In a post-‘Roe’ world, abortion pills won’t be enough

Christie Pitney is a certified nurse midwife who was working at a federally funded health center in California’s Central Valley when the pandemic struck. In those early months, several of her patients struggled to get abortions. Under normal circumstances, the closest abortion clinic is 45 minutes away, but during the pandemic, clinics around the country suffered staff shortages and canceled services. Patients were having trouble getting to clinics even when they were open.

This is part of a series of articles on the business case for abortion access. See the full package here.

“My patients and the population in that area, they don’t have reliable transportation. They are working six to seven days a week,” she says. “They have childcare needs and don’t have reliable income. Most of them are either working in a packing house or in the fields.” And that’s in California, one of the most accessible states to get an abortion. “The reality is, it’s not just legal barriers.”

Pitney wasn’t able to provide abortions at her center because the Hyde Amendment prohibits federal dollars from being used for abortions, but she wanted to do something to help. In January 2021, she became one of a handful of doctors and nurses in the US to join Aid Access, an organization based in Austria that provides access to medication abortion throughout the United States, regardless of state restrictions. These pills can be taken up to 13 weeks into a pregnancy, according to certain studies, and, as of this year, can be sent through the mail. But while medication abortion is an important piece of abortion care, experts caution that it cannot make up for the vast restrictions that prevent people from ending a pregnancy.

Medication abortion consists of two pills, misoprostol and mifepristone, and the regimen is poised to become even more crucial after the Supreme Court decision this summer. A leaked draft of the decision published by Politico indicated that the Court planned to overturn Roe v. Wade, ending the constitutional right to abortion and sending the issue back to the states. If this decision comes to bear, 13 states with so-called trigger laws will immediately outlaw abortion, and many other states are working to pass restrictive laws.

Knowledge and access: Where abortion falls short

While medication abortion will become even more vital after the Supreme Court’s ruling, it can be used only within the first 10 weeks of pregnancy, according to the Food and Drug Administration (FDA)’s regulations. The States are also moving to further restrict access to abortion pills: 19 states require medication abortion to be prescribed in a person, and legislatures in a number of states are considering bills that would further restrict or ban abortion. Groups like Hey Jane, Just the Pilland Choix are fighting to make sure it’s as accessible as possible by providing virtual appointments and remote prescriptions for the two-pill regimen.

A significant number of Americans aren’t even aware that abortion is an option, including one-third of women between the ages of 18 and 49, according to the Kaiser Family Foundation. This presents a significant challenge for abortion advocates: People who are pregnant can’t request the pills if they don’t even know they exist. (This knowledge gap can also have dire consequencesas Jessica Bruder’s reporting in The Atlantic shows, as people turn to dangerous alternatives in an attempt to end their pregnancy.)

Show Your Abortionan organization working to normalize abortion and ensure safe access, has tried to increase awareness by driving digital billboards around Hollywood, flying a banner over Arizona, and distributing information at art galleries, coffee shops, and vending machines around the country. (They also carried signs and banners explicitly touting abortion pills in front of the Supreme Court in December.) Plan Cwhich conducts research and advocacy around the abortion pill, ran a massive ad campaign in the NYC subway. Meanwhile, other advocacy groups and doctors’ organizations are opening hotlines and launching information campaigns to make sure prescribing and taking the pills are as easy to understand as possible.

A surge in requests

Aid Access, in particular, has found ways to get this medication to people in states with the most burdensome rules. Dr. Rebecca Gomperts founded Aid Access in 2018, after her other organization Women on Webwhich prescribes medication abortion to people around the world, saw an increase in requests out of the US Gomperts is licensed in Austria and therefore not subject to laws in other countries or states. The organization has become a go-to resource when abortion care gets choked.

During the pandemic, Aid Access and other organizations saw requests for medication abortion riseas some states paused abortion services and clinics closed. Up until recently, the FDA required mifepristone to be dispensed in-person at a clinic, so when clinics shuttered, people weren’t able to access pills. In response, the American Civil Liberties Union (ACLU) sued the FDA to temporarily remove the in-person requirements; Several months later, a judge granted an injunction on the rule, allowing doctors to mail out prescriptions. In the wake of that decision, a slew of online abortion clinics cropped up. In 2020, more than half of abortions in the US were achieved by the two-pill regimen.

Then in September 2021, Aid Access was again hit with a major spike in requests, as Texas banned abortion after six weeks of pregnancy. A study found that applications increased nearly 1,200% that week. Abigail Aiken, the researcher at the University of Texas at Austin who led the study, reviewed Aid Access’ data the week of the Texas ban went into effect and found that the average daily number of requests out of Texas for abortion medication went from 11 per day to 138.

People weren’t only getting abortion pills for immediate use, they were also stocking up for the future. Pitney says the drugs have an 18-month shelf life. (Although some moved advise against stockpiling many packs as it could limit access for people who need them immediately.) It took three months for the number of requests to die down, says Pitney.

In December, Texas enacted a law that makes it illegal to use medication abortion beyond seven weeks of pregnancy and to send it by mail. That same month, the FDA permanently removed the in-person requirement, allowing patients to receive medication abortion by mail. These dueling federal and state laws create murky legal territory for people who need an abortion. Earlier this month, when the Supreme Court draft decision overturning Roe v. Wade leaked, requests to Aid Access increased by 2,900% in the 24 hours following the news.

When patients who are located in restricted-access states request pills from Aid Access, the prescriptions are shipped from pharmacies in India and usually take 2 to 3 weeks to reach patients—a limitation of this model. Patients in states that don’t restrict medication abortion are able to get the pills much faster from local providers. Regardless, Pitney notes that there’s a ceiling on what Aid Access can do to support people who need an abortion. “We’re only ever going to be able to offer our services up to a certain point,” she says.

Post-Roe world

Amy Miller is the founder of Whole Woman’s Health, a network of nine health clinics around the country that provide abortion services, including four in Texas. Whole Woman’s Health is the lead plaintiff in a lawsuit that hopes to reverse the ban in Texas; the clinic was also the lead plaintiff in a 2016 decision that upheld the right to an abortion. She says her clinics have struggled to connect patients with care as restrictions have tightened, and she’s preparing for a post-Roe world.

Already, her doctors are getting licensed in other states, so they can support patients who are forced to seek out-of-state care. Her organization is also working with abortion funds and tactical-support organizations to coordinate travel and connect patients with other providers. “We’ve built our own sort of internal abortion-support system so that we don’t have to duplicate things like ultrasound lab work in multiple places,” she says. “We can really try to streamline their travel and transition for care in a different state.” This includes creating a list of pro-choice hotels, restaurants, and low-cost daycare centers, including, ironically, YMCAs.

Whole Woman’s Health also offers virtual appointments and provides medication abortion, but Miller says it’s not a panacea.

“My fear is that it’s being sort of pitched as, it’s gonna solve the abortion problem,” says Miller. “Not everybody has a credit card where they can pay over the phone. Not everybody has a safe place that they can pass a pregnancy, and not everybody’s under 10 weeks or 11 weeks.” legal experts are now warning that credit card records could be used to incriminate people who seek out abortions or the organizations providing medication abortion in states where it’s restricted.

But to Miller’s point, abortion also isn’t a cheap option. It averages $500, and can be as much as $750, depending on where you live and whether you have insurance. According to the Minneapolis Fednearly 40% of Black and Latino working adults would have trouble paying for a $400 emergency expense.

Aid Access has committed to a pay-what-you-can model for its services. So far, enough people pay the full amount that the organization is able to offset the cost for those who can’t. Aid Access care providers walk people through the process and connect them with a hotline to help them handle problems as they come up. “We do everything we can not send patients to the ER unless absolutely necessary,” says Pitney. “Because we know that healthcare in the US is extremely expensive and can put people into huge amounts of debt.”

But there’s always the possibility a person may have to go to the hospital. Medication abortion is extremely safe, and research has shown it sends fewer people to the ER than Tylenol and Viagra. Still, passing a pregnancy involves heavy bleeding and can feel like a medical emergency. In very rare cases, leftover tissue in the uterus may cause an infection. If this happens, a person can always go to an emergency room and say’ve had a miscarriage, but this means not being fully transparent with the doctor on hand (there’s no way to tell the difference between an induced miscarriage and a naturally occurring one). Still, a 2015 case in which a woman was prosecuted for aborting a pregnancy raises concerns that as states move to criminalize abortion, this could become more common.

“Is it better than what happened before-Roe?Miller asks. “Of course, but that’s not the framework of adequate access to abortion.”

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