The long and winding history of the war on abortion drugs

Along with the stethoscope and camembert cheese, mifepristone may be one of France’s greatest inventions. It’s one of two drugs taken for medical abortions, along with misoprostol, and has been making headlines in the US, where a Texas judge issued a ruling to ban it nationwide. FRANCE 24 takes a look at the history of these two drugs.

Two separate rulings filed one after another in quick succession on April 7 had US abortion providers holding their breath. The first, issued by Trump-appointed federal judge Matthew Kacsmaryk, ordered a hold on mifepristone, one of two drugs taken for medical abortions. The second, issued by Obama-appointed federal judge Thomas O. Rice, came less than an hour later. His ruling ordered the exact opposite.

Kacsmaryk argued that the Food and Drug Administration had improperly approved the drug 23 years ago. But Rice briskly bit back, telling US authorities to hold off on any restrictions in at least 17 states.

The case was eventually taken to the US Supreme Court, who decided two weeks later to temporarily preserve access to mifepristone. In practice, this means the lower court rulings are effectively frozen and the case is now in the hands of an appeals court, where oral arguments have been scheduled for May 17. But the case will almost certainly end back in the Supreme Court.

Ever since the constitutional right to abortion was overturned in the US last June, international media coverage on the topic has spread like wildfire. But the latest threat to reproductive rights in the US has put two pills in the spotlight: mifepristone and misoprostol. Taken together, they are the most effective way of having a medical abortion. And while their histories are mired in controversy, they are often misunderstood.

Misoprostol, the underdog

Where it is legal, a medical abortion means taking a combination of two pills. Mifepristone is taken first. It’s a synthetic steroid that blocks progesterone, the hormone necessary for a pregnancy to develop. Then between 24 and 48 hours later, misoprostol, a prostaglandin that induces contractions, is taken to clear the uterus. “But ‘medical abortion’ gets used as a blanket term to cover two different methods,” explained Dr. Sydney Calkin, senior lecturer at Queen Mary University in London and author of “Abortion Pills Go Global”. In many places where mifepristone is not available, misoprostol is used on its own.

Misoprostol was developed in 1973 by US pharmaceutical company Searle. Under the name Cytotec, the pill was originally marketed as a treatment for gastrointestinal problems and ulcers. Up until the late 1980s, it had not been associated with abortions. But when misoprostol hit the Brazilian market in August 1986 and was approved for over-the-counter sale in pharmacies, everything changed.

Brazilian activists at the time read the “do not use if pregnant” warning on Cytotec bottles and decided to take a chance. Which worked. Off-label use of misoprostol was effective in causing an abortion. In a country where access to abortion had been illegal since 1890, with exceptions in case of rape or danger to a mother’s life added in 1940, misoprostol provided a way out. “That realization then spread informally across Latin America through informal activist networks that would share information and practices about how to safely use it,” said Calkin.

What began as an operation led by activists under the radar started making headlines. Researchers eventually caught on to the workaround and in 1991, after a German physician published an article warning of its “misuse” in Brazil, the drug was no longer available in the country without a prescription. Mifepristone, the other abortion pill, had also recently been approved for sale in France and China, and the recommended combination of taking both quickly came into use.

As misoprostol became more and more entangled with abortion, laws around the drug toughened. In 1998, Brazilian health authority Anvisa put misoprostol (and opiates) on a list of controlled drugs, meaning anyone caught importing or buying the pill could face up to 15 years in prison. Its use in Brazil is now restricted to registered hospitals for narrowly prescribed uses.

“Misoprostol’s patent holder has always been very resistant to its association with abortion,” explained Calkin, “so it has resisted licensing the drug for any kind of reproductive uses".

