When Roe v. Wade fell, telehealth company Abortion on Demand received a surge of inquiries from patients trying to schedule appointments online. Many of them were from states that had rushed to impose bans or restrictions, and they were frantically searching for help. But the company, which provides mail-order abortion pills, had to turn them down.
Jamie Phifer, the company’s founder, was heartbroken. But she and her staff scrambled to help people by other means. “We were coordinating care for all these patients who couldn’t use our services,” says Phifer. Since then, the company has seen a steady climb in demand, mostly from people in states where abortion access is still protected but driving distances are prohibitive or clinic wait times are weeks long. “They can’t get into a physical clinic for care,” she says, so pills are a desirable alternative.
Abortion pills, also known as medication abortion, offer a safe and effective way of ending a pregnancy at up to 10 weeks without a surgical procedure. The two-step regimen has been available in the United States since 2000, when the Food and Drug Administration approved mifepristone, which is taken first to block a hormone essential to pregnancy. The second drug, misoprostol, is taken 24 to 48 hours later and empties the uterus. The pills can be dispensed in person by brick-and-mortar clinics or by telehealth-only services like Abortion on Demand, which prescribe them virtually and ship them by mail.
Before last June’s Dobbs v. Jackson Women’s Health Organization ruling that ended the national right to an abortion, use of the pills was already on the rise in the US. In 2017, they were used for 39 percent of abortions, according to the Guttmacher Institute, a New York–based policy and research organization. In 2020, the latest year for which full data is available, that figure was up to 53 percent, marking a tipping point: Pills had become the preferred method for abortion in the US.
Prior to the Covid-19 pandemic, telehealth abortion was off-limits in the US, and mifepristone was highly regulated by the FDA. Even in the bluest states, patients seeking abortion pills were required to see a medical professional in person. But access changed in July 2020 after a coalition of medical groups successfully sued the FDA to loosen regulations.
Since those changes, and since Dobbs, interest in getting the pills by mail has increased. So have efforts to prevent people from accessing abortion in this way, leading to an uncertain future for mifepristone and those who seek it out.
This has pushed the abortion pill to the center of a struggle over who can obtain reproductive healthcare in the US. As red states restricted access post-Dobbs, people wanting abortions were forced to either travel for a procedure or telehealth appointment, or seek out a “self-managed” abortion by ordering pills from outside the US. But as the total number of legal abortions across the United States has fallen since June 2022, the number of those services via telehealth, and likely the use of pills overall, has increased.
The virtual clinic Hey Jane, for example, saw significant jumps in pill requests within each of the nine states it operates in, with an average increase of 134 percent. But in blue states that act as safe havens for relatively red regions, the jump was more significant. Post-Dobbs, demand for mail-order pills in Colorado went up 231 percent. In Illinois, requests rose 301 percent.
Similarly, Carafem, which provides telehealth services in 16 states, has seen a 91 percent overall increase in the number of medication abortions it provides. “Telehealth has really exploded in terms of people’s awareness and their preferences to receive care in this way,” says Melissa Grant, Carafem’s cofounder and chief operating officer. “We had no idea how important this technology was going to become in such a short period of time.”
This rise in mail-order pills is reflected in this Society of Family Planning’s new WeCount report, which tracked abortion access in the US in the nine months following the Dobbs decision. It found that from July 2022 to March 2023, bans enacted in 13 states led to an average of 2,849 fewer abortions being performed in the US each month compared to April 2022, which the group used as its pre-Dobbs baseline. At the same time, the number of abortions provided by virtual-only telehealth providers increased from an average of 4,025 abortions per month, or 5 percent of all abortions, to an average of 7,461, or 9 percent.
Given the recent shift to abortion pills, as well as the increase in telehealth use since the pandemic, Ushma Upadhyay, co-chair of the WeCount project, estimates that medication now accounts for around 60 percent of all abortions in the US. Upadhyay, a public health scientist at UC San Francisco, says that’s not surprising: Medication abortion is convenient, less intrusive than surgery, and can be done at home. “Patients appreciate the autonomy and privacy,” she says.
People in states where abortion is banned or heavily restricted can also access these services through roundabout—but legal—means. They can physically travel to protected states to log on to appointments or to pick up medication. Or, Upadhyay says, some people have providers mail the medications to a post office just across their state’s border, or to a friend’s home in another state, or use mail forwarding services.
