Women in states that ban abortion will still be able to end unwanted pregnancies with prescription abortion pills ordered online from overseas, though the legal situation is murky and carries potential risks.
The Supreme Court on Friday overturned the landmark 1973 Roe v. Wade ruling that protected abortion as a constitutional right across the U.S. — allowing states to impose partial or full bans on the procedure.
At least eight states immediately banned all forms of abortion, including medical abortions using the pill, within hours of the Supreme Court’s decision. Health-care providers who perform abortions, and in some cases people who help patients get the procedure, would face criminal prosecutions and yearslong prison sentences. In Missouri, for example, anyone who performs an abortion faces up to 15 years in prison.
However, the states prohibit the prosecution of women who receive abortions, according to the text of the legislation in the eight states. Many women with unwanted pregnancies who cannot travel out of state for an abortion will likely end their pregnancies alone at home with abortion pills purchased online through international telehealth companies like Aid Access.
“Under certain circumstances, it will be possible for women to get medication abortion from these internet providers and self manage their abortion, so it will provide some access to some people but not enough,” said Dr. Jenn Villavicencio with the American College of Obstetricians and Gynecologists.
“People can, with the right information, safely manage their own abortion in the first trimester,” she said.
Aid Access is an international telemedicine abortion provider founded by Dutch physician Rebecca Gompert. Its European doctors provide online consultations and write prescriptions for abortion pills, which are then filled and mailed by a pharmacy in India.
Aid Access told CNBC it will continue mailing pills to women in all U.S. states, including those that banned the procedure. U.S. telehealth providers will be banned from prescribing and sending abortion pills to women in states that outlaw the procedure.
The abortion pill, mifepristone, is approved in the U.S. to end pregnancies before the 10th week of pregnancy. The Food and Drug Administration first approved the medication in 2000, but required women to obtain it in person under a program that monitors certain drugs for safety risks.
Abortion rights advocates fiercely criticized the FDA requirements, arguing that mifepristone had a long and proven track of record as a safe and effective way to end an early pregnancy.
In response to the Covid pandemic last year, the FDA temporarily lifted the requirement that women obtain the pill in person. In December, the drug regulator permanently ended the in-person requirement, which will allow certified pharmacies in the U.S. to fill and send prescriptions by mail.
The pill, or medication abortion, has become increasingly common in the U.S. In, 2020, more than 50% of abortions in the U.S. were with the pill, according to a survey of all known providers by the Guttmacher Institute.
Aid Access will be one of the few options left for many women in U.S. states that have banned the procedure. The organization’s European doctors face little legal risk from state laws in the U.S.. However, health-care providers in the U.S. that offer abortions pills through telehealth into states that have banned the procedure would potentially face legal consequences.
In telehealth, the patient’s location generally governs which laws need to be followed, said Amanda Allen, senior counsel and director at the Lawyering Project. A health-care provider in New York, where abortion is legal, that offers the pill through telehealth to a patient who lives in Texas would be subject to Texas law, Allen said. The provider could face criminal penalties and their medical license could come under scrutiny, she said.
“Unfortunately, that is going to mean very, very few choices for people in these ban states,” Allen said. “Telemedicine is not going to be a band aid to the situation,” she said.
Abortion bans went into effect in Arkansas, Kentucky, Louisiana, Missouri, Oklahoma, South Dakota, Utah and Alabama on Friday. Idaho, Tennessee and Texas will implement bans in 30 days. Bans in Mississippi, North Dakota and Wyoming are set to take effect after a certification process.
Nearly all of these states specifically outlaw the prescription or administration of any drug to terminate a pregnancy, while in other states the bans are written so broadly that they include the pill as well.
“They all apply throughout pregnancy to any method of abortion so medication abortion would not be available to people in those states,” said Elizabeth Nash, an expert on state abortion laws at the Guttmacher Institute. Women will have two options — cross state lines or order pills online.
“People are increasingly using online access,” Nash said, “but we’re going to see unfortunately how many more people will seek care that way.”
Crossing state lines
Abortion rights advocates in the U.S. are finding ways for women to maintain access to the abortion pill despite state bans.
Just The Pill, a Minnesota online clinic that provides abortion pills through telemedicine, is setting up mobile clinics in states where abortion is legal that border states where the procedure is banned or severely restricted. Patients would cross the border for a consultation and then the pill would be mailed to an address, UPS access point or general delivery at a Post Office for pickup in the state where it’s legal.
Just The Pill plans to launch a mobile clinic in Colorado later this month and bring a group of patients across the border from Texas, which had already banned abortion after the sixth week of pregnancy. Just The Pill is looking at New Mexico and Illinois as future sites for mobile clinics because they are close to states that have either already banned abortion or will do so soon.
The strategy carries legal risks. It’s unclear if states that have banned abortion will attempt to take action against providers in other states that offer the procedure to women crossing state lines.
“Our plan is to move into safe states, where abortion is protected either constitutionally or otherwise, and to help people travel to those safe states to provide care knowing that there are there’s going to be lots of legal risks,” said Dr. Julie Amaon, the medical director at Just The Pill.
President Joe Biden and the U.S. Justice Department, in stern a warning on Friday to states banning abortion, said they will exercise all power at their disposal to protect women crossing states lines to receive the procedure in states where abortion remains legal.
“If any state or local official, high or low, tries to interfere with a woman’s exercising her basic right to travel, I will do everything in my power to fight that deeply un-American attack,” Biden said in an address to the nation after the Supreme Court ruling.
