Over the past decade, Louisiana hospitals began stocking specialized carts designed to treat hemorrhages, one of the most common pregnancy complications in the state. The plug-in cart can be wheeled from room to room and holds surgical tools and lifesaving medications to stem blood loss.
A state law passed in 2024 forced hospitals to remove a key drug — misoprostol — from the medical cart and keep it locked in a secure room designated for controlled substances.
For physicians like New Orleans obstetrician-gynecologist Nicole Freehill, misoprostol is the go-to medication to treat hemorrhages. The drug is uniquely cheap, safe, and shelf-stable, she said.
But it’s also the second in a two-pill procedure that millions of people have used to have medical abortions. Because of that use, Louisiana lawmakers reclassified misoprostol as a controlled substance, a category typically reserved for addictive drugs.
Now, physicians like her have gone from reaching over to the cart to grab misoprostol to waiting at least two minutes while a nurse sprints to retrieve the medication, Freehill said.
“ You could literally have someone lose, like, a liter of blood or more in that time frame,” Freehill said. “You could have a significantly worse hemorrhage for literally someone running to this medicine and running back because it can’t be on that cart 2 feet from you while you’re treating the hemorrhage.”
She said the reclassification of misoprostol as a controlled substance has set back progress to decrease the frequency of postpartum hemorrhage and blood transfusions. Under the law, her preliminary research found, hemorrhage rates have worsened statewide, she said.
Although the cart includes alternative drugs to treat hemorrhages, they can’t be used if a patient has certain preexisting conditions like asthma or high blood pressure. They’re also more costly.
“ There’s unfortunately a lot of patients nowadays that have these conditions that we might be forced to go straight to misoprostol first without any other real good option because of their medical history,” Freehill said.
Misoprostol has other uses in reproductive healthcare. It prepares women’s cervixes ahead of common, sometimes painful procedures such as inserting an IUD. It also plays a critical role in inducing labor and managing failed pregnancies.
In medication abortions, misoprostol is combined with a medication called mifepristone, which Louisiana also reclassified as a controlled substance. Both mifepristone and misoprostol have uses outside reproductive healthcare, including treating Cushing’s syndrome and preventing stomach ulcers caused by anti-inflammatory drugs.
When Louisiana passed a near-total ban on abortions after Roe v. Wade was overturned in 2022, the number of abortion procedures performed in the state dropped from 7,444 in 2021 to fewer than five in 2024. Similar trends occurred in other states that largely banned abortions that year.
However, in the years since, the number of abortions has largely remained the same in Louisiana and nationally as people receive medication abortions through telemedicine and pills sent across state lines. More than 7,500 Louisianans received medication abortions in 2024, the year the law passed, according to the Society of Family Planning.
Since then, states with abortion bans have tried to stymie the shift to medication abortions prescribed in telehealth appointments and shipped by mail, looking to close what they saw as a loophole through legislation and lawsuits.
Kimya Forouzan, the state policy adviser for the Guttmacher Institute, a nonprofit reproductive rights advocacy group, said the assault on medication abortions comes as more states that have maintained abortion rights pass laws to shield prescribing providers from prosecution.
“This has been a really important lifeline for a lot of people in states with total bans who are looking to access abortion,” Forouzan said. “However, I think a lot of the restrictive states know that this is happening, and they have wanted to increase the threat and the threat of liability to providers who are doing this.”
Louisiana’s controlled-substance law became one way to do so, though it was originally passed to ensure strict penalties for coerced abortions. Republican state Sen. Thomas Pressly of Shreveport, who introduced the bill, said he did so after his brother-in-law fed his sister the pills to cause an abortion without her knowledge. She gave birth to the baby, and the husband was sentenced to six months in prison after the failed attempt.
The bill was later amended in the legislature to add more restrictions and monitoring of mifepristone and misoprostol by classifying them as controlled substances.
Last October, Louisiana also tried to halt medication abortions by telehealth with a federal lawsuit against the FDA. The case is pending before the U.S. Supreme Court.
The New Orleans Health Department called for the repeal of the law in a report released last September, based on surveys of patients, doctors, and pharmacists. Patients reported delays in treatment while hemorrhaging after birth. Fewer pharmacies filled prescriptions for misoprostol, frustrating doctors.
“ There’s no evidence that it is reducing elective abortions in Louisiana. There’s no evidence that it is helping anybody. There’s only evidence of harm,” said Dara Kass, an emergency physician and a professor at Brown University.
Since Louisiana’s law passed, similar legislation has been introduced in at least nine states, despite established abortion bans.
But so far, no other states have reclassified the medications. Pushback from the medical community and reproductive health advocates over implementation has surprisingly stifled any other attempts, said Alina Salganicoff, director of the women’s health policy program at KFF, a health information nonprofit that includes KFF Health News.
“This puts a risk inside the healthcare system and potentially could delay really extremely time-sensitive lifesaving care,” Salganicoff said. “Especially where we have situations where we have really an unacceptably high maternal mortality situation in the United States.”
Instead of being a model for other states, Louisiana’s law has served as a cautionary tale. Freehill, the New Orleans OB-GYN, said her colleagues have also had patients struggle to fill their misoprostol prescriptions ahead of uterus examinations intended to help with their fertility.
“ So it’s having the complete opposite effect of what it’s been intended,” she said.
According to the New Orleans Health Department’s report, some pharmacists said they were too afraid to release the medication to the patient, confused about what’s required under the law. Others refused to fill prescriptions and stock the medication because they preferred to “stay away from any abortion pills.”
Tehmi Chassion, a pharmacist and a Democratic state representative in Lafayette, is pushing the state to study the law’s impact, given the loss of access to the medications.
Louisiana allows pharmacists to choose not to dispense medication if they are uncomfortable doing so, but Chassion said some pharmacists may be crossing a line by blocking access to medication based on their personal beliefs.
“ Those medications have helped save thousands of lives, and we just need to get to a safe space where prescribers and patients don’t have any worries,” Chassion said.