A hidden abortion crew prepares to confront a post-Roe America

From the other side of the debate, elevated interest in online access to abortion pills represents a longtime nightmare for anti-abortion activists. Ever since medication abortions were approved by the FDA in the 1990s, anti-abortion figures have warned the drugs could make terminating a pregnancy too convenient and too easy. Then-presidential candidate George W. Bush warned that “making this abortion pill widespread would make abortions more and more common.”

Those warnings persisted just after the pandemic. “If the abortion lobby’s ultimate dream succeeds, however, brick-and-mortar facilities will become obsolete,” wrote Marjorie Dannenfelser, the president of the anti-abortion-rights Susan B. Anthony List in a Townhall column, criticizing abortion-rights activists’ efforts to prioritize abortion care in the stimulus package. Instead, Dannenfelser wrote, the “next frontier” is to use the internet and the mail to ship abortion pills — thereby leveraging new tech and organizations to spread abortion nationwide.

It’s a fear that’s likely to get even stronger. The Biden administration’s Food and Drug Administration recently signaled it’s looking at overturning one of the key restrictions obstructing the distribution of one of the drugs used in a medication abortion regimen, the requirement that only doctors can provide the pills.

It’s an about-face after the Trump administration FDA took action against one of the main online providers, Aid Access, and some of the overseas pharmacies that served them. Social conservatives had strongly lobbied the FDA and Health and Human Services Department to take action against online providers. Now, with the change in the administration, there’s a change in policy.

“They want to make it seem that it’s as unserious as picking up a vitamin from CVS,” said Roger Severino, a prominent social conservative who served as director of HHS’ Office for Civil Rights during the Trump administration. Severino argued the economics of medication abortions are more favorable for abortion providers; and it’s generally cheaper to provide abortions via a pill than through surgery.

Indeed, surgical abortions can cost $400 or $500; medications are potentially quite cheap. Wells said she was inspired to start promoting access when she saw the pills available in Ethiopia for $7. And those low prices are available online, if you look in the right places.

So while pro-abortion-rights activists might use different language, they largely agree medications — which can be shipped by mail directly to a patient — are more convenient and affordable. It’s the “21st century abortion,” Wells said. “There used to be the model of ‘how many clinics are across a state?’” Now, doctors or providers can see patients over Zoom and rely on the mail to get pills to patients. It’s a way to “diffuse and expand access.”

But getting that care was a tricky process last year. There were legal restrictions: States erected regulations, and the FDA maintained rules making it difficult to mail the pills.

Then there were disruptions to supply: Many medications were sourced from India, which suspended exports in March 2020. The whole model “was no longer viable,” said Wells.

That’s to say nothing of slowdowns in the mail: not so bad if you’re waiting on a new charger; a big problem if you need medications in a couple weeks.

The two drugs used to terminate a pregnancy can be safely administered up to the 77 days of gestation, according to recommendations from the American Academy of Family Physicians. A move by England’s National Health Service to encourage at-home abortions found no increase in complications. But many conservatives maintain that making the drugs available, outside the direct control of a doctor, would enable women to use them improperly — such as on later-term pregnancies — which could cause potentially dangerous side effects.

“The reason there was an in-person requirement was to make sure you had a qualified doctor” to keep an eye on problems, Severino said

But abortion-rights advocates maintain that those fears are overblown — and some point to the fact that the numbers of self-managed abortions soared during the pandemic with few reports of serious side effects.

Indeed, as lockdowns took hold, improvisations reigned. “We figured out providers in the U.S. could write prescriptions to misoprostol,” Wells said. Misoprostol is one-half of the typical regimen to abort a fetus; taken alone, it’s somewhat less effective than in tandem with mifepristone. “That was a stopgap.”

Even the FDA’s regulations were interpreted by some physicians to allow for at-home abortions in some circumstances. Some doctors decided to send prescriptions by mail — as long as they took control of the dispensing and mailing process.

The efforts by doctors determined to continue providing services in the face of opposition is one facet of what Wells calls “conscientious provisioning” — a trend of doctors and providers pushing the extent of the law to give access to abortions regardless of legal restrictions.

“We’ve had providers saying, these rules are causing me to assault my patients, providing incorrect information to patients,” she said.

Wells said Plan C has talked with some 200 providers. In states where teleabortion — in which a doctor instructs the patient over a video link — is legal, doctors and other providers have helped power a wave of new startups. Companies like Choix or Just The Pill take advantage of some blue states’ suddenly looser restrictions to make abortions more easily available.

The new options — often presented in sleek, trendy graphics closer to a millennial-skewing startup than the typical health care website — attracted a different type of patient than had typically sought abortions online.

Whereas a recent Journal of the American Medical Association article found users of Aid Access were mostly unable to afford in-clinic care in states that imposed extensive restrictions, one New York doctor said her new, online clientele was more affluent. What unites both groups of patients: a desire for privacy away from the stigma of seeking an abortion.

That’s one of the potential advantages of teleabortion, and a reason more patients are likely to turn to underground options, even if Roe v. Wade were left in force. There are online forums, like /r/abortion, providing information and links to internet pharmacies.

There are also “abortion doula” groups, like Mountain Access Brigade, that offer connective services — like rides to clinics or online options — for patients. They’re closely related to a type of activism that Yellowhammer Fund’s Marty calls “aunties” — online gatherings of volunteers who group together to support patients seeking abortions, from giving rides to escorting patients into clinics.

They spent the pandemic upgrading their technology, said Katie, a nom de guerre shared by the volunteers of that group.

The group takes “privacy very, very, very seriously, and use technology to that end,” she said, and builds software to manage their business: sharing scheduling and calling duties, or giving very carefully worded advice — not materials or active facilitation — on self-managed abortion.

“It’s funny how legality is often about the words you use and not the actions you take,” she said. “But that is walking the tightrope of what’s left of Roe v Wade.”

Patients can also take advantage of other improvisations: getting pills shipped to postal offices in less-regulated states, for example. For abortion rights activists, the inventiveness is proof that patients will seek out abortions regardless of the legal structure.

The problem, they say, is increasing static from anti-abortion activists. Multiple activists interviewed for this article believe activists are trying to confuse patients on the internet.

For example, a user searching “Plan C” on Google might find results related to Wells’ project to provide access to abortions; but they might also see results from so-called crisis pregnancy centers, groups run by anti-abortion activists that seek to dissuade users from getting an abortion — certainly for long enough so that an abortion can’t be done pharmaceutically or legally.

Some activists are also warning about “infiltration.” Online “auntie” groups are one target, activists believe. Marty’s updated “Handbook” cautions that “Abortion opponents have grown more adept at inserting themselves into these spaces and harassing or derailing patients seeking support.”

Such misinformation is part of the reason why Marty’s become pessimistic. She worries that women in blue states will get more convenient, available abortions — while red states will crack down to a higher degree.

“The FDA will let people get pills mailed to their house, and so people feel more comfortable believing things will get better — despite the fact that half the country still can’t get abortion via telemedicine and many of the rest can’t afford the pills through these services anyway,” she predicted.