Robin Marty, the operations director of West Alabama Women’s Center, said in some cases women who have had complications from the pill or thought they were having complications have been refused care at emergency rooms at some hospitals in Alabama.
“Anyone who is having any sort of pregnancy complication needs to understand that there is nothing that they need to say to a doctor when they go in other than ‘I’m pregnant – I’m scared and I think I’m having a miscarriage,” Marty said. “That is all the information that they need to provide. Doctors owe them an examination. Emergency rooms owe them medical care.”
Websites such as Plan C are also providing information on how patients are finding ways to obtain the abortion pill. In some cases, people are setting up telehealth consultations in states such as California, where abortion is protected, through services where a video visit is not required so they do not have to provide their location. They then set up a virtual mailbox on the Internet, have the abortion pill mailed to that address, and then have the package forwarded to their home, according to Plan C’s website.
There are also several internet companies that mail generic abortion pills directly to people’s addresses without prescriptions or consultations. The medication costs anywhere from $200 to more than $400 depending on the website. Plan C has ordered medication from several of these companies, tested them at a lab and found they were real abortion pills, said Elisa Wells, the group’s co-founder. Plan C published results from its tests in the journal Contraception in 2017.
However, the pills have not been inspected by the FDA, so their safety and effectiveness is not guaranteed by a U.S. regulator. It’s also unclear who runs these companies and where in the world they are based. The FDA has in the past sought to shut down such websites.
“There is never a guarantee, but based on our test purchases and initial laboratory testing, the sites we list on our website appear to provide real pills of adequate quality,” Wells said.
Dr. Abigail Aiken, an expert on reproductive health at the University of Texas at Austin, said pills from online websites would have to be regularly tested to ensure they are authentic. Aiken said it is important to make sure the pills come in a blister pack that is properly sealed, because exposure to air can impact the medication’s effectiveness. She also said the advantage of Aid Access, as opposed to other websites, is they have staffed help desk to answer patient questions and provide information about the process.
Aiken and Aid Access published a study in The Lancet in February that examined the records of nearly 2,800 people in the U.S. who used abortion pills prescribed by the group from March 2018 to 2019. About 96% of the patients reported that they successfully ended their pregnancy without surgical intervention. One percent of patients reported a serious side effect where they needed treatment, including blood transfusion and intravenous antibiotics. No deaths were reported.
Aid Access offers financial assistance to patients with a sliding scale that generally ranges from $55 to $150 depending on the patient’s circumstances, according to Robin Tucker, a nurse practitioner works for the group in Maine, Maryland and Virginia. Delivery from pharmacy in India to the U.S. generally takes one to three weeks, though Aid Access is looking at finding a pharmacy in Mexico or Canada to shorten delivery time, Tucker said.
It is illegal in most cases for U.S. citizens to import drugs for personal use from outside the country, though the individuals usually aren’t targeted for prosecution. The FDA issued a cease and desist letter to Aid Access in 2019, though the organization has continued mailing pills.
Biden, the Justice Department, and the Health and Human Services Department on Friday indicated that they will take action to expand access to the pill within the U.S., though it’s not yet clear how.
Legal risk for women
Although the laws in states poised to ban abortion do not hold the pregnant person legally liable for an abortion, Allen warned that there are instances where local authorities have sought to prosecute women for having abortions, even though the law does not permit it.
“These laws might say they exempt the pregnant person from liability, but in practice, we don’t even need to speculate about how this is going to pan out in real life,” Allen said. “And that’s because people are already being prosecuted for their pregnancy outcomes in this country.”
In April, a women in South Texas was charged with murder after allegedly having a self-induced abortion, although state law exempts women from prosecution for having abortions. A hospital reported her to the country sheriff’s department. District Attorney Gocha Allen Ramirez ultimately dismissed the indictment, saying it is clear that she “cannot and should not be prosecuted for the allegation against her.”
How the pill works
The abortion pill is about 97% effective at ending pregnancy though it’s most successful when taken at 49 days or earlier, according to a report by the American College of Obstetricians and Gynecologists. Common side effects include nausea, vomiting, diarrhea, weakness, headache, dizziness, fevers and chills.
Women take one mifepristone pill orally and then four misoprostol pills one to two days later. The patient places two misoprostol pills between the cheek and gum on one side of the mouth and the other two pills on the other side of the mouth and waits for them to dissolve. Mifepristone blocks the hormone progesterone, which allows the lining of the uterus to break down and prevents the pregnancy from continuing. Misoprostol causes contractions that empty the uterus, basically inducing a miscarriage.
Serious complications are rare but they can include an incomplete abortion, blood clots in the uterus, bleeding too much, infection and allergic reactions, according to Planned Parenthood. In the event of an incomplete abortion, the tissue left in the uterus might need to be removed through surgical abortion.
Women who take the abortion pill should have access to a phone and transportation to a medical facility in the event serious complications do occur, according to the National Abortion Federation. However, it’s unclear how much access women in banned states will have to health-care if they are one of the rare patients who has complications from the pill. At least one clinic in Alabama said women have been turned away from emergency rooms when they sought care for too much bleeding.
Some people should not have medication abortions. They include women with ectopic pregnancies because the pill does not terminate these pregnancies. Women with blood clotting disorders, adrenal failure, inherited porphyria, those on long-term steroid therapy or who have a history of allergic reactions to the pill also should not take it, according to the FDA. Women with IUDs in place should have them removed before having a medication abortion.