On an April evening in Houston, 26-year-old Shannon, a pseudonymous tech in a medical diagnostics lab, sat on the closed lid of her toilet and tried to steady herself against a room that appeared to be spinning. Her breathing was shallow, her palms were clammy and her heart beat furiously out of her chest. “No, no, no,” she thought to herself. “Not now.”
In her hand was a positive pregnancy test, its double pink lines foreshadowing a future she wasn’t ready for. “It wasn’t the result I wanted,” she explains. “My boyfriend and I were still finishing up our graduate degrees and in the process of finding jobs. We were in no position to have a child.”
She knew she needed an abortion, but her decision couldn’t have come at a worse time. With coronavirus raging, Texas Governor Greg Abbott had just announced that abortion clinics like Planned Parenthood didn’t qualify as “essential services” and had to close, and her gynecologist had shuttered her doors at the start of quarantine. A quick search for other providers in her area turned up nothing, and the reality began to sink in: If she wanted an abortion in the midst of pandemic Texas, she wasn’t going to be able to get one from a clinic.
“I was terrified,” she tells me. “It was a really dark feeling to think that, in a state of rabid pro-lifers, that I might have no control over a situation that could drastically affect my life. All because of some obstacles that a man [Abbott] put in place to make a difficult situation even harder.” It was, she says, a “really shitty time to get pregnant.”
Determined not to give up, she started researching other options, eventually coming across a website called Plan C, a researcher-run information hub sponsored by the National Women’s Health Network that aims to mainstream the use of at-home abortion with the drugs mifepristone and misoprostol. It was there that she discovered that she didn’t need to go to a clinic at all — she could just order the pills online.
The site gave her a variety of options for doing so, ranking them by the quality and reliability of products and services. Some offered digital consultations with doctors who provide medical support and prescriptions via telemedicine, a growing practice often referred to as “teleabortion.” Others took the doctor out of the equation entirely, offering up online marketplaces of abortion pills available at the click of a button on sites like MedSide24 and AbortionRx. Both, says Plan C co-founder and co-director Elisa Wells, are “safe and effective options for early abortion.”
Shannon went the non-doctor route, deciding on AbortionRx after reading a favorable account of it on Plan C. Also hugely popular among women on Reddit, AbortionRx claims to be the “#1 Online Pharmacy for Women’s Care” and the “Most Reliable Abortion Clinic for Women Worldwide.” The site offers a selection of “FDA-approved” birth control and abortion pill options ranging from $99 to $399, and promises to ship them “quick and on-time,” from an undisclosed foreign location, directly to customers’ homes. It didn’t seem to be explicitly illegal to order from them, so Shannon put in an order for an “RU486 kit” — a combi-pack of mifepristone and misoprostol — tacked on an extra $50 for expedited shipping and waited for her order to arrive.
Exactly seven days later, she received a small, unmarked brown envelope with a handwritten address and zero mention of “women’s products” or anything else on the package that would have given it away. As she tore through its tape and handwritten label, something occurred to her. I just ordered an abortion online, she thought. Why don’t more people know about this?
In a pandemic-stricken country with some of the strictest abortion legislation in the Western world, more people probably should. At-home abortion with pills isn’t only more affordable, convenient and quarantine-proof than clinic-based care, it’s also exceedingly safe and effective. Mifepristone, the first drug in the pair, has a better safety record and less adverse effects than Tylenol, Viagra and penicillin. Misoprostol, the drug you take after it, is a common ingredient found in everything from ulcer medications to arthritis pills, and is available over-the-counter in many countries for no more than $5 to $7. When taken together before the 10th week of pregnancy, they’re 95 to 98 percent effective at inducing the miscarriage needed for abortion.
This combination of drugs, Wells points out, is the same one prescribed by clinicians at Planned Parenthood, recommended by the American College of Obstetricians and Gynecologists and approved by the World Health Organization for the termination of early pregnancy. However, since mifepristone is heavily regulated in the U.S. — for political reasons, not medical ones — it’s not always possible to take them together. Many women end up taking misoprostol alone, which, according to a meta-review of nearly 13,000 pregnant women, is effective between 78 and 94 percent of the time, depending on the dosage and method of administration. In any case, both abortion drugs are legal to take in all 50 states when prescribed by a doctor for that specific purpose.
