Telemedicine & Mail-Order Pills: The Digital Fight for Abortion in Post-Roe US

As the abortion pill is much harder to police, the battle against it is expected to be fought via online tracking.

Image used for representational purposes only.

(Photo: iStockphoto)

“I think back-alley abortions is not a term we use any more. Years of medical advancement has led to it being about access to medications for self-management of an abortion,” says Washington-based gynaecologist Dr Anuj Khattar.

Unlike half a century back in pre-Roe America, most pregnant Americans in post-Roe US will not be risking their lives in dark back lanes getting illegal abortions. Abortion and the legal war to clamp it has shifted online.

In 2020, 54 percent of all abortions in the US were done via medication – a less invasive and less expensive two-pill method (authorised by the FDA in 2000), for pregnancies up to 10 weeks – as per the Guttmacher Institute.

The sanction for telemedicine and the pandemic made it easier to access medical abortion, moving it into the world of video call consultations followed by postal pill deliveries.

Abortion via medication made it easier for women who found it difficult to travel to an abortion provider or preferred being able to terminate a pregnancy in their homes. But with Roe vs Wade no longer being the legal precedent, the decision about legality of abortions has returned to individual states.

A few restrictive ones have already enacted total abortion bans. In this scenario, one thing is clear: More and more people will now prefer the medical abortion pills to terminate their pregnancy.

And hence, the pill is all set to be the new battleground – conservative legislatures and anti-abortion groups will find ways to monitor, physically and digitally, and persecute those travelling to other states (where abortion is legal) to get abortion medication.

Big Rise in Demand for Abortion Pills in US

Organisations who provide appointments in-person and via telemedicine are seeing a surge in request for abortion pills not only since the legal right to abortion in USA was overturned by a Supreme Court decision, but even before that – when an opinion draft of the decision was leaked in May, and previous to that, when abortion became illegal in Texas and Oklahoma.

“There has been a significant change in interest and demand. In just one day the number of visitors to Aid Access site increased from 1,100 to 35,000 – the day the US Supreme Court’s Dobbs decision draft got leaked. Clinicians are reporting multiple times the number of patients than before,” says Washington DC-based clinician Robin Tucker, who provides medical abortions and gynaecology services. She is part of a team of Aid Access (an international non-profit organisation) doctors and nurses who prescribe and send abortion pills via telemedicine.

Similarly, other groups like Just the Pill have reported spikes in appointment and medicine requests, especially from residents of states where abortion became or was likely to become illegal as soon as the Supreme Court withdrew the constitutional protection.

Mobile Clinics, Mail Forwarding Services, Foreign Pharmacies: Pro-Choice Groups Find Creative Ways to Make Pills More Accessible

As pro-choice groups like Planned Parenthood, NARAL Pro-Choice America, etc, who have persevered for more than half a century to protect the legality of abortions in the US, start fighting legal battles state-by-state to understand where laws will land now, reproductive rights organisations are simultaneously fine-tuning and expanding creative ways to send abortion pills to those who request them, including mobile clinics along borders of abortion-unfriendly states.

Dr Khattar says, “Many patients can seek care through telemedicine services depending on the laws of their state. In states with significant restrictions against abortion care, websites such as www.plancpills.org or www.abortionfinder.org can help connect patients with care that they may need."

As abortions become illegal, the number of clinical and surgical appointments have fallen, but the demand for abortion has not reduced. To address the need for abortion pills, people are finding alternate ways to find them, supported by pro-choice organisations. PlanC conducts research about how people are accessing abortion pills in the US. It has a section on its website about creative ways people are finding pills in restricted areas.

Effective workarounds include a list of vetted and quality-tested online pharmacies for ordering abortion pills directly from outside the US, which do not require prescriptions.

Another process they list for people in restrictive states is to use mail forwarding services to access telemedicine abortion care from health care providers located in states that allow it. Because providers are only allowed to mail pills to patients who have an address in the states where the provider is licensed to practice, people are renting a mailing address from mail forwarding services – circumventing the system by getting pills forwarded by mail to their own address.

Another alternative mentioned is – some people ask friends who live in a state that has telemedicine abortion access to get the pills delivered at their address and later collect them. Others identify a nearby state that offers pills by mail and have the medicine shipped to the nearest post office along the border.

Robin Tucker says, “For example, you can look up online for a post office just over the border from Texas, get a packet delivered to that post office and pick it up, if you can get to the border of the hostile state. I don’t give my patients third degree on why they are getting pills delivered to a border post office or why does someone in Texas have a prescription in Virginia.”

Aid Access has clinicians who offer telemedicine abortions and pills to patients in states where abortion remains legal. Its Dutch founder Dr Rebecca Gomperts, famous for offering abortions to women in boats in international waters (Women on Waves) to bypass anti-abortion laws – during the pre-abortion pills and internet era – now sends pills in nondescript packets to those who seek medication abortions in the US states where it is illegal.

“Dr Gomperts sees patients from any of the hostile states. US clinicians can’t as they are prohibited. She is protected by the laws where she is lives (Europe) and will not be extradited if one of the states come after her. The prescriptions come from a pharmacy in India and take 2-3 weeks.”

Robyn Tucker, Clinician, Washington DC

She laughs and adds, “She (Dr Gomperts) is not going to visit Texas or Florida any time soon. She will have dramatical legal consequences if she were physically visit these states!”

Given the uncertain legal scenario in many states, Tucker has also seen an increase in requests for advance abortion pills. “People are requesting to purchasing pills ahead of time. The new increase of cases requesting for medication, a lot are from those who are not pregnant at the moment, as things are volatile. I do provide advance pills to patients,” she says.

Privacy a Big Concern as Anti-Abortion Groups Now Target Abortion Pills

Mail-order abortion pills are referred to as "a growing public health threat" by pro-life groups. Americans United for Life, an anti-abortion advocacy group, has listed laws against medication abortion as first among the organisation’s "pressing priorities" for 2022.

Abortion-unfriendly states have already begun passing laws to restrict medication abortion, including banning it earlier than 10 weeks’ gestation and requiring patients to visit providers in person despite FDA rules.

Nineteen states had barred the use of telemedicine for abortion, even prior to overturning of Roe. But in the current scenario, other than having to open all mail packets, how will restrictive states track pill deliveries? Much harder to police, the battle against the abortion pill will shift to online tracking. Anti-abortion groups are expected to track and collect data on patients’ doctor’s visits, and their internet searches, especially those crossing state lines.

There is likely to be a spread of misinformation about the safety of abortion pills. On the other hand, organisations like National Advocates for Pregnant Women and Repro Legal Helpline are ready to support people who self-manage abortions, navigate complex laws.

Priya Desai of Oklahoma Call for Reproductive Justice says, “We are in a particularly delicate situation and it’s hard to provide concrete answers when we do not know how district attorneys are going to enforce these laws or how the state will address conflicting anti-abortion laws. I will say we are asking people to get educated on digital security as internet searches and communications can be used against criminalised individuals.”

Unlike in the past, when law enforcement went after clinics and medical providers to clamp down on abortions, the new hunt for controlling movement of pills will make citizens their target.

Even though numerous American corporations have come out in support of employees who might need to travel out of state for accessing abortion care, many of those companies are mute about shielding millions of users, who might have their data brandished against them in a post-Roe US.

(Savita Patel is a San Francisco Bay Area-based journalist and producer. She reports on Indian diaspora, India-US ties, geopolitics, technology, public health, and environment. She tweets at @SsavitaPatel.)