In August 1986, a stomach ulcer medication called Cytotec arrived on pharmacy shelves across Brazil. It came in a small box, and on the label, printed clearly, was a warning: do not take it if you are pregnant because it can cause miscarriage.

Abortion had been illegal in Brazil since 1890, so women who needed one faced a brutal menu of options that were dangerous, expensive, and often deadly. In fact, unsafe abortions were one of the leading causes of maternal death in the country.

But then, in a five-year span, Brazil’s maternal mortality rates fell 21%. It turned out that Brazilians in need of an abortion read the “do not use if pregnant” warning on Cytotec bottles and quickly realized that it worked as an abortion option. Word moved through whisper networks from neighborhoods in Recife to pharmacies in São Paulo, and Brazilian pharmacists started to recommend the product for safely terminating pregnancies as a workaround around the criminalization of abortion.

Brazilian doctors started calling the Cytotec medication “Saint-otec” because far fewer women were dying from abortion complications thanks to this ulcer pill.

That was nearly forty years ago.

Today, American courts threaten access to abortions in the U.S. with the restriction of mifepristone, an abortion pill used in ~65% of U.S. abortions, which dominates every headline.

The legal, medical, and public health implications are enormous.

But regardless of what happens in courts, American women have access to the same lesser-known option that changed everything in Brazil. Most don’t know it exists.

The other option: Misoprostol only

If you’ve been following the news about medication abortions, you’ve probably been picturing one pill. But for a medication abortion in the U.S., patients are given two: mifepristone (”mife”) followed by misoprostol (”miso”).

The legal cases have focused entirely on mife, because it was specifically approved by the FDA in 2000 for abortion.

Miso’s FDA approval, by contrast, still officially says “stomach ulcers.” This is the same ulcer drug Brazilian women figured out forty years ago. It has simply been used off-label for abortion, labor induction, postpartum hemorrhage prevention, and more ever since.

Why isn’t miso only routinely used in the U.S.?

Clinical consensus holds that the combined regimen (mife+miso) is slightly more effective at ending a pregnancy than miso alone.

This is primarily based on pooled data from a wide range of studies that included various ways people can use the medication, i.e., different dosages, routes of administration, and dose intervals.

But when scientists review studies on the currently endorsed miso-only regimen (3+ doses of 800 ug miso taken every 3 hours), miso-only may be more effective than commonly thought.

A 2024 analysis looked across eight study groups that examined 3+ doses of miso only: ~90% had a complete abortion (compared to ~95% expected for the combined mife+miso regimen).

Miso only for abortion is also safe: only 0.7% of ~12,000 users from a 2019 meta-analysis had a blood transfusion or were hospitalized for abortion-related reasons.

Some people worry that using miso only may be a more physically uncomfortable way to terminate a pregnancy than mife+miso due to the gastrointestinal effects of miso, but the comparative research on this is weak. A Cochrane Review concluded no difference in side effects, except maybe more diarrhea with miso-only.

More research is needed, and some is already underway. Researchers are leading a randomized controlled trial in the U.S. to collect MUCH more detailed data on the side effects of the miso-only regimen compared with the mife+miso regimen, so that patients and providers alike know what to expect.

Restricting mife is still unconscionable

The medical evidence is overwhelmingly clear: use of these pills is medically safe—safer than other medications we routinely use, and certainly safer than childbirth.

The National Academies of Sciences, Engineering and Medicine even released a comprehensive report emphasizing the safety of abortion care, including medication abortion.

These medications are also highly effective for ending pregnancies and result in a complete abortion in nearly all cases. In fact, in March 2022, the WHO strengthened its guidelines on medication abortion, taking into account evidence over the past decade on self-managed medication abortion as a safe and effective model of abortion care (not “just” as a last resort).

What this means for you

As this plays out in court in a loud, confusing, and exhausting way, one of the quietest forms of harm in reproductive health care is when people don’t know all their options, and the choice gets made for them.

Abortion is one of the more common health experiences we have, so having information for yourself or your loved ones is imperative.

1. Spread the word: medication abortion access has not ended. Regardless of what happens with mife in the courts, all of us deserve accurate information, compassionate care, and the ability to make decisions about our own bodies.
2. Trusted sources for finding care include INeedAnA.com or AbuzzHealth.
3. If you need legal advice, call If/When/How’s free Repro Helpline: 844-868-2812.
4. If you’re going through this alone, you don’t have to. Call the Miscarriage and Abortion Hotline. They’re here for you: 833-246-2632.

No matter what happens with this current case on mife, patients will continue to need abortion pills, and dedicated clinicians and advocates will still have a solid option to provide them.

Bottom line

Restricting access to mife is epidemiologically baseless given 26 years of robust safety and effectiveness data.

Yet, even if Americans ultimately end up with constrained choice, not all medication abortion is off the table.

People will still have access to a safe and effective method of medication abortion care: miso only.

Let’s hope it doesn’t come to this, but whisper networks still work, just ask Brazil. Pass it on.

Love, YLE and HM

Heidi Moseson, PhD, is a reproductive epidemiologist and scientist at Ibis Reproductive Health. She studies abortion access in the U.S. with a particular focus on self-managed abortion with medications.

Your Local Epidemiologist (YLE) is founded and operated by Dr. Katelyn Jetelina, MPH PhD—an epidemiologist, wife. YLE reaches over 425,000 people in over 132 countries with one goal: “Translate” ever-evolving public health science so that people are well-equipped to make evidence-based decisions. This newsletter is free to everyone, thanks to the generous support of fellow YLE community members. To support the effort, subscribe or upgrade below: