Abortion fund directors nationwide have been raising the alarm for months about declining donations and their struggles to meet the needs of those seeking help with the financial burdens of finding abortion care, especially those who live in one of?22 states?with near-total bans or severely restrictive abortion laws. (Photo by Scott Olson/Getty Images)

Advocates for abortion access say compounding crises of abortion bans, rising economic costs and systemic health care issues are beginning to cause significant funding challenges and potential disruptions to reproductive care of all kinds.

Several people described it as a “perfect storm” of problems with the U.S. health care system, particularly post-pandemic, and the rise of abortion bans and other reproductive care restrictions in the wake of the Dobbs v. Jackson Women’s Health Organization decision in June 2022. Many individuals must now travel hundreds or thousands of miles to seek abortion care, and the consolidation of demand at a smaller number of clinics is increasing wait times, which means pregnancies progress to a more advanced stage and the costs balloon further. According to leaders of Planned Parenthood affiliates and abortion funds, there simply aren’t enough dollars right now to support the need at any level. A recent report from #WeCount showed the number of abortions nationwide started to increase in 2017 and has continued to increase post-Dobbs, with more than 102,000 abortions in January alone.

Abortion fund directors nationwide have been raising the alarm for months about declining donation revenue and their struggles to meet the needs of those seeking help with the financial burdens of finding abortion care, especially those who live in one of 22 states with near-total bans or severely restrictive abortion laws. That includes every state in the Southeast.

Planned Parenthood of Northern New England announced at the beginning of the month a projected funding shortfall of about $8.6 million over the next three years, and Planned Parenthood of Greater New York announced just a few days later that it would pause abortion care at or beyond 20 weeks because of financial struggles that began earlier this year. The National Abortion Federation runs America’s largest financial assistance program for abortion patients and said that just in the first half of this year it has partially funded more than 60,000 people’s abortions — a total of around $6 million per month — but has now had to reduce patient grants from 50% of the cost of care to 30%.

Even in areas with new abortion restrictions, such as Florida, donations have declined significantly. Stephanie Loraine Pi?eiro, executive director of Florida Access Network, said during a June press conference that the month after the Dobbs decision ended federal abortion rights, the fund received $200,000 in individual donations — but after the state supreme court decision in April 2024 reduced the state’s abortion ban from 15 gestational weeks to six weeks, the fund received just $40,000 in donations.

“That is a stark difference, and it has everything to do with donors feeling burnt out,” Loraine Pi?eiro said.

States with abortion access face hostile political winds?

Planned Parenthood Federation of America told States Newsroom it is meeting its fundraising goals, but the organization’s local health centers and regional affiliates are struggling to provide care in the current climate.

Nicole Clegg, interim CEO of Planned Parenthood of Northern New England, told States Newsroom the affiliate has always been under-resourced and under-reimbursed for the care it provides, which includes birth control, testing for sexually transmitted diseases and routine gynecological care in addition to abortion services. But now that the region, which includes Maine, Vermont and New Hampshire, is taking on more patients from states with abortion bans, it is reaching a tipping point.

“The services we provide are just not valued by the insurance industry, or Medicaid and Medicare — they have always been poorly reimbursed,” Clegg said. “Once costs really started to skyrocket, the margin we were operating with disappeared.”

According to an analysis of health care spending and costs by KFF, health spending tripled between the year 2000 and 2022, from $1.4 trillion to $4.5 trillion. The pandemic accelerated that spending, but the analysis also said the aging population of the U.S., rising rates of chronic conditions, inflation, and expansions of insurance coverage have also driven up costs.

A bill that would have provided nearly $3.4 million to Maine’s family planning centers got caught in legislative wrangling that affected many appropriations bills at the end of the session.

In New Hampshire, which allows abortions until 24 weeks of pregnancy, the affiliate had nearly secured a multi-year grant of more than $2 million total, with the support of Republican Gov. Chris Sununu. However, Clegg said that when the grant went before an executive council for final approval in 2023, the members struck it down, saying they didn’t want taxpayer dollars to fund abortions. Both led to the projected $8.6 million shortfall over the next three years.

“The executive council has become increasingly hostile to Planned Parenthood,” Clegg said.

Planned Parenthood Great Northwest, which includes northwestern states as well as Hawaii, Alaska, Indiana and Kentucky, also said it is facing financial challenges that put access to care at risk. Lisa Humes-Schulz, vice president of policy and communications for Planned Parenthood Alliance Advocates, said in a statement that the affiliate is facing the same health care cost challenges, an underfunded federal family planning program, workforce shortages and rising labor costs. Great Northwest includes Idaho, where there is a near-total abortion ban and which was at the center of a recent U.S. Supreme Court case over whether emergency room physicians could be prosecuted under the state law for providing an abortion in the case of a medical emergency. The affiliate’s clinics in Washington have seen an influx of patients from Idaho as a result of the abortion ban over the past two years, including some emergency patients that were airlifted out of Idaho.