Both drugs have been available in clinics and by telemedicine for years, but there’s been a much greater demand for them lately. Driven in part by repressive legislation from conservative states that limits access to abortion and the growing preference for the convenience, privacy and comfort of self-managed care, pills have become the preferred alternative to the high cost, over-regulation and occasional inaccessibility of clinics in certain states. (It doesn’t hurt that they allow women to bypass the gauntlets of pro-lifers that often picket outside clinics to terrorize them, either.)
Nothing, however, has put the importance and necessity of abortion pills into focus quite like the pandemic. With much of the country still under quarantine amidst an ever-raging virus, interest in these pills — and the services that provide them — has soared to new heights. As unemployment rises, economic insecurity runs rampant and people’s options for travel and childcare become severely limited by quarantine, abortion pills have emerged not just as a mere convenience, but as the de facto option for safe and effective abortion during COVID.
At the same time, this type of care presents women with a new frontier of choice they can use to circumvent the spate of restrictive new abortion legislation conservative lawmakers have passed since the pandemic began. Though states like Florida, Ohio and Tennessee have capitalized on the panic and disarray to further limit women’s access to clinics with heartbeat bills and clinic closures, abortion-by-internet bypasses the clinic entirely and tips the balance of power back into the hands of women themselves. “Abortion opponents really don’t know what to do with that,” says Jill Adams, the executive director of the reproductive justice lawyering service If/When/How. “Their whole framework is built around limiting abortion care in clinics, not at home.”
Aid Access is one of the better-known and more reliable physician-based telemedicine services that helps women manage their own abortions from home. Operated by Dutch physician and reproductive rights activist Rebecca Gomperts, the program uses a network of U.S.-based physicians and pharmacies to ship abortion pills to anyone in the country who is less than nine weeks pregnant. Unlike many clinic-based abortions, no lab work or ultrasounds to confirm the pregnancy are necessary; all a patient has to do is confirm that they are pregnant and complete an online questionnaire, which Gomperts personally reviews to see if they qualify.
If they do, she connects them with clinicians in the U.S. who write a prescription that they can either fill at their local pharmacy or have delivered to their home. Most often, the script is just for misoprostol, though — New York and Washington are the only two states in which Aid Access is currently shipping both medications directly to patients.
Not that most people in the other 48 states really mind. Misoprostol is still an effective, convenient and quarantine-friendly option, and Aid Access gets it to patients for cheap. While they do ask for a small donation to support their services, they also waive this fee for anyone who can’t pay. Most people walk away with little more than a $35 dent in their bank account, and they usually get their pills within just a few days. The low price tag is almost entirely due to patient donations — many people pay more than their fare for Gomperts’ service so that she can help others, too.
Aid Access has been a godsend for women who can’t afford or access clinic-based care during the pandemic. Between March 20th and April 11th alone, they saw a 27 percent increase in requests for self-managed abortion care, especially from people in conservative states like Texas and Ohio. But it’s also been prone to the same COVID-based complications as any business that deals with shipping.
Originally, Aid Access provided prescriptions that patients could get filled through an online pharmacy based in India, but when the country closed its airports on March 20th to curb the virus’ spread, Gomperts was unable to get the mifepristone plus misoprostol combi-packs to her U.S. patients, and scores of women were left with little recourse. And while Aid Access is back up and running — this time out of the U.S. — many women were forced to look elsewhere for help.
Amy, a 26-year-old office administrator in Portland (and another pseudonym), was one of them. In early April, a full week of non-stop morning sickness tipped her off to the fact that her birth control pills might have failed. “I was pretty upset,” she says over Reddit DM, explaining that she takes medication that causes birth defects and shares a rare genetic condition with her boyfriend that they’re both determined not to pass on. “I couldn’t keep the child even if I wanted to, so for us, the decision was easy.”
Aid Access was her first choice for safe care during COVID, but after learning about their backlog, she decided to try Planned Parenthood instead, hoping to snag the in-person appointment she needed for the mifepristone combo. To her surprise, they turned her away. They were trying to limit contact during COVID, they told her. Maybe she’d like to try teleabortion instead? The phone operator kept her on the line while she rummaged around her desk for a number. “Here,” she said after a beat, “try TelAbortion.”
TelAbortion is an FDA-approved research study to evaluate the use of telemedicine to provide for medication abortion. It’s similar to Aid Access in that there’s a doctor on the other end of the line, but the qualification requirements are much more involved. In addition to enrolling in the study, patients must complete an ultrasound or pelvic exam to confirm that they’re pregnant as well as have a video call with a physician to answer any questions and ensure they want to proceed. “It’s essentially the same process as a clinic abortion, only the patient doesn’t have to go to the clinic at all,” explains Elizabeth Raymond, a senior medical associate at Gynuity Health Projects, which oversees the study.
