The Future of Abortion Access Is Coming to Your Mailbox

This article is part of POPSUGAR's project Roe, 50 Years Later, a collection of stories marking what would have been the 50th anniversary of Roe v. Wade. This moment comes more than six months after the Supreme Court struck down the constitutional right to an abortion in Dobbs v. Jackson Women's Health Organization, and these stories seek to mark the past, present, and future of abortion access in America.

There's a significant delivery making its way to mailboxes across the country: abortion pills. These packages have become increasingly important after a year that saw substantial rollbacks to abortion access in various parts of the country.

Using a pill regimen to end a pregnancy (also known as a medication abortion) had been rising for years before the Supreme Court's June 2022 ruling in Dobbs v. Jackson Women's Health Organization, which took away the constitutional right to an abortion. In 2020, the abortion pill accounted for 53 percent of facility-based abortions in the United States — the first time pill usage surpassed surgical procedures, according to the Guttmacher Institute. The number significantly increased from only three years prior, when 39 percent of abortions were administered with pills.

Now, in a post-Roe America in which more than a dozen states currently have abortion bans in place, experts say abortion induced by pills is the future. From getting the abortion pill delivered from overseas to finding workarounds with providers out of state, patients in states with restricted access are increasingly turning to this option. The procedure is widely considered safe and effective up to 10 weeks in pregnancy. (Overall, 80.9 percent of abortions in 2020 occurred before the 10th week of pregnancy, the Centers for Disease Control and Prevention reports.)

As Bethany Corbin, an attorney specializing in women's health, contraception, and abortion, puts it: "I think obtaining abortion pills by mail is going to become a primary method of abortion access, particularly in states where abortion is restricted."

Policies around accessing abortion pills by mail are also changing rapidly. On Jan. 3, the Food and Drug Administration expanded the distribution of abortion pills to retail pharmacies. Under the new regulation, certified pharmacies can distribute mifepristone — which is used in conjunction with misoprostol, a more easily accessible drug, to end a pregnancy — in person or through the mail to patients who have a prescription from a certified provider.

Under the new rules, providers and pharmacies seeking certification must complete prescriber agreement forms and pharmacy agreement forms, respectively. Nationwide pharmacies such as CVS and Walgreens have announced they will apply for certification. Before this ruling, certified doctor's offices and clinics or specific mail-order services were the only avenues to access mifepristone, and there was also an in-person requirement in place, which the FDA did away with as well.

"Decades of monitoring the use of mifepristone in this country and in others have shown that it is a safe and effective method for inducing abortion," Julia Arnold VanRooyen, MD, a gynecologic surgeon and reproductive-rights advocate, tells POPSUGAR. "Allowing pharmacies to dispense mifepristone with a prescription will increase access to medication abortion for those who live in states that allow abortion."

Dr. VanRooyen points to the United States's high maternal mortality rates as even more reason for expanded abortion-pill access. According to the CDC, the maternal mortality rate in 2020 was 23.8 per 100,000 live births. The rate for Black women was 55.3 per 100,000, which was 2.9 times the rate for non-Hispanic white women.

As a whole, it's critical to note that abortion bans are more detrimental to people of color. According to the CDC, in 2019, abortion rates were 3.6 and 3.3 times higher among Black women and Hispanic women, respectively, compared with non-Hispanic white women. Limited abortion access will further disproportionately impact these patients because of historically racist healthcare practices, reduced transportation access, fewer savings, and other factors, a report from the Kaiser Family Foundation found.

According to Corbin, the new FDA policies will not be felt everywhere. "The political nature of abortion may still deter some pharmacies from dispensing abortion medication," she says.

Most pressingly, the latest expansion doesn't include states in which abortion is banned because any regulated abortion, whether via a surgical procedure or through distributed pills, is prohibited. In recent days, officials in states like Alabama and Florida have also explicitly said that the FDA rule changes will not apply to their residents. Additionally, 18 states currently require a clinician to be present when abortion pills are taken, according to the Guttmacher Institute.

"I believe we're going to see lawsuits regarding whether these state laws, which limit access to abortion pills by mail, are lawful, given that the FDA has said it is safe and effective to dispense abortion pills by mail," Corbin says. "It's currently unclear whether state abortion bans can override the FDA's approval of a drug."

President Joe Biden's Department of Justice, meanwhile, has assured the US Postal Service (USPS) that it can continue to deliver packages of abortion pills nationwide, even in states that outlaw abortion. But this approval could change if a conservative administration moves into the White House, experts say. And antiabortion organizations and lawmakers are currently seeking other avenues to crack down on the illegal distribution of abortion pills via mail, The Washington Post reports.

In many instances, lawyers and doctors struggle alongside pregnant people to decipher laws regarding when and how pills can be distributed. This uncertainty can leave doctors facing a dilemma: they could risk punishment for prescribing the abortion pill, says Shari Karney, a victims' rights attorney who represents victims of sexual assault, rape, child sex abuse, and sexual harassment.