“Unlike other safety net providers, we are trying to navigate these business challenges on top of the unprecedented political attacks focused on providers of abortion care and gender-affirming care,” Humes-Schulz said.

For Planned Parenthood of Greater New York, financial struggles have already prompted a change in care. After the state legislature failed to increase Medicaid reimbursement rates for medication abortion, the affiliate said it implemented executive pay cuts, consolidated job functions and closed small health centers to make up deficits. More than half of the patients that visit Planned Parenthood centers rely on Medicaid.

But it took another step in temporarily stopping abortions at 20 or more weeks starting Sept. 3 because it can’t afford to cover the vendor costs for anesthesia. Only one Planned Parenthood location in New York City will offer deep sedation and abortions at 20 or more weeks for now.

‘Unprecedented is not even the word anymore’

The struggles also extend to organizations that provide more basic infrastructure for abortion clinics, such as the Abortion Care Network, which started a campaign called Keep Our Clinics to raise funds for independent abortion clinics. Independent clinics make up 55% of abortion providers, according to the network, while Planned Parenthood comprises 41%, and the remaining 4% occur at physicians’ offices and hospitals. The vast majority of clinics offering abortion care after 22 weeks — about 86% — are also independent.

Erin Grant, co-executive director of the Abortion Care Network, told States Newsroom the organization’s mission is to provide grant funding for independent clinics to support infrastructure needs — such as supplies, equipment, building repair, security, and litigation support — rather than patient care. The network has supported 32 clinics, and gave out $700,000 to providers in recent months.

But for the network too, donations are down by one-third. The full amount of donations to the Keep Our Clinics campaign goes to clinic members, and the organization granted nearly $5 million to clinics in 2022, but only $3.4 million in 2023. The requests for support did not go down during that time, but donations did.

Grant said it’s important to support the infrastructure of independent abortion clinics because once they close, it is extremely difficult to work through the bureaucratic process again to reopen them. In areas with newly instituted six-week abortion bans, such as Florida, Iowa and South Carolina, more clinics have closed their doors.

“We are in times where ‘unprecedented’ is not even the word anymore, and there is so much happening that calls for our attention. … There’s a need in this moment for us to hold multiple crises across communities,” Grant said. “… This isn’t something we get to say we did as an immediate need, because there’s decades of work ahead to build the actual infrastructure to have health care access, let alone abortion access in this country.”

During a June press call, several leaders of state abortion funds discussed funding struggles. Oriaku Njoku, executive director of the National Network of Abortion Funds, said the funds provided more than $36 million in abortion funding and $10 million in logistical support in 2023.

“This is not the same movement that it was five years ago, let alone 50 years ago, and yet we’re still operating and funding as if it were the same issue as it was before,” Njoku said.

There are nine clinics in Ohio, where voters affirmed their desire to keep access to abortion in 2023, but it is surrounded by three states with near-total bans — Indiana, Kentucky and West Virginia. Lexis Dotson-Dufault, executive director of the Abortion Fund of Ohio, said during the press conference that her organization averaged about 100 patients per month in 2022, but now it averages more than 500.

“While abortion funds have a huge increase in need, we are not seeing a huge increase in money coming in to support this need,” Dotson-Dufault said.

National Abortion Federation: Without cutbacks, funding would run out by fall?

Planned Parenthood Federation of America, the national organization, did not directly address whether it would provide more support to the affiliates facing significant financial troubles.

“While issues around funding are a concern, it is important to note that the reproductive health care ecosystem is straining under the weight of the post-Dobbs crisis,” a Planned Parenthood spokesperson said in a statement. “PPFA is working to support affiliates as they take action to adapt and continue to provide care.”

The organization’s comments came a few days after 41 abortion funds from around the country signed on to an op-ed in The Nation saying there is a disconnect between the most visible national reproductive rights organizations, like Planned Parenthood and the National Abortion Federation, and grassroots groups working to directly support those who need care. The op-ed called out the National Abortion Federation for cutting back its financial assistance program in July, from 50% of the cost of seeking care to 30%. Signers included the Abortion Fund of Ohio and the Florida Access Network.

Brittany Fonteno, CEO and president of the National Abortion Federation, called the change an “incredibly heartbreaking and difficult” decision that had to be made despite an “incredible and generous budget” that is the largest it has ever been. She said that in the first half of this year, NAF was funding at $6 million per month for abortion care, and then upwards of $200,000 per month in patient assistance funds to help with associated travel costs. These patient assistance funds are completely funded by foundation and individual donors, Fonteno said, noting that individual donations dropped nearly 40% in 2023 from the previous year after the Dobbs decision leaked.

In 2023, NAF said it funded 106,865 people with an average amount of $519 per patient. So far in 2024, the hotline has funded 66,330 people at an average of $541 per patient.

“We’re truly in a public health emergency right now, and unfortunately, we just can’t keep pace with the patient need,” Fonteno told States Newsroom. “We had to make this decision in order to make sure that we could stretch our funds and make sure that we could help as many people as possible for the rest of this year. If we hadn’t made this decision, then we would have run out of funding in the fall.”

The changes include no longer making exceptions for those in later stages of pregnancy who face higher costs — sometimes as much as $10,000, Fonteno said — because the procedure costs more or they have to travel further to find a clinic that can provide it. That “exception budget,” which was also used for patients facing extreme circumstances like intimate partner violence, will not exist for the remainder of the year, according to Fonteno.

“Of course, we’re working incredibly hard to try to fundraise, to try to get the word out and bring awareness to this issue. And if we’re able to fundraise, we may be able to consider increasing the funding that we’re able to do,” she said.

Presidential election matters, director says?

Clegg, interim CEO of Planned Parenthood of Northern New England, said the problems will only get exponentially worse if the presidential election in November breaks for Republicans over Democrats. Project 2025, the blueprint document produced by the Heritage Foundation for the next Republican presidential administration to follow, calls for the federal government to prohibit Planned Parenthood from receiving any Medicaid funds (for non-abortion reproductive health services; federal funding of abortion is currently prohibited) and issue guidance to states that says they are free to defund Planned Parenthood in their state Medicaid plans as well.

Instead, it calls for the funding to be redirected to “health centers that provide real health care for women.” The anti-abortion organizations involved in crafting the document, such as Susan B. Anthony Pro-Life America, often promote funding for crisis pregnancy centers, which counsel pregnant patients against abortion and are known to spread misinformation about the procedure. A recent analysis from reproductive rights advocacy group Equity Forward showed nearly $490 million was allocated in 23 state budgets over the past two years for crisis pregnancy centers, most of which were in the same states that restrict abortion access.

“It’s not just making sure the public understands that we need them to engage and partner with us to make sure we can keep providing the care; it’s also having them connect the dots to the November election and understand that who they vote for, who they put in office is going to determine our future,” Clegg said.

Kentucky’s non-doctor health care workforce is on the mend, though state hospitals still have thousands of unfilled positions.?(Warodom Changyencham/Getty Images)

Both the overall number of abortions and the use of telehealth abortion care continue to increase in the United States, according to the latest #WeCount report released Wednesday.

Telehealth made up 20% of all abortion care in the first three months of 2024, and the monthly total of abortions exceeded 100,000 for the first time since the group began tracking abortion data in 2022.

#WeCount is a collaborative group of researchers who collect national abortion data from clinics every month and is a project of the Society of Family Planning, a membership organization focused on abortion and contraception science. Dr. Alison Norris, co-chair of the group, said the data captures about 80% of abortion clinics nationwide. Using that data, the group makes estimates to account for clinics that do not provide reports.

From January to March 2024, there were about 19,700 telehealth abortions per month, according to the report. The states with the biggest jumps in the average number of abortions per month compared with the first three months of 2023 include New York, California, Virginia, Kansas and Pennsylvania. Kansas saw 59% more telehealth abortions and 29% more in-person abortions each month.

Norris said the use of telehealth has continued to grow, particularly now that five states — New York, Massachusetts, Washington, Vermont and Colorado — specifically shield those who provide telehealth abortions from legal ramifications if they work with patients from states with abortion restrictions. Maine will become the sixth state when its shield law takes effect on Friday. Fourteen states in the U.S. have a near-total ban on abortion.

“There was already a move toward telehealth (during the COVID pandemic), but I think it was accelerated by the need,” Norris said.

Telehealth abortions provided by clinicians in states with shield laws averaged 9,200 per month from January to March 2024, according to the report. That’s an increase of about 1,200 per month from the last report that showed data from October to December 2023.

In the nine months from July 2023 to March 2024, over 65,000 people in states with near-total or six-week bans and states with telehealth restrictions have accessed medication abortion provided under shield laws.

But the vast majority of abortions still take place in person, Norris said, in part because medication abortion can only be prescribed via telehealth through 10 weeks’ gestation, and because some people just prefer to be seen in person.

The overall number of abortions per month has grown as well, with a high of 102,350 in January. The average over the first three months of 2024 was 98,990 — the highest monthly number during the last quarter of 2023 was 91,470.