Yet just as medication is becoming more crucial to abortion access, its future is at risk. In April, a federal judge in Texas attempted to invalidate the FDA’s approval of mifepristone. For now, the US Supreme Court has blocked that ruling from going into effect until the case works its way through an appeals process. Ultimately, the courts could make mifepristone illegal across the US or roll back recent changes that have made it accessible via telehealth. Either would make access to abortion even more fraught.
“We’ve learned through the pandemic that telehealth is a very safe and effective way of delivering care to patients,” says Dana Northcraft, founding director of RHITES (Reproductive Health Initiative for Telehealth Equity and Solutions). “There is no reason other than political extremism to take that away.”
A Patchwork of Rights
The story of abortion pill access is also a story of geography.
In the nine months following the Dobbs decision, the WeCount statistics show telehealth abortions rising in almost all states where the procedure is legal, with some of the biggest spikes in California, Colorado, Illinois, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, and New York. Telehealth abortions plummeted or stayed at zero in states with bans.
The report provides the most granular data available, but it doesn’t show a complete picture on the use of abortion pills in the United States. It includes total abortion figures from brick-and-mortar clinics and telehealth-only services but doesn’t break down how many patients opted for the pills over a surgical procedure at clinics like Planned Parenthood, which offer both.
What it does show is the ebb and flow of telehealth abortions based on the particulars of state law. In California, a sanctuary state that shields people who have an abortion or help provide one, telehealth abortions rose from 690 in April 2022 to 1,210 in March 2023. Massachusetts, another protective state, saw telehealth abortions more than triple, from 70 to 230 over those months. In Illinois—one of the last safe havens for abortion in the midwest—telehealth services more than doubled over the same period, from 330 to 750.
Cristina Villarreal, chief external affairs officer for Planned Parenthood of Illinois, says the demand for medication abortion is now up 51 percent at its clinics from the same time last year, and that the organization is “providing more abortion care across the board,” including surgical procedures. Many brick-and-mortar clinics in protected states are having to do more surgical abortions—especially later in pregnancy.
“This is a predictable consequence of abortion bans, because there are fewer places for people to access care,” says Colleen McNicholas, the chief medical officer at Planned Parenthood of the St. Louis Region and Southwest Missouri.
In fact, Illinois is picking up some of that demand from neighboring Missouri, which prohibits most abortions. Before Dobbs, medication abortion accounted for 62 percent of all abortions at Planned Parenthood of the St. Louis Region and Southwest Missouri, which provides abortions across the state line in Illinois. Now, medication abortion accounts for around 55 percent of its abortions.
Out-of-state patients may opt for a surgical abortion because the procedure is almost always effective. Abortion pills are about 98 percent effective for pregnancies up to nine weeks but get less effective after that. A small number of patients may still require a surgical procedure if the medication doesn’t work or causes excessive bleeding—and patients traveling long distances for an abortion may not want to take the risk of pills not working.
Planned Parenthood of the North Central States—which covers Iowa, Minnesota, and Nebraska—has experienced just a 2 percent increase in medication abortion use, compared to a 22 percent increase in surgical abortions since Dobbs. “We are seeing more patients choose a surgical abortion, primarily among patients that must drive long distances to their appointments,” says Ruth Richardson, the region’s president and CEO. These patients are most often coming from Texas, Louisiana, and Missouri, she says.
With clinics in blue states shouldering most of the abortion care burden, Phifer says telehealth services are helping to offload demand on brick-and-mortar clinics. That scenario is playing out in Colorado, where monthly telehealth abortions rose from about 220 in April 2022 to 460 in March 2023, according to WeCount. Nancy Fang, an abortion provider at the Comprehensive Women’s Health Center in Denver, says requests for the pills are actually down at her clinic, but she thinks that’s because so many telehealth services now exist for patients in Colorado. Overall, she says, the center is also doing more procedural abortions and is seeing more out-of-state patients.
Similarly, Kansas—which is surrounded by states that have banned abortion, like Oklahoma, Texas, Missouri, and Arkansas—is one of Abortion on Demand’s highest-volume states. Telehealth abortions became available there in December after a state judge blocked a law that prohibited them. Telehealth caught on quickly in the state, accounting for 80 abortions this January, 100 in February, and 140 in March.
Grant, of Carafem, says she’s also noticing an increase in telehealth patients from rural areas and small towns in blue states that aren’t near a brick-and-mortar abortion clinic. “They now find this as a very acceptable and easier-to-use strategy for abortion care than traveling into an urban setting,” she says.