Navigating the restrictions in an individual's situation can become so time-consuming that the window for an abortion passes. Take one case Karney dealt with a few months ago, for example: a 15-year-old in Texas was impregnated by her stepfather, Karney says. In Texas, abortion is banned in every case except a life-threatening medical emergency, and anyone under 18 requires parental permission or a judicial bypass.

"The laws in Texas are so difficult, complex, and punitive that I had to refer her to a Texas lawyer friend who helps victims of child sexual abuse," Karney says. "It took so long to try and get her legal and medical help that she was forced to carry the pregnancy to term. She is at severe medical risk, as her body is not fully developed enough to carry this pregnancy safely."

Since the Dobbs ruling, advocates say there has been a shift toward self-managed abortions — via pills that are obtained through avenues that skirt the law — in restrictive states. Nonprofit abortion-rights organizations, such as Mayday, provide extensive resources regarding accessing abortion pills, regardless of where in the United States you live.

"Medication abortion pills are safer to use than over-the-counter Tylenol," Jennifer Lincoln, MD, IBCLC, president and executive director of Mayday, says. According to Dr. Lincoln, people who take the two-pill regimen and "have had thorough counseling either in person, virtually, or via reading material need emergency care less than one percent of the time." She recommends that anyone considering a medication abortion — especially a self-managed one — review information on digital footprints, safety, and legal risk, as well as speak to Repro Legal Hotline about any further questions. Recently, a ProPublica investigation found that some online pharmacies providing pills could be sharing sensitive data with Google and other third parties.

According to Corbin, one avenue some patients in restricted-access states are using involves scheduling a telehealth consultation with a provider in a state with greater access and then using mail forwarding to get the pills in hand. In this scenario, patients set up a virtual mailbox within a state with greater access, but when the abortion pills ship, they are forwarded to the patient's actual home address. This workaround allows them to access out-of-state care without having to travel physically, Corbin says.

Another form of self-managed abortion is happening when patients receive medication from overseas. This could involve either having a known person ship or deliver pills or ordering pills through an overseas company. Multiple experts who spoke to POPSUGAR emphasized that it is difficult for the individual to be caught or for the state to punish an international organization.

"In these cases, the pills are often manufactured overseas and then imported into the US," Corbin says. These pills are not always FDA approved and may lead to someone taking an unsafe substance — an issue that will disproportionately impact people of color, she adds. (The FDA does not recommend buying abortion pills online or transporting them from overseas.)

However, there are several trusted organizations distributing pills from overseas, the most well known of which may be the nonprofit organization Aid Access. Rebecca Gomperts, MD, PhD, of the Netherlands started Aid Access in 2018 with the purpose of providing abortion pills and science-backed answers to people living in areas with abortion restrictions.

As Dr. Gomperts describes, patients fill out a form with questions such as their age, how far into their pregnancy they are, if they have a person to be with them for the abortion, and their feelings around the abortion. Their answers are then reviewed by a doctor to ensure they are a candidate for a medication abortion. The doctor then writes the prescription, and a partner organization ships the medicine. A donation of $105 to $150 (depending on location) is suggested, but anyone unable to pay it is asked to donate what they can. The pills expire in about three years, according to Dr. Gomperts.

Recipients then receive an email with detailed instructions. They take mifepristone first, then misoprostol a day later. Eventually, they experience something akin to a miscarriage, Dr. Gomperts says. People in the US can access a hotline of doctors at any time, she adds.

A February 2022 study from the journal Lancet Regional Health looked at patients who accessed abortion pills via Aid Access and found a 98 percent success rate in ending the pregnancy through the provided abortion pills for people who were less than 10 weeks along. The same percentage of people said they were satisfied with the experience.

At Aid Access, requests for abortion pills across 30 states increased from a mean of 82.6 per day between September 2021 and May 2022 to a mean of 213.7 per day between June and August 2022, according to a research letter from the Journal of the American Medical Association. Currently, Aid Access still ships abortion pills to people in all 50 states.

Dr. Gomperts acknowledges the legal risk for herself and people undergoing medication abortions in states where it's banned. While penalties have generally targeted providers, some political leaders have spoken out about prosecuting patients. She points to a recent announcement from Steve Marshall, the attorney general in Alabama — a state that has a near-total abortion ban. While the law doesn't penalize abortion-seekers (though it does punish providers), Marshall suggested that individuals using the abortion pill could be prosecuted under a 2006 law that prohibits a person from exposing children to chemicals (previous cases have held that the law applies to unborn children). In this case, people could be prosecuted for medication, but not surgical, abortions. Dr. Gomperts also says she is concerned for providers and patients regarding inequality in the legal system, such as racial profiling.

That's why Dr. Gomperts advises patients to try to get their hands on mifepristone and misoprostol as soon as they can in the event that they will need the abortion pill down the line.

"If you can, ask your doctor to prescribe it, because it's now in the pharmacies," she says. "Make sure you have the pills in your home so that you don't have to deal with it when you're pregnant and you're stressed out. I think it should be like the morning-after pill — just have them in your medicine cabinet." Image Source: Getty / zenaphoto, Nenov, ELISA WELLS, and MirageC and Photo Illustration: Michelle Alfonso