Shane Tolentino for NPR
On the day of the leaked draft of the Supreme Court decision to overturn Roe v. Wade, a woman named Nora was at home in her one-bedroom apartment getting through a medical abortion. She’d stocked up on menstrual pads and painkillers, and steeled herself to get through a tough day.
Having children "is something I so badly want," Nora told NPR, "but I'm 22 and I'm poor, and I just can't even wrap my head around it."
(NPR is using Nora's first name only out of concern for her personal safety.)
For Nora, who lives in upstate New York, deciding to end the pregnancy was hard. But getting the Food and Drug Administration-approved abortion pills was not.
She got a medical consult online and received the pills by mail, through a provider called Aid Access. It's one of a handful of U.S. telehealth abortion services that have sprung up in recent years.
The services, with names like HeyJane and Abortion on Demand, have used pandemic-era changes to rules around telehealth and abortion medications to fulfill a growing demand for safe, at-home abortions.
As many U.S. states gear up to restrict abortion access in anticipation of the Supreme Court decision, the physicians, midwives and nurse practitioners behind these services are preparing for an even bigger surge in demand.
"The future of abortion access is going to be getting pills out there and into the hands of people," says Robin Tucker, a nurse midwife and nurse practitioner who provides abortions through Aid Access and in private practice. "That's one of the interventions that can provide the most autonomy in an environment where people are going to lose reproductive rights."
Groups that provide abortion pills are also preparing to face significant new obstacles, as anti-abortion states push back against expanded online access. Both patients and clinicians are testing the boundaries of a service that is fully legal in many states — but operates in a legal gray area in others.
Transforming abortion care
Prior to the pandemic, getting an abortion in the U.S. could be a difficult, complex and often expensive process for pregnant people. Telehealth abortion has rapidly transformed that.
In the past, patients usually had to go to freestanding clinics that offer abortion – and often had to drive quite far to get to one. That takes "time to arrange child care, time off work, gas money, finding a place to stay," says Dr. Jamie Phifer, founder and medical director of Abortion on Demand, a company that sends abortion medications through the mail. Patients also faced harassment from anti-abortion protestors, who often targeted the clinics.
Now, patients can access pill abortions privately from home, with a credit card and a few taps on a smartphone.
"Most of my patients are sitting in their parked cars ... Some of them are sitting on the couch, breastfeeding their infants," says Phifer, whose organization currently provides abortion pills to patients in 21 states. "Telemedicine abortion actually folds into normal, everyday experiences that abortion care couldn't otherwise do."
For Nora, the experience of getting the pills was "quick and easy" – "I sent the email [to Aid Access], thought nothing of it, and went to work," she says, "They reached back to me immediately."
In a span of about two weeks, Nora realized she was pregnant, decided to get an abortion, got a consult and the pills through Aid Access and completed the abortion.
Telehealth abortions are medication-based abortions that generally rely on a two-drug combination. The first drug, mifepristone, blocks a hormone needed to continue an early pregnancy, and the second, misoprostol, contracts the uterus to expel the pregnancy. The FDA has said the pills are safe and effective for ending pregnancies up to ten weeks; the World Health Organization says they work up to 12 weeks.
While the pills were approved by the FDA in 2000, their use made up just under a quarter of all abortions by 2011, lagging behind procedural, or "surgical," abortions. By 2020 medication-based abortions accounted for just over half of abortions in the United States.
Until the pandemic, FDA regulations made it complicated to get the medications. Patients had to see a certified clinician in person at a clinic or hospital to get the pills.
Then in 2021, the FDA changed some of those regulations, making it legal for the medicine to be sent in the mail. The pandemic also brought a boom of telehealth services in all fields of medicine, as insurance companies expanded coverage for online visits.
The result has been an surge of requests for abortion pills, say online abortion providers. And with further restrictions on abortion looming, demand continues to grow.
"It's been exponential," says Christie Pitney, a nurse midwife who provides medication abortions through Aid Access and in private practice. In the 24-hour period after the news broke about the impending Supreme Court decision, Pitney says, Aid Access' website traffic went up 2800%.
Legal gray areas ahead
Despite its fast expansion, abortion-rights advocates caution that telehealth abortion will not be a quick fix to the problem of abortion access if Roe v. Wade is overturned.
For Nora, who lives in New York, every step of her telehealth abortion – from filling in a form online, to getting the pills by mail – was fully legal. Indeed, most telehealth abortion providers comply with state laws and officially operate only in states where their services are legal.
But that leaves potential gaps in access amid a legal landscape that's shifting quickly.
"We're in uncharted territory," says Alina Salganicoff, a senior vice president at the Kaiser Family Foundation and their director of women's health policy. "I think it's going to be challenging for providers. I think it's going to be challenging for patients. And I think we're going to see a lot of litigation as these cases move forward."
There are many kinds of state laws restricting abortion, and "whether it's gestational age limits, state-mandated ultrasound, extended waiting periods – they also apply to telemedicine abortions within that state," says Phifer of Abortion on Demand.