The Rise of Self-Managed Abortions
The pandemic upended the American healthcare system—but not all of the shifts were bad. The era of social distancing pushed regulators to allow telehealth providers to operate as they never had before. In July 2020, after a coalition of medical groups sued the FDA to loosen regulations and won, abortion providers were able to prescribe mifepristone after an online consultation. This led to the creation of virtual clinics—like Choix, Abortion on Demand, and Hey Jane—which quickly began providing pill-by-mail services in states that decided to permit telehealth abortion services.
This expansion of care came with limits, though. Plenty of states, like Texas, Louisiana, and Arizona, forbade abortion by mail even before they restricted other types of abortion following the Dobbs decision.
Pharmacies still have to get specially certified to dole out the medication, and very few bother. Today, most medication abortion orders in the US are fulfilled by the California-based online pharmacy Honeybee Health, which was the first to do so and ships to 24 states that allow abortion by mail.
In January 2021, the Supreme Court reinstated the FDA regulation requiring women to pick up mifepristone in person—but the FDA refused to enforce it. Online clinics kept operating in the states that allow them, but their federal legal status remained precarious until January 2023, when the FDA made dispensing the pills by mail permanently legal. “It was very validating,” says Jessica Nouhavandi, Honeybee Health’s cofounder and head pharmacist. “We operated in a gray space for a long time because we thought it was the right thing to do. And we were willing to risk everything to do it.”
Still, patients who live in states where abortion is now banned are left with few options, especially if they cannot travel to another state to receive an online appointment or pick up their pills. For them, there remains a different gray space option: a self-managed abortion, where a pregnant person acquires and takes the medication on their own.
While US telehealth companies and brick-and-mortar clinics cannot ship abortion pills to those states, a network of overseas suppliers remains willing to do it, banking on their physical distance from the US and the lack of comprehensive surveillance of the mail. Some of these suppliers are activists, like the nonprofit Aid Access that offers virtual medical support, or the collective of medical professionals known as PrivateEmma. Others are no-frills online stores that simply mail the pills without asking questions or providing medical support. Prices vary—some activist groups provide them for free or at a heavy discount, while for-profit pharmacies can charge anywhere from $100 to $500 for the two-pill regimen.
But there are risks. While Aid Access founder Rebecca Gomperts says it’s “very rare” for packages to get confiscated, buyers could still run afoul of their state’s abortion laws. And although groups like Aid Access and PrivateEmma take pains to ensure the safety of the pills they send, the quality of medications from for-profit overseas pharmacies can’t always be guaranteed.
Because these abortions are performed outside the US healthcare system, they are difficult to track. Last November, a paper in the Journal of the American Medical Association examined how requests for self-managed abortions had changed after Dobbs. The study examined anonymized data provided by Aid Access, and found that requests rose 160 percent in the months following the ruling, from a baseline of 83 requests per day from September 2021 to May 2022 to 214 per day between June 24 and August 31 2022.
That the rise in requests was not a brief spike; instead, it reflects a new reality in which self-managed abortions have a more prominent role in the US, says lead author Abigail Aiken, the principal investigator of Project SANA at the University of Texas at Austin. Since the study was published, Aiken has continued her research, and says that from September 2022 to March 2023, requests increased further, to 234 per day. Aiken says Project SANA’s newest analysis shows that requests increased in the wake of the Texas mifepristone lawsuit; in April 2023, they saw 344 average daily requests, a significant boost.
Pill suppliers have confirmed this upswing in interest, particularly in states where legal access is restricted. “There has been an increase in requests post-Dobbs,” says Billy Adams, a spokesperson for PrivateEmma, adding that today Texas remains the state with the highest number of requests overall. “I believe that Texans are extremely worried,” he says. One recent Texas-based customer offered to pay PrivateEmma for 20 pills, so the organization could then dole them out to people in need.
While self-managed abortions are on the rise post-Dobbs, they are unlikely to offset the decline in abortions provided in the formal healthcare system, says Suzanne Bell, assistant professor of population, family, and reproductive health at the Johns Hopkins Bloomberg School of Public Health. “Most people are still not aware of this option, it can be costly, and delays in pregnancy recognition, coupled with delays in receipt of the medication abortion pills via mail, will push many people beyond the FDA-approved gestational limit of 10 weeks for medication abortion,” she says.
The Fate of Abortion Pills
Medication abortion is now the next front in the larger battle over reproductive rights in the US.