Right now, TelAbortion has a network of providers in 11 states that have FDA approval to ship both misoprostol and mifepristone to patients by mail, making it an attractive option to women looking for an at-home abortion with both drugs and a healthy dose of medical oversight (though a federal judge ruled last week that the FDA couldn’t enforce regulations that prohibited clinicans from mailing pills to patients during the pandemic).
Amy liked the sound of that, so she enrolled in the study, completed her lab work and had her consultation. Her mifepristone arrived via FedEx the next day. Once she received it, she picked up the misoprostol from her pharmacy — along with some nausea medication and a bottle of 800 milligrams ibuprofen to help with the pain — and was able to have her abortion later that night. “It was nice to be able to take the pills when it was convenient for me,” she says. “It’s so hard navigating the options, especially during COVID, so I’m thankful that there was an option like this available.”
Many other women are, too. Interest in TelAbortion has increased dramatically since the pandemic began, and Raymond says there are now twice as many women enrolled in the study as there were in March. Before the virus hit, they were offering services in 11 states, but they’ve recently added two more — Illinois and Maryland — as well as the District of Columbia. This, Raymond says, is a direct result of how COVID changed the way women access care. “People don’t want to go to clinics right now,” she says. “They’d rather stay at home where they know they’re safe.”
Raymond also suspects that the Supreme Court’s recent ruling that insurance companies can opt out of mandatory birth control will increase interest not only in TelAbortion, but any service where women can access both birth control and abortion pills. “Anytime you take away birth control, you see a rise in unwanted pregnancies,” she says. “More unwanted pregnancies generally means more abortions.”
TelAbortion, like Aid Access, has its downsides. For one, as mentioned earlier, the FDA requires TelAbortion patients to undergo an ultrasound or pelvic exam, though neither is considered necessary for quality care. Both require the same sort of close-contact medical care that makes clinics — or any indoor space, for that matter — particularly dangerous during COVID. It’s also not as affordable; though Raymond says the cost of the services vary by city and study site, it’s more expensive than Aid Access (unless the patient has Medicaid that covers abortion), and Amy says the service cost her around $250.
More importantly, though, TelAbortion’s services aren’t universal. They can’t be. Laws regarding self-managed abortion and abortion by telemedicine vary from state to state and are often unclear, making it difficult to know whether their study violates any state laws. Out of an abundance of caution, they only operate in areas where they know their services are legal.
Nevertheless, they’ve gotten creative about getting pills to women who live in more abortion-hostile states. Recently, Raymond says they were able to send the drugs to a number of Texas women who drove across state lines to New Mexico to have their consultations and fill their prescriptions. “We don’t do that often, but it’s a feasible workaround for people with the time and resources to travel,” she says. “The practice of medicine occurs where a patient is, so as long as that’s where the consultation takes place, we can still get them pills if they provide us a mailing address somewhere else.”
Shannon was actually in talks with TelAbortion about trying something like that, but she ultimately decided against it. Houston is a 12-hour drive from New Mexico, and she didn’t exactly have a lot of time off. “I work in a medical diagnostics lab,” she says. “All of COVID has been go-time.” Aid Access and in-person clinics weren’t going to work, either; in the “crappy” window of time that her pregnancy took place, Aid Access was stuck in India and clinics in Texas were closed.
The only option she had left, she says, were internet pharmacies. “What else was I going to do?” she says. “A coat hanger?”
Unlike telemedicine services like Aid Access or TelAbortion, internet pharmacies let you order abortion pills online, without a doctor, and with no more fanfare than what’s needed to order takeout. Many of them operate outside of the U.S., often from other countries where abortion pills are either unregulated or fully legal over-the-counter. According to Wells, most sites charge between $149 and $360 for pills, including shipping, and they show up in unmarked packages, on your doorstep, in anywhere from three days to three weeks.
If that sounds like a scam, it doesn’t help that many online pharmacies look like one, too. AbortionRx, the pharmacy Shannon chose, seems particularly suspect. Rife with misspellings, generic stock photos and the sort of sloppy graphic design that usually foreshadows the onset of a Trojan virus, it appears, at least on first glance, to be some sort of hot-pink flytrap for desperate women. Phrases like, “We are here to offer you friendly, informed customer service in addition to save your Hard Earn Money” aren’t exactly comforting, and banner ads for an “XMAS NEW YEAR’S SALE” — in July — don’t give women like Shannon the impression that the site is tended to.
