Washington pharmacists who prescribed abortion pill didn’t follow usual no-test protocol

Last year, Washington state announced a pilot program allowing pharmacists to prescribe abortion pills, without women seeing a doctor first. This week, nearly a year later, the results of the pilot program — which prescribed abortion pills to 43 women — were released.

According to NPR, the program was committed in conjunction with Uplift International, a pro-abortion health care group, which partnered with Honeybee Health, a mail-order abortion pill company. Initially, Washington pharmacists said they lacked “sufficient knowledge of medication abortion, which is not covered by pharmacy school curricula,” but the program went forward anyway.

The Pharmacist Abortion Access Project reported that the program was conducted between October 31 and November 26, with 10 pharmacists across Washington, who prescribed abortion pills to 43 patients. Women were eligible if they were 18, could provide a Washington state mailing address (with no requirement to prove actual residency), and were up to 10 weeks pregnant. They paid a mere $40 for the pills, and completed online forms giving information about their pregnancies and medical histories. They then received the pills from Honeybee Health.

Program put more safeguards in place than most women receive

Interestingly, women who participated in the pilot program received more care than they do from most certified abortion pill prescribers. As the New York Times explained (emphasis added):

Don Downing, a co-director of the project and a professor emeritus of pharmacy at the University of Washington, said that in addition to providing a hotline for questions or concerns, pharmacists had contacted patients to see how they were doing, asking questions like: “Have you had excessive bleeding or no bleeding? Do you have fever, pain, whatever?”

He said that during the follow-up, patients had asked typical questions, like whether they were experiencing appropriate levels of bleeding from passing the pregnancy tissue. “We did not have any seriously negative outcomes at all, but we had a full network of other resources available in case that happened, so that we could take care of them,” he said.

Jessica Nouhavandi, a pharmacist and president of Honeybee Health, as well as co-director of the pilot program, even specifically said they were more thorough than the typical protocol for dispensing abortion pills. “We went a little deeper about medical history,” she said. “We wanted our pharmacists to feel more comfortable.”

Uplift International CEO Dr. Beth Rivin told The Washington Standard that the training protocol was created “with Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington” and “has a list of clinics where patients can be referred if any in-person follow-up care is necessary, including ultrasounds, blood tests or other exams” (emphasis added).

“If (patients) had questions, the platform allowed for messaging between the pharmacist and the individual, and patients were followed up with at one week and four to five weeks after prescriptions were written,” Rivin said.

What the pharmacists in this program did for these 43 women went far beyond anything that women obtaining pills online or from brick-and-mortar facilities would typically receive. When women undergo abortions, they rarely receive follow-up care, particularly not if they undergo the dangerous no-test protocol.

Instead, other women who obtain the abortion pill typically receive no referrals; they visit ERs or urgent care facilities if they experience complications.

Risks of the abortion pill

The abortion industry has been promoting the no-test protocol for chemical abortions for years, despite the risks.

Peer-reviewed studies have found risks of side effects after chemical abortions, including hemorrhage, sepsis, and death. The abortion pill regimen has been found to be four times more dangerous than first-trimester surgical abortions, and the FDA’s 2023 mifepristone label states that 2.9 to 4.6% of women who take it report to the emergency room for complications. Another study further confirmed that 6% of women who participated had abortion pill complications severe enough to visit either an urgent care center or a hospital emergency room. Another study found that women are not properly prepared for the amount of pain they experience during chemical abortions.

Without a pre-abortion ultrasound, prescribers may not be able to rule out contraindications like ectopic pregnancy (which is life-threatening if left untreated), and are utilizing a woman’s best guess about her last menstrual period — which could miscalculate gestational age. Furthermore, mifepristone, the first drug in the two-drug abortion pill regimen, has a black box warning about various potential side effects, including sepsis. The symptoms of an ectopic pregnancy may not always be obvious, and a no-test protocol with the lack of a physical exam puts women at risk.

In addition to these problems, prescribing the abortion pill without any in-person visit puts women at a greater risk of coercion.

1st Trimester Abortion | The Abortion Pill | What Is Abortion?

A sketchy study

Numerous media outlets reporting on Washington’s pilot program attempted to portray the abortion pill as safe, citing a study published in the journal Nature, which identified over 6,000 women who underwent telehealth chemical abortions.

Pro-abortion funders and authors

Studies have been removed by medical journals on the sheer basis that they were done by researchers associated with pro-life organizations. However, there is a double standard: pro-abortion researchers with abortion industry connections do not receive the same scrutiny.