And it’s a battle that is already incredibly messy. The Texas judge’s April ruling triggered widespread uncertainty about the future of access to mifepristone, in part by hinting that an antiquated anti-vice law known as the Comstock Act might apply to it, despite the Biden Administration emphasizing that it does not. The Supreme Court’s stay temporarily hit the pause button, kicking the matter back down to the US Fifth Circuit Court of Appeals. In May, a panel of judges heard oral arguments but have not issued a decision—and it is not clear when they will.
The Texas ruling also conflicted with one made the same day by a judge in Washington state, directing US authorities to preserve mifepristone access in 17 states and the District of Columbia.
Meanwhile, new suits have been filed in an effort to maintain mifepristone access, including a pair of unrelated suits challenging state restrictions in North Carolina and West Virginia. GenBioPro, the primary US manufacturer of generic mifepristone, is the plaintiff in the West Virginia suit, and is also suing the FDA, arguing that the regulatory body should not comply if the courts order mifepristone off the market.
Even information about abortion could become endangered. In April, state lawmakers in Texas introduced a bill that would outlaw simply providing facts about abortion access.
This legal limbo has bewildered people who are not sure whether they can lawfully access abortion pills. “I think the primary intent of a lot of these [anti-abortion] lawsuits is to confuse, and we definitely see patients coming forward, not clear on what they can and cannot do,” says Kiki Freedman, CEO of Hey Jane.
“It has been extremely stressful for patients and providers alike,” says Cindy Adams, CEO of telehealth abortion provider Choix, which serves six states. The futures of these companies depend on the caprices of a court system frequently in conflict with itself, as well as potential changes in US state and federal laws.
If the Supreme Court does ultimately rule in favor of restricting mifepristone access, the implications will be massive. The courts have never revoked an FDA-approved medication before, so there is no precedent to follow. Nor is it even clear that they can revoke one without establishing that doing so poses an immediate health threat. Even if the courts stop short of a ban, they could roll mifepristone regulations back to what they were pre-pandemic, once again requiring in-person visits for patients—a move that would dismantle the new telehealth access available within the US.
Undermining the FDA’s authority may be too radical even for the most conservative judges. Skye Perryman, a lawyer for GenBioPro and president of the legal advocacy organization Democracy Forward, believes that there will be “industrywide implications” if right-wing interests are able to circumvent the FDA. The move could, for example, hobble the development of new drugs by creating a chaotic regulatory environment. Medications that special interests groups find controversial could also be banned despite evidence that they are safe and effective. Obvious next targets would be birth control medications or vaccines.
More than 500 pharmaceutical executives and industry insiders have already sent a letter urging the courts to respect the FDA’s power to regulate medicines, and filed a brief with the Fifth Circuit. “The district court’s lawless opinion will empower any plaintiff to grind drug approvals to a halt, disrupting patients’ access to critical medicines,” they wrote. “That outcome would chill crucial research and development, undermine the viability of investments in this important sector, and wreak havoc on drug development.”
Providers Aren’t Backing Down
Honeybee, the US online pharmacy that supplies mifepristone, plans to continue providing it as long as the drug’s FDA approval remains valid, Nouhavandi says. And US-based telehealth providers plan to keep helping patients for as long as they can. Choix CEO Adams thinks that even if the Fifth Circuit bans mifepristone, the ruling will be appealed, and the drug will continue to be available until the Supreme Court weighs in again. “Our sense is the stay is likely to be in place for the next year or so,” she says.
And even if mifepristone becomes illegal in the US, medication abortion will persist. “A total ban would be catastrophic,” Adams says, as it will become an obstacle to prompt healthcare—but she points out that it will not stop overseas suppliers, both nonprofit and commercial, from sending pills into the US.
PrivateEmma, for example, is anticipating an additional swell in requests if mifepristone is banned, Billy Adams says. In addition to ramping up its supply, the group would create a 24/7 hotline staffed by doctors to answer questions.
There’s also a backup plan. Many abortion providers are prepared to switch to a misoprostol-only regimen, providing just the second pill rather than the preferred two-pill regime. Though it is marginally less effective than taking both pills and carries a higher risk of side effects, the World Health Organization and the American College of Obstetricians and Gynecologists both see a misoprostol-only abortion as an acceptable alternative.
Freedman is still optimistic that Hey Jane and other telehealth clinics will continue to be able to do their work. “I would like to maintain faith that the scientific entities of our government will preserve integrity in making decisions around medicine,” she says. “We’d like to believe that logic will prevail in the end.”