Norris said the data shows the number of abortions began to rise nationally in 2017, and while it’s hard to pinpoint the cause, there are new factors that could be contributing. Some people who needed an abortion before the Dobbs decision in 2022 could get them once states passed legislation to remove barriers. And for those who faced financial issues obtaining an abortion, she said, there is more awareness of abortion funds and other sources of support.

“There’s a lot more information in the ecosystem, there’s better resources on the internet, and there’s potentially been a destigmatization of abortion, given how much it’s in the media and being talked about by politicians,” Norris said.

Although she views it as a positive that many people who live in states with near-total bans or six-week bans are able to access abortion via telehealth, she said it’s still an unfair situation.

“Those bans and those restrictions are not evidence-based in terms of public health science, and the fact that thousands and thousands of people don’t have access to ordinary and safe health care that’s time-sensitive just because of the state where they live, it is an injustice that I hope people keep their eyes on,” Norris said. “It’s important that people maintain the will to keep advocating for access for all people in the U.S., no matter where they live.”

According to 2017 data from the Guttmacher Institute, 88% of abortions took place before the end of the first trimester of pregnancy at 12 weeks. (Getty Images)

It’s an oft-repeated talking point of anti-abortion rights groups and Republican politicians, before and after the June 2022 Dobbs decision — that those who are supportive of abortion rights also must be in favor of abortions that happen during the last weeks of pregnancy, or even “after birth.”

Former President Donald Trump brought it up in the June debate against President Joe Biden, saying Biden’s position on restoring abortion access would lead to doctors being able to “take the life of the baby in the ninth month, and even after birth.”

Trump’s newly announced vice presidential running mate, Republican Sen. J.D. Vance of Ohio, told Fox News this week that Biden “wants taxpayer-funded abortions up until the moment of birth.”

And candidates in states such as North Dakota and Montana have campaigned on that rhetoric in recent months, saying some states allow “post-birth abortions” or abortion “the day before” a due date.

In reality, abortion “after birth” does not happen, because it would be categorized as murder under all state laws. And while abortions do occur later in pregnancy, they are exceptionally rare and happen for many diverse reasons, such as a fatal fetal diagnosis and financial or travel barriers that extend timelines.

Abortion-rights advocates say the rhetoric is used because public opinion polls show support becomes more mixed for abortion after 24 weeks, which is the second trimester of pregnancy and the medically recognized point of viability, when a fetus can reasonably be expected to survive outside of the womb with medical interventions. That argument was seemingly bolstered by an anti-abortion group’s campaign strategy meeting against Amendment 4 in Florida this week, a ballot question that would restore abortion access to 24 weeks in the state where a six-week ban is currently the law, before many people know they’re pregnant. During a presentation, the campaign organizers displayed a slide that said, “How we win: We win by talking about late-term abortion.”

Even before Roe v. Wade was overturned by the Dobbs decision, abortion was only protected as a federal right until viability, at which point it could be restricted by states. So if a Democratic presidential administration or Congress were to re-establish and codify Roe as the standard, third-trimester abortion would likely remain restricted in many states. In some states where abortion is legal and there is no restriction by gestational age, such as Alaska, it is still unavailable past the second trimester because there are no clinics that provide it.

According to 2017 data from the Guttmacher Institute, an abortion-rights organization that gathers provider-specific data from across the country, 88% of abortions took place before the end of the first trimester of pregnancy at 12 weeks. A little over 10% happened between 13 and 20 weeks, and 1.3% occurred after 21 weeks, about halfway through the second trimester. Out of 862,320 abortions tracked that year, that means 11,210 happened after 21 weeks. The Centers for Disease Control and Prevention shows a slightly lower number of 1.1% after 21 weeks, but does not receive abortion data from Maryland, as it is voluntary reporting. Guttmacher reaches out to individual clinics to collect data, and several of the small number of clinics that take patients later in pregnancy are located in Maryland.

‘I don’t need people to feel comfortable with it’

The time between 21 and 40 weeks is a long span in a pregnancy, and in 20 states, abortion is generally banned after 22 or 24 weeks. Only nine states and the District of Columbia don’t ascribe gestational limits to their abortion laws, and of those, only four — Maryland, New Mexico, Oregon and Colorado — and the District of Columbia have clinics that openly say they will take patients past 28 weeks.

One of those is Partners in Abortion Care in Maryland, where Dr. Diane Horvath is chief medical officer. That clinic opened in October 2022, and saw about 500 patients in its first year of operation. Horvath told States Newsroom that because there are so few clinics that will take patients at an advanced stage of pregnancy, the people who come to them have generally had to make it through many barriers to access care. That includes their home state laws, travel barriers, time restrictions and costs. In 14 states, a near-total ban on abortion is the law, and five others have bans before 12 weeks.

