Inside the Effort to Expand Abortion Pill Access
YouThe Supreme Court annuls Roe V. WadeAs a draft opinion indicates, it is likely that abortion will be outlawed or restricted to only half the United States this summer. But that doesn’t necessarily mean the country will return to a world before 1973, when the landmark Supreme Court case enshrined a constitutional right to abortion.
The availability of online ordering for abortion pills and shipping them by mail has fundamentally altered American women’s rights. The regimen of two drugs, mifepristone and misoprostol, can in theory be safely taken anywhere, including in the privacy of people’s homes, eliminating the need to undergo a procedure, travel out of state, take time off work, or confront protestors outside of a clinic. In part because of this convenience, abortion pills—also known as medication abortion—are now the most common method of ending a pregnancy in the U.S.
Advocates for abortion rights say there are still many obstacles to accessing the drugs. Due to a complicated patchwork of legal and regulatory hurdles in different states, combined with societal issues such as poverty and a lack of internet access, many would-be patients either have never heard of abortion pills, or don’t know where to get them, how to take them safely, and whether they’re legal. Many doctors are also confused. Even those who don’t currently offer abortions are often unaware of the details of abortion and have to navigate confusing legal pitfalls and misinformation for their clients and themselves. Laws passed by 19 conservative states that prohibit telemedicine have complicated the legal landscape. They also limit the locations where pills may be given. Amid this confusing landscape, many are turning to the internet, where they’re confronted with different problems: misleading information, websites designed to mimic reliable organizations, and platforms that can collect their data and take more knowledge to safely navigate.
The Supreme Court is poised for overturn RoeAs Republican-led States pass more restrictive laws, abortion rights activists are trying to keep ahead. In the last few months, advocacy groups have published online guides to obtaining abortion pills, purchased ad campaigns on the New York City subway, and launched online courses on how to “self-manage” abortions outside the established health care system. Internet privacy specialists have created toolkits that help people protect their digital footprints and set up hotlines to answer questions about abortion pills. The millions that groups funding abortions raise are used to cover or subsidize individual pills, as well as to assist people in traveling to countries where they can legally prescribe them. Medical organizations fund programs to educate medical residents on medication abortion. This is in addition to encouraging doctors from all walks of the spectrum to be up-to-speed about the legal environment, misinformation, and abortion pills.
Elisa Wells is co-founder and president of Plan C. This organization provides information on how to access and use abortion pills. She believes that medication will play a crucial role in any post-abortion world.Roe era. “One of the huge differences between then and now is that you do have these pills, they are in our communities, they are accessible through the internet,” she says. “And we hope that will at least lead to medically safe access to care even when it is restricted.”
Patient and healthcare staff should be made aware of the dangers associated with abortion pills.
Since 2000 when mifepristone received approval from the U.S. Food and Drug Administration, (FDA), medication abortions have steadily increased. In the U.S., the vast majority of abortions are completed at or before 13 weeks of pregnancy—so abortion pills, which are approved for use up to 10 weeks, are an option for many patients. U.S. abortions were 54% facilitated by pills in 2020. Due to the COVID-19 Pandemic in which conservative states made some brick and mortar clinics temporarily shut down, access to telehealth increased, this increase was partially due. The FDA’s April 2021 decision to remove restrictions from mailing abortion pills in the midst of the pandemic was another major factor. It extended this policy indefinitely in December.
Mifepristone (the abortion pill) and Misoprostol (which is taken the next day to cause cramping, bleeding, to empty the uterus), are both pictured in Santa Teresa by Dr. Franz Theards Womens Reproductive Clinic on May 7, 2022
Paul Ratje—The Washington Post/Getty Images
However, even though the number of abortions has increased, the access has not been equally distributed. Ushma, an associate professor at University of California San Francisco who leads a study of the use of Telehealth to obtain abortion pills in 22 US states, said that this is a result of the increase in abortion use.
“There are many people who don’t know that abortion pills even exist,” she says. “If they do know that abortion pills exist, they don’t know that they can access them through telehealth without an in-person visit, that they don’t have to tell many people about their decision.” Only about 1 in 5 adults had heard of medication abortion in 2020, according to the nonpartisan Kaiser Family Foundation (KFF).
Upadhyay states that it is more likely for people of color, immigrant, rural residents, or teenagers to get abortion pills. Upadhyay found that none of the major medication abortion companies she studied offer Medicaid services or provide services in other languages than English. Other companies may have similar restrictions. People who are black or Hispanic and low-income and people living far from the cities may not have access to broadband internet and might struggle to obtain prescriptions through telehealth.