And some states like Arizona, Louisiana and Tennessee have specifically banned using telehealth services for abortion. Others, like Texas, have criminalized sending abortion medications in the mail.
Many of these state-level laws are in flux: a number of them have been blocked by lower courts because Roe is still in effect, but if abortion rights are overturned they may well stick.
Salganicoff, who researches telehealth abortion, says there are many legal "gray areas" which are likely to become even more ambiguous if Roe is overturned: What will it mean for a patient to get an abortion in one state if her doctor is in another? What will happen to friends or family members that send pills to patients in states where abortion is banned? Can anti-abortion states prosecute doctors across state lines, and will abortion-friendly states be able to protect their clinicians?
"One issue is how the rules will play out, and the other issue is how they will be enforced," Salganicoff says, "The lawyers will be busy."
Abortion rights activists are petitioning blue states to protect their clinicians from penalties. "We're lobbying the state to pass assurances that my license will not be in jeopardy; that my malpractice will not be in jeopardy; and that I will not be extradited to another state and prosecuted," says a New-York based telehealth abortion provider who asked to remain anonymous out of fear for her family's safety.
States including Connecticut, California and Washington have passed, or are considering passing, laws to protect their clinicians from liability, according to KFF's Salganicoff.
"If I have these protections, I would be able to send medication abortion pills to people in any state, with the understanding that this is an FDA-approved medication, and that I am providing a service that I am licensed to do," the New York provider says. "This can't take a backseat because, for people who can't afford to hop a plane to New York, California, to states [where abortion will remain legal], they basically are not going to have access."
Patients in states where telehealth abortion is banned or in legal limbo could turn to one organization that will still provide the pills. Aid Access has a workaround for states where telehealth abortion is illegal. Their founder, a doctor who is based in Europe, uses an Indian pharmacy to send abortion pills to patients in states where their U.S. providers can not. This approach works for now, but sits in a legal limbo between U.S. and international law, and there are some drawbacks; getting the drugs from India can delay the abortion by several weeks.
For anti-abortion groups, reducing abortions is the goal. They are hopeful that if the Supreme Court overrules Roe, abortion everywhere – including telehealth abortion – will be more difficult to access.
"The real moral question of: 'What is pre-born human life? And doesn't that deserve to be protected?'" says Dr. Michael Valley, an obstetrician gynecologist and member of American Association of Pro-Life Obstetricians and Gynecologists. "That will be a question that ultimately, depending on the decision, goes back to the states and the people to decide."
‘Not a panacea’
Beside legal restrictions, there are other obstacles to using telemedicine for abortions. For one thing, majority of people who seek abortions are poor or low-income, and may not have the resources or technology seek abortion care online.
People without reliable internet access may find it difficult to use web platforms or video chat software. It might be hard for some people to get a pill shipment in the mail, if they don't have stable housing or a place to open a package in private.
"We can't assume that telemedicine abortion is a panacea," Abortion on Demand's Phifer says. "It's not going to serve everybody, and it can't."
Telehealth abortion providers say they screen for complications, such as patients with symptoms of ectopic pregnancies or severe anemia, as well as those with pregnancies at a later gestational age. These patients may not be good candidates for fully remote abortions, and may be advised to seek in-person care.
Still, some doctors worry that these remote screenings will miss critical warnings that would be picked up with ultrasounds and bloodwork — must-haves in the traditional model of care.
"It just does a disservice to women to not provide the care that we always have," says Valley. "We have to do better – medical providers as well as our society as a whole – to support those mothers."
But telehealth abortion providers point to the growing body of research that shows that, for patients who are good candidates, these methods are safe and effective and patients are satisfied with the experience. Even without an ultrasound very few people require in-person follow-up care, like an emergency room visit.
And for those who have cleared the logistical and medical hurdles, the experience can still be weighted with social pressure and shame. Though her actions were legal, Nora felt like she had to hide what was happening when she got her abortion. "It was very lonely, even though I have a monstrous unit of support," she says.
Her mom spotted her $150 for the pills. Her boyfriend stayed with her through the whole experience, except when he ran out to get her orange juice. "I just told a couple of important people," she says. Even so, it was hard to take the casual judgment and vitriol she heard online and around her – with the Supreme Court's leaked draft decision in the news.
Pitney, a clinician with Aid Access, says the service prides itself on providing discreet abortion access, very few questions asked. But it's not the ideal situation: "I hate that we're having to work in a society where we need these workarounds. But I appreciate that they're available," she says.
Still Phifer, who works for Abortion on Demand, says that for most of her patients, the whole process is simple to navigate because the pills are so safe.
"The most common feedback we get is: 'I can't believe this is so easy. I'm crying because this is so easy,'" Phifer says. "It folds into their everyday lives compared to in-person care where you had to travel to the clinic, you had to set up child care, often you had to take time off of work ... It feels more normal for people."
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