“Nobody ever thinks they’re going to need a later abortion, but when you need it, you need it 100%,” Horvath said. “Just like you’d never imagine yourself needing a later abortion, this could happen to you or anybody that you love.”

The idea of an abortion happening in a person’s third trimester of pregnancy can be uncomfortable for the average person, Horvath said, and for some physicians. Some doctors? may have their own objections to it, or they may just choose not to make their feelings known about it at all for fear of being targeted by anti-abortion activists. Nobody should have to participate in that type of care, she said. But when a position is open at her clinic, she receives hundreds of applications.

Horvath said in all the time she’s been practicing abortion care, she’s never seen a patient who walked in during their third trimester of pregnancy who wanted to terminate simply because they were tired of being pregnant, as some anti-abortion groups might suggest. The idea that people are choosing that path “carelessly” is just wrong, she said.

“The circumstances in which people are seeking abortions later in pregnancy are really dire. This is not to say every abortion has horrible circumstances, but by the time you find yourself later in pregnancy, lots has gone wrong for you, and this may be due to something that was completely out of your control,” Horvath said. “It’s so easy to demonize when you don’t want to understand something.”

The most important point, she said, is that there isn’t a line in pregnancy where the government becomes more well-equipped to make decisions about a pregnancy than the person carrying it, and there is no possible way to fully understand what a person making that decision is going through.

“It’s possible to feel uncomfortable about this care and the circumstances under which it occurs and still support someone’s ability to get that care when they need it,” Horvath said. “I don’t need people to feel comfortable with it.”

Women interviewed about abortions had fetal anomalies, financial difficulties

As States Newsroom has reported through a series called “When and Where: Abortion Access in America,” there are many situations when a clinical diagnosis of severe fetal anomalies happens at a routine anatomy scan, which is typically scheduled at 20 weeks. That leaves only two weeks to get an appointment in a majority of states with legal access — and post-Dobbs, it can be a tall order to get an appointment that quickly, as clinics have been inundated with patients from other states where no access is available at any stage.

Katrina Kimport, a professor at the Advancing New Standards in Reproductive Health program at the University of California San Francisco, has published at least two studies about abortions that take place in the third trimester, including one that detailed interviews with 28 women of different races between the ages of 18 and 46. Their gestational ages ranged between 24 and 35 weeks.

One woman in Kimport’s study who had already had a complication with a previous pregnancy was assured at 20 weeks that everything was going well this time. But at 29 weeks, her doctors observed problems with the fetus’ brain and initially said she shouldn’t worry too much. But further testing showed pieces of the brain were missing or concave, and specialists eventually told her there was no possibility it was compatible with life.

“There’s a heartbreaking number of ways that pregnancy can go wrong,” Kimport said.

Two women didn’t know they were pregnant until their third trimesters — both of whom were still having regular menstrual cycles, indicating they were not pregnant.

Others reported significant financial difficulties affording the procedure, which can cost at least $500 during the first trimester and increase to tens of thousands of dollars in late stages of pregnancy, on top of the costs of? out-of-state travel for some of the women. One of the women reported that she and her boyfriend were living on the street. To the extent any of them received financial assistance to obtain the abortion, according to Kimport’s research, it was through local or regional abortion funds. Many insurance providers do not cover out-of-state abortion care.

Anti-abortion physician says there is ‘never’ a reason for abortion late in pregnancy

The Charlotte Lozier Institute, a research arm of anti-abortion rights organization Susan B. Anthony Pro-Life America, did not grant an interview for this story, but sent along its own prepared papers on the subject. In one of those papers, the Institute points out there is some research that indicates fetal anomalies or maternal health conditions make up a minority of abortions that happen late in pregnancy, and more often it is because of unplanned pregnancy, economic considerations and relationship issues.

Horvath said it is true that the circumstances include people who are dealing with complex situations in their own lives, like one patient she could remember whose house burned down. That patient was already in a shelter with her children, Horvath said, and could barely provide for them.

While some might suggest having the child anyway and putting it up for adoption at that point, Horvath said that isn’t something that should be forced on a person.

“The idea that somebody owes society or an infertile couple a baby is not just,” she said. “We have one of the worst maternal and infant mortality rates in the world, so to force someone to continue a pregnancy beyond the point they’ve decided is not the right time is putting them at risk to give a baby to someone else.”

The Institute also quotes an anti-abortion rights physician who says there is never an appropriate situation for an abortion at that stage of pregnancy to take place.

“The infant may need to be delivered prematurely and die as a result of that, but it is not necessary to take the infant’s life,” said Dr. Byron Calhoun, a known anti-abortion activist perinatologist. “Further, if a fetus has an adverse prenatal diagnosis, all patients should be offered perinatal hospice care since this is far better for maternal health than any elective abortion. Perinatal hospice allows the parents to be parents and provide all the love they can for their child.”