The Nature study was authored by abortion activists, not neutral scientists or doctors, who were associated with the pro-abortion Advancing New Standards in Reproductive Health (ANSIRH), the University of California, and other pro-abortion groups. The editor of the Nature study, Jennifer Sargent, has openly discussed her pro-abortion bias against pro-life groups.

“As an editor, I’ve seen quite a few thinly veiled anti-abortion papers funded by ultra religious, pro-life organizations. It is the responsibility of journals, editors and reviewers to ensure these agendas are not promoted through biased scientific approaches,” she wrote on Twitter (now “X”) in 2019 (emphasis added). Biased scientific approaches, however, are not limited to the pro-life camp.

In the study, data was taken from the California Home Abortion by Telehealth (CHAT) study — which, again, was run, sponsored, and funded by pro-abortion groups. Every single one of the study authors likewise have ties to pro-abortion groups. There are also methodology problems with the study, which relied solely on survey data. It did not track health outcomes from all of the women who had obtained chemical abortions, and out of the over 6,000 women who participated, follow-up contact was obtained from just over 4,600. Yet, even with nearly a quarter of the women and their potential complications unknown, the study authors still admitted that some women experienced complications.

Unusual results

According to the Nature study, 81 women visited emergency rooms (just under 1.8% of the women who participated in follow-up contact), which is significantly lower than the FDA mifepristone label’s listing of 2.9-4.6% for ER visits, and also not in line with a previous telabortion study’s 6% rate. The study also claims 15 women experienced “serious adverse events” which were defined as “blood transfusion; abdominal surgery (including salpingectomy, laparotomy and laparoscopy to treat an ectopic pregnancy); hospital admission requiring overnight stay; or death.” (It does not appear that ER visits were included as “serious adverse events.”) Ten women were reportedly hospitalized, with six receiving blood transfusions. Two were treated for infections. (Interestingly enough, the study notes that “Among patients with unknown outcomes, two requested abortion pill reversal after they took mifepristone but before misoprostol. Both were advised that evidence-based reversal treatment does not exist and referred to urgent in-person care. No further information on their outcomes was available.”)

This study had some other unusual results. Though the estimated rate of ectopic pregnancy in the general population is 1-2% (or 2-5% if using assisted reproductive technologies), the authors claim only six women out of the 4,454 women (.13%) who participated with followup experienced ectopic pregnancies, which they state is consistent with some other studies.

However, this appears to be because the CHAT study, from which the Nature study extracted its data, claimed to use a “standard no-test protocol,” but the study authors actually eliminated women who exhibited symptoms of ectopic pregnancy and sent them for ultrasounds prior to administering the abortion pill. The Nature study authors state:

Patients who had any risk factors for or symptoms of ectopic pregnancy or were potentially beyond the gestational limit of the virtual clinic were referred for pre-abortion ultrasonography….

As per the published protocol, patients were evaluated for medical eligibility based on the reported medical history. Pregnancy duration at intake was primarily based on self-reported date of last menstrual period or by ultrasonography, if available. Some patients had already had ultrasonography before contacting the virtual clinic. Additionally, patients were referred for pre-abortion ultrasonography if they had any risk factors for, or symptoms of, ectopic pregnancy or were potentially beyond the gestational limit of the virtual clinic.

Some of those patients came back to participate if ectopic pregnancy was ruled out by ultrasound; others didn’t. Additionally, “Each clinic had two scheduled follow-up interactions” to ensure that the abortion was complete, and “referred patients to in-person care if any adverse event or incomplete abortion was suspected and outcomes of care were documented whenever possible.”

In actual practice (not in studies), the no-test protocol does not include ultrasounds or blood testing of any kind. Women who obtain mail-order abortion pills receive them with no testing or ultrasounds at all, and typically have no followup visits or phone calls.

This data skewed the study’s rate of ectopic pregnancy, making it appear far less than what it truly is for the average woman obtaining the no-test protocol abortion pill regimen, since women were screened for the condition beforehand. Even a late 2024 abortion pill study published in the New England Journal of Medicine reported a 1.3% ectopic pregnancy rate (consistent with the general population) among its 1,504 participants.

Mifepristone is contraindicated for anyone experiencing an ectopic pregnancy, and cannot treat this condition, which is most often diagnosed between six and 10 weeks of pregnancy (also typically the time frame when the abortion pill is administered).

Despite these many potential issues, the goal is to expand the Washington state pilot program to allow pharmacists in Washington and other states to prescribe abortion pills to women. “We think this could have a huge impact in our state,” Downing said, adding that, “This is about meeting women where they are.”

The safety of those women, however, seems less important than promoting abortion at any cost.

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