Nearly two-thirds of the first 3,200 patients who have received abortion pills in Upadhyay’s study are white, compared to the national population of abortion patients, which is about 40% white. Upadhyay’s research also shows that 82% of those who have accessed abortion pills live in urban areas and nearly 75% were between 18 and 34 years old.
Accessing abortion pills in countries that ban them is one of the challenges
While medication abortion is not yet illegal in any state other than Oklahoma which just passed a law banning all abortion from the moment of “fertilization,” legislators in 22 states have introduced a flurry of new bills since January that would severely restrict access to or outright ban abortion pills. Numerous states already have laws that require the doctor who prescribes the abortion pills to be present at the time they are given. This effectively bans telehealth visits in which the pill is prescribed and then sent to the patient. Telehealth has been explicitly prohibited in some states. The self-managed option of abortion has been banned by three states. And while lawmakers have otherwise traditionally targeted abortion providers rather than patients, abortion pills—which patients can get by mail or can order online without a doctor’s involvement—complicate that dynamic.
Not only is it more difficult for officials to enforce laws against providers who don’t live in their state, but the impending Supreme Court decision has also emboldened some anti-abortion lawmakers. On May 4, two days after the Supreme Court leak, lawmakers in Louisiana advanced legislation that would classify all abortion—including medication abortion—as homicide and allow prosecutors to charge patients. While that bill is extreme by any measure, even states that don’t explicitly criminalize patient actions could expose individuals to legal risk.
Concerns about how state officials treat those with restrictions on abortion have been raised by Lizelle Herrera’s arrest in Texas of Lizelle Herrera, 26, last month. Her case was brought to the attention of law enforcement by staff at Herrera’s hospital. She was sentenced to three days imprisonment, despite the fact that authorities dropped her murder charge. Texas banned abortions within six weeks of pregnancy. However, that law does not carry any criminal penalties for those who choose to seek abortions.
“I worry about the chilling effect,” says Cynthia Conti-Cook, a civil rights attorney and technology fellow at the Ford Foundation. “The people who are most likely to be targeted for investigation, surveilled and prosecuted … are communities that are majority Black people and immigrant communities, and communities that in any other way have experienced historical oppression.”
Leah Coplon (a certified midwife and director for clinical operations at Abortion on Demand), answers patients’ questions about legal liability. Abortion on Demand delivers abortion pills to 21 states by mail. AbortionOnDemand only sends abortion pills to states where they are legal. Some patients worry about the scrutiny of law enforcement and health care officials. Other patients fear that friends or family members might take steps to prevent them from getting an abortion. Coplon explains that because the outcome of a medication abortion looks exactly like a miscarriage, and can be treated as such in a health care setting, patients don’t have to tell anyone they have taken the pills.
If you live in one of 19 restricted states, patients can still get abortion pills at an in-person clinic, or via international services such as the Austrian-based Aid Access. This group was founded by Dr. Rebecca Gomperts and ships pills to all 50 US states. Gomperts can work with nine U.S.-based suppliers for patients. Patients in other restricted states will need to be referred by Gomperts, who also sources the pills from India. In 2019, the FDA demanded that Aid Access stop, saying the generic mifepristone was a “misbranded and unapproved drug,” but Aid Access sued the agency and the FDA ultimately did not take further action against the organization.
The supporters of the ROSA, Reproductive Rights Against Oppression, Sexism and Austerity, rally at Guildhall Square, Londonderry, Northern Ireland, on May 31st, 2018, led by Dr. Rebecca Gomperts (2nd R).
Charles McQuillan—Getty Images
Many U.S. providers also find workarounds. Sometimes Dr. Julie Amaon is the medical director at Just the Pill’s telehealth abortion pill business. She tells her patients to go to the closest state where they can get pills via telehealth. After that, she arranges to have the pills sent via FedEx or UPS to pick up at Post Office locations. Just the Pill will also be deploying mobile clinics to other states such as New Mexico and Illinois. This will allow abortion to continue to be legal in these states. However, it will not work for those bordering states where strict anti-abortion laws apply. Such mobile clinics will help “offload all the medication abortions so [brick-and-mortar clinics] can focus on procedures,” Amaon says.
Hey Jane is another company that provides telehealth services for abortion. It also ships to Post Office boxes in the states where it’s legal. Kiki Freedman, CEO of Hey Jane, says that she picked these states as they have a high likelihood to receive a large number of patients in the event that abortion is banned by GOP-led states.