The Institute did not provide evidence that hospice care is better for maternal health, but perinatal hospice is an option for anyone who wants to do that rather than have an abortion, when the fetus is typically given an injection to stop the heart and then removed from the uterus. Kimport said she has also interviewed women who could not deliver a baby vaginally because of a health condition, and would be forced to have a Cesarean section surgery if abortion was not available.

Physicians who are affiliated with the Lozier Institute have also told news outlets such as the Washington Post that “up to the moment of birth” means any stage of pregnancy past 22 weeks, whereas others would think of it as the last two to three weeks of a 40-week pregnancy.

“Some of the failure to push back on these really outrageously false claims comes from the fact that there are so many things that are wrong about it and it’s hard to know where to start,” Kimport said.

Some anti-abortion organizations call Plan B, which is an emergency contraceptive designed to prevent pregnancy after unprotected sex, an abortion drug because it can prevent the implantation of a fertilized egg. (Photo illustration by Justin Sullivan/Getty Images)

Clinic closures in the wake of the Dobbs decision and questions about the legality of emergency contraceptives, including disinformation that some are abortion drugs, may have contributed to a sharp drop in the rate of prescriptions for contraceptives in states with the most restrictive abortion bans, according to a University of California study.

The decline was significant in most states with restrictive bans following Dobbs in June 2022 that returned regulation of abortion procedures to the states, the study found. The group of researchers, led by pharmacy professor Dima Qato, used data from national prescription audit databases to estimate the monthly volume of prescriptions dispensed at pharmacies nationwide and state-by-state. It represents estimates from more than 93% of retail pharmacies.

“Given that abortion would be restricted in many states even more after Dobbs, I wondered whether now more people would get covered through contraception to prevent pregnancy and the need for an abortion,” Qato said.

Over the past six months, especially in states with near-total abortion bans, lawmakers have discussed proposals that would protect access to contraception, but those efforts have largely failed because of concern over whether that would include emergency contraception. Some anti-abortion organizations call Plan B, which is an emergency contraceptive designed to prevent pregnancy after unprotected sex, an abortion drug because it can prevent the implantation of a fertilized egg.

The researchers think those conversations have led to confusion among residents who aren’t sure if emergency contraceptives are still legal in their state. That confusion could also extend to pharmacists. While Plan B is available over the counter at many retail stores and pharmacies, including Amazon, it can also be obtained by prescription, which is the only data point the study captured. According to the research, the rate of obtaining it through prescription between 2021 and 2023 dropped more than 70% in four states with near-total bans — Arkansas, Kentucky, Louisiana and Tennessee. It declined by about 60% in Missouri.

The increases peaked in July 2022 and then dropped to levels lower than the pre-Dobbs period, Qato said.

“For patients that are seeking emergency contraception but can’t get it prescribed or filled, that’s where it matters,” Qato said. “They want to take it, they know it’s an option, and now they’re faced with hesitant prescribers and pharmacies.”

Half of women surveyed in ban states are unsure if Plan B is legal

A Kaiser Family Foundation poll released in early 2023 found that more than 30% of adults surveyed were unsure if Plan B was legal in all 50 states and over the counter — and half of women living in states with abortion bans were under the impression that emergency contraceptives were illegal or were unsure if they were legal.

Conversely, in two states with near-total bans, Idaho and South Dakota, the rate of prescriptions for emergency contraceptives increased by 148% and 182%, respectively. Those numbers were attributed to increases in ulipristal, which is also known as Ella, rather than levonorgestrel, known as Plan B. Ella can be effective at preventing pregnancy up to five days after unprotected sex, while Plan B is most effective within three days and is also less effective in people who weigh more than 165 pounds, while Ella does not have that limitation.

Between the 12 states with the most restrictive bans, the combined decline of emergency contraceptive prescriptions was 60%, and the decline for oral contraceptives was 24%.

Qato said she expected to see lower rates of emergency contraceptive use in the most restrictive states, particularly with the conversations likening them to abortion drugs, but she wasn’t expecting to also see a drop in monthly oral contraceptive prescriptions. Among states with the most restrictive bans, the largest decrease of 28% was in Texas, while most other states had decreases of about 20%, including Kentucky, Louisiana, Alabama and Tennessee.

Qato also theorized that the closure of abortion clinics in those states with bans contributed to the decreases, since most clinics that provided abortions prior to Dobbs also offered prescriptions for oral and emergency contraceptives, IUDs and other family planning services such as screenings for sexually transmitted diseases. The study found no change in the use of IUDs and other forms of contraception such as the patch or vaginal ring.

Over-the-counter options only help certain people?