Mifepristone, the 'pill of Cain'

“Mifepristone has always been understood as an abortion drug, first and foremost,” Dr. Calkin explained. Its inventor, endocrinologist and biochemist Étienne-Émile Baulieu, said so himself. In a recent interview with the New York Times, the 96-year-old described being haunted by memories of his medical residency, which he completed before France passed its abortion bill in 1975. He recalled how women were admitted to the hospital he worked in after terminating pregnancies with sticks, and how surgeons would instruct their employees not to administer anesthesia “to teach them a lesson”. So he began brainstorming the idea for an “unpregnancy pill” and convinced pharmaceutical company Roussel-Uclaf, for which he was consulting at the time, to let him develop a progesterone blocker.

Baulieu first synthesized mifepristone in 1980 under the name “RU-468”, “RU” referring to Roussel-Uclaf and “468” to the sequencing number of the molecule. But the rollout of the pill, from its first medical trials to its market approval, was a hard-fought battle. “There was a trans-national effort by anti-abortion activists from France and the US … to stop its market introduction,” said Dr. Claudia Roesch, a research fellow at the German Historical Institute Washington who studied the backlash around mifepristone. Anti-abortion protesters blocked the entrances of French embassies in the US, as well as company headquarters in the US, France and Germany.

“Protesters would even compare medical abortion to the Holocaust,” Roesch said. Roussel-Uclaf’s main stakeholder was German company Hoechst AG, which had been part of IG Farben during World War II, the company that produced the cyanide gas used by Nazis in concentration camps. “They sent gruesome images to their headquarters in Germany and the US,” she said.

Mifepristone was eventually approved for use by French health authorities in September 1988. But opposition was so intense that less than a month later, Roussel-Uclaf said it would pull the pill from the market. Luckily the French government held a stake in the company, so the then French health minister Claude Évin pressured the company to resume selling it. ''From the moment government approval for the drug was granted, RU 486 became the moral property of women, not just the property of the drug company,” he said in a televised address.

China approved mifepristone the same year that France did, in 1988, “for very different reasons", said Dr. Sydney Calkin. It was approved in the UK in 1991, Sweden in 1992 and in the US in 2000. Countries with access to abortion like Australia and Canada only approved the drug much later, in 2012 and 2014 respectively. “The kind of controversy around abortion politics in those countries means there was a lot of delay,” Calkin explained.

Even after it was approved, Baulieu’s revolutionary pill was, and continues to be, a hot topic. The Vatican went as far as denouncing RU-468 in the 1990s as “the pill of Cain: the monster that cynically kills its brothers", according to a Boston Globe article from 1997. And as recently as March 2022, Republican lawmaker Danny Bentley falsely claimed the pill was developed in WWII under the name Zyklon B, the name of the gas used to kill Jewish people during the Holocaust. This is a sign of how long-lasting and effective the anti-abortion tactics used in the 80s were.

The war on abortion drugs

In Latin American countries, the misoprostol-only regimen is still widely used. “It’s much easier to get than mifepristone,” Calkin explained.

“It’s a lifeline for many people. But the risks vary from country to country. In El Salvador for example, abortion can land you anywhere from two to 50 years in prison. Women who have miscarried have ended up incarcerated because authorities suspect they performed an abortion. In Uruguay, on the other hand, if someone has taken misoprostol and suffers complications as a result, they won’t face penalties. “Doctors will help you manage the consequences of your abortion,” Calkin said.

Thanks to generic versions of both pills that are mass-manufactured in India and China, and the fact that they are also readily available in Mexico, activist networks like Aid Access and Women on Waves have ways of providing people living in restricted areas with medical abortions. The Covid-19 pandemic has also paved the way for telemedicine to become more common, meaning pills can be sent by mail.

But the war on abortion drugs is still rampant. Although a nationwide ban of mifepristone in the US has been ruled out for the moment, the state of Wyoming has outlawed the use of abortion pills, a law that will come into effect on July 1, 2023.

As for France, 76% of all abortions are medical, whether carried out in clinics or at home. And while Macron promised to enshrine abortion rights into the constitution “in the coming months” on International Women’s Day, he may find that it will be more challenging than he thought.