“It definitely sketched me out,” she says. “I could tell it was made by someone whose first language wasn’t English. That doesn’t automatically make it sketchy — I’m not one of those Southern assholes — but it did make me skeptical about the quality of their products and whether or not they were regulated.” She spent the week after her order in a state of mild paranoia, peering out her window in search of unmarked cars and biting her nails over the thought that she’d sunk her money into a scam, or worse, committed a crime. “I was honestly concerned about the legalities of it all,” she says.
Yet, as rough-around-the-edges as they seem, the pills that online pharmacies sell are, for the most part, totally legit. In 2017, Wells and Raymond published a study in Contraception investigating the purity and reliability of abortion drugs sourced from online pharmacies. Of the 20 packages containing mifepristone and misoprostol they ordered from 16 websites, every one contained the active ingredients in sufficient amounts for an abortion. “That was very encouraging,” says Raymond. “I’d caution that we haven’t tested since 2017, but right now, there’s no reason to believe that this is a bad medical option for people who can’t access these drugs from U.S. providers.”
Likewise, ordering them online isn’t necessarily as risky as it seems. While FDA law prohibits individuals from importing pharmaceuticals into the U.S. for personal use, Adams says they’ve also made an administrative decision not to enforce it. In fact, they even offer guidance on their site about how to safely purchase medications over the internet. In it, they state, quite clearly, that they make allowances for drugs that are “for a serious condition for which effective treatment may not be available domestically either through commercial or clinical means.”
Because neither the regulation nor the allowances to it specifically mention abortion pills — nor do they define what a “serious condition” is — the legality of buying them from foreign internet pharmacies is unclear. One could feasibly argue, then, that what they ordered was legal to import.
That said, abortion pills have been used as evidence to charge women with a different, much more serious crime. “Unfortunately, there are prosecutors who are just hellbent on punishing someone who they think has ended a pregnancy, or helped another person end a pregnancy,” says Adams. “They’ll punish them with any law they can find.”
In past cases, women who self-manage their own abortions with pills (and other methods like herbs and manual aspiration) have been charged with drug possession, practicing medicine without a license, neglect, abuse of a corpse and even concealment of birth, an old-timey illegality that prohibits women from disposing of a newborn’s corpse without a burial license. Unfortunately, Adams says, those who are already at greater risk of criminalization due to their race, gender identity or economic status face increased risk of prosecution.
Purvi Patel, an Indian-American woman in Indiana who was charged with feticide and neglect after attempting to manage her own abortion with pills in 2013, is one of the more alarming examples. After seeking medical help for the uninterrupted bleeding she was experiencing after miscarrying, Patel admitted to a doctor at a Catholic hospital that she’d had an abortion. The doctor reported her to police, who discovered that she’d purchased pills by going through her phone. For this, she received a 20-year sentence, becoming the first woman in U.S. history to be convicted and charged with feticide for having an unlawful abortion (her sentence was later reduced, but not before she spent three years in prison).
Thankfully, though, instances like hers are extremely rare. Because misoprostol doesn’t show up in the blood during or after a medical abortion and there’s no physiological difference between a medically induced miscarriage and a natural one, it’s nearly impossible to prove that a person actually ingested an abortion drug. As such, Adams says only very small number of people in the U.S. have been prosecuted for charges related to using abortion pills obtained online.
Still, Raymond warns that while online pharmacy abortion drugs appear to be okay, ordering them is still nowhere near as safe as getting them from an FDA-approved source within the U.S. “Online pharmacies are an option, but they’re not a solution,” Raymond says. “Buying pills of unknown origin — from some other country and a doctor you don’t know — that’s not ideal. We need to do better in this country with our own physicians and our own regulated drugs.”
Until then, however, women like Shannon are being “pleasantly surprised” by the abortion options they’re discovering during COVID. She took the mifepristone on a Friday evening without side effects. Then, 24 hours later, she took the misoprostol. “I started having pretty serious cramping, chills and an upset stomach about three hours later and the bleeding started shortly after,” she tells me. “The heavy cramping and chills started to subside about an hour and a half later, and I ended up going to sleep for the rest of the evening.” It wasn’t pleasant per se, but it wasn’t awful, either.
What it was, she explains, is relieving. “I was very thankful,” she concludes. “To be able to manage my own abortion from home — especially during the pandemic — made a very stressful thing a lot more tolerable.”