In her research, Qato noted that two years after Iowa imposed Medicaid coverage restrictions on family planning clinics that provided abortions, the use of contraceptives declined by two-thirds.

A report from the Guttmacher Institute released this week showed 42 clinics that provided abortions nationwide closed their doors between 2020 and 2024. The number of abortions have also increased during that time, and more than 80% still take place at brick-and-mortar clinics rather than via telehealth or by mail.

While Plan B and Opill — an oral contraceptive — are available over the counter, Qato said those options are still untenable for some people who need contraceptives the most, including low-income women and women of color.

“Opill is convenient for those who don’t want to go to the doctor and have that discretionary income to purchase it, but low-income women relied on clinics that are now closed, they relied on prescriptions that they now don’t have,” Qato said. “Those options are accessible, but not affordable to women who could really benefit from it.”

While Qato said there should be a focus on restoring and protecting access to abortion, there should also be efforts to protect contraception in the most restrictive states. She is alarmed to see initial increases after Dobbs and then such steep declines.

“It suggests that we may observe increases in live births from unintended pregnancies in women who were forced to have a child that wasn’t planned because the state didn’t protect or introduced fear of criminalization or liability for patients, doctors, or pharmacists,” she said. “A woman may not feel safe choosing emergency contraception in those states anymore.”

This story has been updated to correctly identify the University of Southern California as the institution that conducted a study that found a sharp drop in the rate of prescriptions for contraceptives in states with the most restrictive abortion bans.

A protester at a Planned Parenthood Great Northwest rally in Boise, Idaho, holds up a sign about the EMTALA case on April 21, 2024. (Otto Kitsinger/Idaho Capital Sun)

As expected after the court said it inadvertently uploaded the opinion prematurely on Wednesday, the U.S. Supreme Court issued a decision Thursday remanding a case about emergency abortions in Idaho back to the Ninth Circuit Court of Appeals for now.

The decision was 6-3, with conservative Justices Samuel Alito, Neil Gorsuch and Clarence Thomas dissenting. It was issued “per curiam,” meaning there is no lead author of the overall opinion.

The justices affirming the decision wrote that they determined the court took the case too early in the process. It granted the request to hear the case in January before the Ninth Circuit Court of Appeals could hold its own hearing on an injunction that blocked enforcement of the law against emergency room physicians who might need to perform an abortion to prevent a pregnant patient from experiencing significant health effects from infection or other conditions. The government argued Idaho could not enforce its criminal abortion ban in emergency rooms because it would violate a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA, which requires Medicare-funded hospitals to treat patients who come to an emergency room regardless of their ability to pay.

Loss of federal protection in Idaho spurs pregnant patients to plan for emergency air transport

When justices agreed to hear the case, the court also dropped the injunction, leaving doctors in Idaho open to prosecution under its criminal abortion ban, which carries penalties of jail time, fines and the loss of a medical license. Idaho’s civil law also allows immediate and extended family members to sue the doctors for up to $20,000 over an abortion procedure.

Idaho’s ban contains only an exception to save the pregnant patient’s life, not to prevent detrimental health outcomes, including the loss of future fertility, which is a risk with severe infection or bleeding. Without further clarity written into the law, doctors have said they can’t confidently assess when to safely intervene to save someone’s life. Rather than take the chance, high-risk obstetric specialists have airlifted patients to a facility out of state that can freely perform the procedure before it’s too late. In 2023, the state’s largest hospital system said at their facilities such transfers happened once, but occurred six times between January and April, when the injunction was lifted.

Justice Amy Coney Barrett, who is typically conservative in her rulings, said the court’s decisions to hear the case and drop the injunction were premised on the belief that Idaho would suffer “irreparable harm” under the injunction and that the cases were ready for the court’s immediate determination. She wrote that the briefings and oral argument in April shed more light on the case, and made it clear that conscience objections were covered under EMTALA and other concerns about an interpretation that would include emergency mental health concerns did not apply.

“I am now convinced that these cases are no longer appropriate for early resolution,” Barrett wrote.

Dr. Caitlin Gustafson, president of a group of Idaho physicians who have spoken out against the ban and submitted a brief to the court in the case, said the decision is not the end of her coalition’s work.

“We are relieved by the Supreme Court’s decision,” Gustafson said. “However, this ruling addresses only a small part of the ever-increasing barriers across the health care landscape. The coalition remains committed to advocating for comprehensive policy updates to fill the gaps in healthcare access created by Idaho’s restrictive laws, which jeopardize patient safety. We will not relent until private healthcare decisions are once again at the discretion of patients and their physicians, free from political interference.”

Ahead of the decision, more than 6,000 doctors from around the country also appealed to the court to protect ER physicians, along with medical professionals in Idaho and advocacy organizations.

