On June 24th, 2022 the Supreme Court of the United States overturned Roe v. Wade, placing the responsibility for regulating abortion into the states’ hands. Since ratified in 1973, Roe had permitted abortion during the first two trimesters of pregnancy and was seen as a monumental step towards securing citizens the right to ownership of their reproductive health. Abortions, both medicinal and surgical, are components of the WHO Global Reproductive Health Strategy that is grounded in human rights declarations for the “respect and fulfillment of the right of all persons to achieve the highest attainable standards of health.” This includes the right of all people to have control over and decide freely on all matters related to their sexuality, a right that the overturning of Roe has taken from birthing people in the US. In 13 states the right to an abortion was immediately revoked, with those seeking one potentially facing up to 99 years in prison or up to a $100,000 fine. In 14 other states, trigger bans are in the process of being ratified into law to further restrict or ban abortions altogether. This leaves 23 US states where abortions remain legal, but clinics are few and far between, especially for those living in rural areas of the country. 89% of US counties do not have a clinic that provides abortion care and more than one-third of patients seeking abortions in 2014 had to travel over 25 miles to access a clinic, a mileage that will only increase with clinics shutting down post-Roe overturn. With options for safe and legal abortions slowly shrinking, many are asking: where can people turn for help managing unintended pregnancies, if not clinics? The answer may be pill service by mail.
Medication abortions account for 54% of abortions performed in the US. Medication abortions are approved for pregnancies up to 10 weeks and entail patients taking a combination of mifepristone and misoprostol. This method has become a cornerstone of abortion treatment since being FDA approved in 2000 due to its minimally invasive method and the ability to be administered outside of a clinical setting. In April 2021, mifepristone and misoprostol were approved by the FDA to be sent by mail during the pandemic and in December 2021, the FDA changed the regulations to permanently allow these pills to be mailed and expanded their access through pharmacies. This decision shifted the legality of online services and telehealth centers to be able to provide abortion medication via mail but it hasn't expanded access entirely. Just the Pill, a non-profit online clinic, requires patients to live in Minnesota, Colorado, Wyoming, or Montana or be able to travel to one of these states to receive their telehealth consultation before sending any medication. Choix, another online telehealth service, serves women in California, Colorado, New Mexico, Maine, and Illinois, following a questionnaire about their medical history. Currently, most online services are limited to providing services to patients who live in-state or can have the medication shipped to an in-state address. While these services are limited they present a budding potential future for abortion and reproductive care.
Pill service by mail is more affordable, wider serving, and accessible for many patients compared to traditional clinics. The cost for a medicinal abortion by mail averages 250 dollars for the medication and consultation while an in-person administration can total over $750, not including any travel expenses for just getting to the clinic. Some services like Choix offer sliding scale payments starting at $175. Online sites also serve patients seeking basic reproductive care and family planning. Just the Pill ships contraception and STI testing along with offering telehealth for all reproductive care and not exclusively t abortions. Many other online clinics offer the same. Moreover, online services not only provide ease of access compared to brick-and-mortar clinics, but also the anonymity some patients may want or require. For patients in unsafe situations or abusive partnerships, abortion medication by mail may be the only option for safely managing an unintended pregnancy. Other patients may not have the time in their day to visit a traditional clinic, which can require forced ultrasounds, 24-hour waiting periods, and counseling sessions. Expanding access to reproductive and sexual care, abortions included, is possible with online clinics and telehealth but, just as the fight for clinical care has been an uphill battle, the fight to preserve pill service by mail is just beginning.
Since the FDA approval of mifepristone and misoprostol for mail delivery, conservative lawmakers have been fighting to limit or stop its distribution altogether. Currently, 32 states mandate that a physician prescribe the medication with 19 of those states requiring that the physician is present, making telehealth impossible. In Texas, any abortion care by mail or online is illegal, with patients facing jail time or fines up to $10,000. If a patient does not reside in a state where medication can be prescribed through telehealth or through the mail, the medication cannot be shipped to their address. Some have found workarounds using VPNs to mask their IP location or having the medication sent to trusted friends or family in states that allow for pill service by mail. Another option for those seeking a medication abortion in states with restrictive laws is the international group Aid Access. Their website lists the states where their US doctors can provide medication by mail. Alternatively, if a patient lives in a restrictive US state or country, Aid Access’s European doctors will provide the prescription for mifepristone and misoprostol along with the information of a trusted pharmacy in India that will ship the medication to the patient.
However, some patients may not have the time to jump through hoops to access medication. Mifepristone is approved for up to 10 weeks which leaves a small window to discover you are pregnant and receive medication in time with shipping delays or workarounds regarding state laws. For some patients, it may be too late. In this way, pill service by mail should be seen as simply an expansion to access and care for those seeking abortions and not a total solution for a post-Roe world. There will always be a need for brick-and-mortar clinics, either for abortions past 10 weeks or for those who have previous medical conditions preventing them from taking mifepristone to begin with.
The WHO estimates that of the 280 million people worldwide who are to become pregnant each year, only 59% of these pregnancies are planned. That leaves 85 million pregnancies unintended. The Guttmacher Institute reported that in the US in 2017 the rates of pregnancies that were either unintended or wanted later were higher in the South and Northeast, areas with more restrictive abortion bans. People will continue to get pregnant, intentionally or not, and restrictions on abortions do little to manage this except to make the lives of birthing people harder. Additionally, abortion bans have an unequal impact on already marginalized communities including BIPOC communities, communities under or at the poverty line, LGBTQ communities, and those with disabilities. The future of abortion in the US is unclear, but pill service by mail provides a small glimmer of hope. What is needed now is action to make medication accessible to all patients, no matter the state they live in, and a commitment to continue to fight for the right of all citizens to manage their reproductive care in any way they choose.
US Abortion Access Funds:
Know the Abortion Rights for your State:
Notes on the inclusive language used in this article:
While abortions and the battle for reproductive rights are issues that face women most predominantly, this issue is not gender-specific. Abortion is a healthcare procedure and part of a comprehensive system of sexual healthcare not specific to women alone. All people regardless of gender identity, sexual orientation, or reproductive status deserve the right to safe, accessible, and supportive reproductive care. This article is written utilizing gender-neutral language with respect to that fact.
Author
Phoebe Norman is currently finishing up her last year at the University of Vermont, where she is studying Public Health and Microbiology. Her dream job is to one day to combine health advocacy and epidemiology researching women's reproductive and sexual health internationally. In the meantime, she’s an avid rock climber and hiker, spending most of her free time outside exploring with friends.
Cover Photo: Photo by Matteo Badini on Unsplash
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