Education via social media can be both essential and difficult.
Melissa Grant is an executive with Carafem which remotely offers abortion pills. She says that stigmatization and misinformation are just as dangerous as strict legal regulations.
“You might say, ‘I have a great dentist,’ but it’s rare you’d say, ‘Hey, this is a great place to have an abortion,’” Grant says. “We’ve had to find ways to reach people and let them know we’re not a crisis pregnancy center, we’re real, and you can come here and trust us.”
Carafem offers a text message support service that allows patients to ask questions while they manage their own abortions. Similar support is also provided by other hotlines such as the Repro Legal Helpline or the Miscarriage Abortion Hotline. These hotlines have recently grown from 40 volunteers to 50.
Others are also working on seed searching and other social media platforms that provide reliable information to support abortion rights. Plan C created an online directory that allows people to search for services in their state who will mail them abortion pills. It also provides information about each state’s laws, as well as the potential legal risks that patients face. Plan C posts information and artwork about abortion on social media. Plan C witnessed a significant spike in traffic on its website one day after the Supreme Court draft was leaked. This was an increase from the average 2,300 visitors per day just before the leak.
“The internet is clearly a huge improvement [from the pre-Roe era] in a lot of ways, and a powerful tool in our ability to share information,” says Wells, Plan C’s co-founder and co-director.
This information is not useful if it’s not available to the person who found it. Many would-be abortion patients either don’t have private access to the internet, or are fearful that their online search histories could leave them exposed to legal liability, providers and scholars say. Some organizations have created guides that will help you protect your data while searching the internet for information on abortions. Other groups have also taken measures to counter the disinformation spread by anti-abortion organizations. They regularly advertise online using imagery and phrases designed to attract women looking for information on abortion to discourage them from terminating their pregnancies.
Anti-abortion pregnancy center websites often include FAQs on medication abortion. However, they also warn people that the procedure can be deadly and encourage them to schedule an appointment. The fine print does not clarify that they offer abortions. Other anti-abortion groups also promote “abortion pill reversal” treatments, an idea that the American College of Obstetricians and Gynecologists says is “not based on science.”
Meta, the parent company of Facebook and Instagram, declined to answer questions about Plan C or other groups’ posts. Meta’s spokesperson stated that the platforms are open to ads and posts raising awareness on abortion. They also allow information and advice about abortion. The company is not allowed to sell prescription drugs directly. All abortion content must also follow the platforms’ policies on topics such as prescription drugs, misinformation, and bullying and harassment.
Dimitratou calls the policies “counterproductive.” “You have to spend a lot of time just through the whole process appealing things and trying to convince them that abortion pills are legal and safe,” she says.
Aid Access has experienced similar problems, says Christie Pitney, a certified nurse midwife who works with the group to prescribe abortion pills in states where telehealth for abortion is legal and helps run the group’s social media. On May 10, as it was seeing a surge in interest following the Supreme Court leak, Aid Access’s Instagram account was suspended, Pitney says. Although it has been reinstated, Pitney and Gomperts state that other problems are still ongoing.
Women on Web is another Gomperts-founded group that sends out abortion pills around the globe. Dimitratou provided screenshots and also ran social media. Dimitratou claims that Women on Web fell 75% in traffic after Google’s algorithm was updated in May 2020.
“How do you make sure that all the people that need you can find you? That’s what is so damaging about these laws. It will make it so difficult for people to find information,” Gomperts says. “When it’s illegal, nobody is there to give that information anymore and it becomes such a taboo. And that is internalized so that people are scared, and they don’t dare to talk about it anymore. And then information becomes much harder to find.”
TIME received confirmation from Google that their algorithm changes do not penalize sites or favor one. “Our Search ranking systems are designed to return relevant results from the most reliable sources, and on critical topics related to health matters, we place an even greater emphasis on signals of reliability,” the spokesperson said. “We give site owners and content producers ample notice of relevant updates along with actionable guidance.”
Google has banned abortion-related advertisements in other countries, such as Poland and Saudi Arabia. Some social media posts are also not allowed in these places. It’s unclear how tech companies will handle ads in the U.S. if some states outlaw abortion entirely, as they’re widely expected to do.
