, FACNM, is an associate professor in the Department of Midwifery and Women’s Health, Frontier Nursing University, Versailles, KY.