An alliance of providers and groups representing abortion rights will meet in June at a conference on digital rights to discuss strategies and to develop their list of recommendations for Big Tech companies to improve the way they navigate social media. Many groups have been trying to get people in touch offline. Since months, local activists for abortion rights have been holding trainings in self-managing abortion. Plan C activists drove around Texas in August with a mobile billboard advertising abortion pills. The group also paid this spring for ads on New York City’s subway.
Plan C’s subway advertisement in Spanish provides medical advice about abortion pills on May 7, 2022, Brooklyn, New York.
Andrew Lichtenstein—Corbis/Getty Images
A new frontline: family doctors and others who don’t perform abortions
Dr. Chelsea Faso, a New York City-based family medicine physician who works with the nonprofit group Physicians for Reproductive Health, says there’s also a need to educate health care providers. She believes that abortion should not be considered any different from other medical care. “Most family docs, like myself, provide care for folks from the cradle until they’re approaching the end of life,” Faso says. “When folks come in with a pregnancy, it really is our responsibility to be able to counsel that person on all of their options.”
The message has been taken to heart by many organizations. A program of the UCSF Bixby Center for Global and Reproductive Health called “Innovating Education in Reproductive Health” has produced a series that teaches healthcare providers in areas where there are strict restrictions on abortion.
Reproductive Health Education in Family Medicine, (RHEDI), aims to promote that message by supporting and funding family medicine residency programs which include abortion in their curricula. Some “medical students are surprised to know that you can be a family medicine doc or a primary care doc and provide abortions,” says Erica Chong, RHEDI’s executive director. “That’s the first hurdle to get over.”
About half of U.S. family doctors were open to offering the drug in 1997. This was just a few years prior to FDA approval. According to 2020 research, just 3% of family physicians in their early years actually perform abortions. Family Medicine. Around 40% indicated they offered only medical abortions.
Emily Godfrey (an abortion provider at the University of Washington) says that regulatory limitations are part of this problem. Even though it has repeatedly been shown to be safe, mifepristone is subject to the FDA’s Risk Evaluation and Mitigation Strategies program, which places safeguards on drugs that regulators think pose potential risks. Godfrey states that providers must be registered before prescribing mifepristone. That extra step could prove to be prohibitive for some, especially for religiously affiliated hospitals that don’t provide abortion care. More than 30 states also require a physician’s prescription, shrinking the provider pool to exclude nurse practitioners, physician assistants, and other clinicians.
RHEDI’s curriculum and program manager Ian Lague says that mifepristone has strict FDA regulations, so some providers may be reluctant to offer it. “A lot of it is a confidence issue,” Lague says. “People feel that they need more training”—even when they’re perfectly qualified. The pills have a 95% effectiveness rate and a lower complication rate than Viagra or Tylenol.
Another barrier is legal requirements. Utah’s doctors must inform patients about the possibility of medication abortion being reversed. Other laws, including ones in Texas and Oklahoma, also make anyone who aids an abortion liable to legal action, so “there’s a lot of fear to even talk about it or refer patients,” says Cindy Adam, CEO of the medication abortion provider Choix.
Local abortion funds and advocacy groups are encouraging doctors to remind them about their rights. They also encourage medical professionals to not report any patients with an unplanned pregnancy to authorities. Even in states where people who enable an abortion can be legally vulnerable, doctors are not required to report patients to the police if they suspect they’ve taken abortion pills. “We have to, as a medical community, reinforce that fact,” Faso says. “There is no mandated reporting law for this and you are violating” patient privacy if you report someone.
Even with all of this knowledge and preparation, advocates and providers say it’s hard to predict exactly what they’ll see if RoeIt has been overturned. Some Democrat-led States are taking steps to increase funding and protect abortion providers. The manufacturer of generic mifepristone is challenging Mississippi’s abortion pill restrictions in a case with a hearing scheduled June 8. Pitney, the Aid Access provider, says that medication abortion will likely reduce the number of people required to travel out of state to access abortions, but calls it a “Band-Aid on a much larger problem of access.” She predicts that unsafe abortion will increase if RoeThis has led to the collapse of many abortion providers. Many have struggled for years with their budgets and will now be unable to offer any services. “The abortion community was stretched thin prior to this,” Pitney says. “But the work is gonna get harder.”
Aid Access’s Gomperts says that so far U.S. laws have not prevented her from mailing pills to any state. Even though lawmakers try to block her from sending pills to the U.S. she can still use the safe and effective abortion pill.
“They might be able to stop me, but that doesn’t mean that they will be able to stop medication abortion,” Gomperts says. “You cannot stop women accessing safe abortions with pills. They’re never going to stop that.”
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