The case now returns to the Ninth Circuit to resume the process, but it could ultimately return to the Supreme Court at a later date.

Protesters gather outside the U.S. Supreme Court on Wednesday, April 24, 2024, while justices hear oral arguments about whether federal law protects emergency abortion care. (Sofia Resnick/States Newsroom)

A document inadvertently uploaded to the U.S. Supreme Court’s website on Wednesday appears to indicate the court will send a case regarding emergency abortion care in Idaho back to the Ninth Circuit Court of Appeals rather than make a decision, according to reporting from Bloomberg Law.

Rather than rule on the merits, the unofficial opinion, as cited by Bloomberg, essentially says the court took the case too soon in the process. The court acknowledged the document was accidentally uploaded for a short period of time on Wednesday, and told Bloomberg an official opinion will be released “in due course.”

“The Court’s Publications Unit inadvertently and briefly uploaded a document to the Court’s website,” said Patricia McCabe, the court’s public information officer. “The Court’s opinion in?Moyle v. United States?and?Idaho v. United States?will be issued in due course.”

According to the unofficial opinion, the decision is 6-3, with Justices Samuel Alito, Neil Gorsuch and Clarence Thomas dissenting.

The opinion, if it holds true, would reinstate the lower court’s injunction that blocked enforcement of the law as it relates to Idaho’s emergency room physicians who might need to perform an abortion when a pregnant patient is at risk of potentially serious health problems. The U.S. Justice Department sued Idaho over its near-total abortion ban in 2022 and said prosecuting physicians under those circumstances would violate the federal Emergency Medical Treatment and Labor Act, or EMTALA, which requires Medicare-funded hospitals to treat patients who come to an emergency room regardless of their ability to pay.

The Ninth Circuit Court of Appeals had scheduled an “en banc” hearing for the case in January, but after attorneys for the state of Idaho and religious conservative law firm Alliance Defending Freedom asked the Supreme Court to hear the case, the Ninth Circuit hearing was vacated and so was the injunction.

Without the injunction, ER doctors are subject to the full extent of Idaho’s abortion ban, which carries penalties of jail time, fines and the loss of a medical license. Those doctors are also subject to Idaho’s civil law that allows immediate and extended family members to sue for up to $20,000 over an abortion procedure.

Idaho’s ban contains only an exception to save the pregnant patient’s life, not to prevent detrimental health outcomes, including the loss of future fertility, which is a risk with severe infection or bleeding. Without further clarity written into the law, doctors in Idaho have said they can’t confidently assess when to safely intervene to save someone’s life and avoid losing their medical license or face between two and five years in prison. Rather than gamble with someone’s life, States Newsroom reported high-risk obstetric specialists have airlifted patients to facilities out of state that can freely perform the procedure before it’s too late. In 2023, such transfers happened once, but occurred six times between January and April, according to the chief medical officer of one of Idaho’s largest health systems.

Those transfers were cited by Justices Elena Kagan and Ketanji Brown Jackson as reasons for their decision to send the case back to the Ninth Circuit.

“As a practical matter, this Court’s intervention meant that Idaho physicians were forced to step back and watch as their patients suffered, or arrange for their patients to be airlifted out of ldaho,” Brown Jackson wrote in the unofficial opinion.

At a scheduled event in Boise, Idaho, on Wednesday, U.S. Health and Human Services Secretary Xavier Becerra said it was important to wait and not speculate about the opinion until it was official. But if true, Becerra said it affirmed the government’s position that anyone in America who is at risk of health problems or death should be able to seek care in an emergency room.

“Whether the care that a professional says you need to stabilize your health or to save your life is an abortion or not, the bottom line is none of us wants to be denied access to an emergency room when we need it,” Becerra said. “And (it’s) why I continue to say when Roe v. Wade was struck down, it impacted more than just abortion care — it impacted access to care, period.”

Dr. Loren Colson, a family physician in Idaho, said at the event that if the opinion holds true, it is only a small comfort to doctors in the state.

“This teeny tiny little carveout allows us as physicians in very specific scenarios to provide the care and hopefully not Life Flight people out of the state so they can go somewhere else to get the care that we can easily provide here, but it does not fix our problem here,” Colson said. “We still have a huge problem when it comes to being able to access abortion.”

The court is scheduled to release more opinions Thursday and Friday morning, and the official ruling could come on either of those days.

An abortion rally in downtown Nashville took protesters on a route to the Tennessee Capitol and the federal courthouse in June 2022. (Photo by John Partipilo/Tennessee Lookout)

In Arizona, the state’s highest court upheld a Civil War-era abortion ban. Florida and South Carolina moved to restrict abortion to six weeks — before many people know they are pregnant. The Alabama Supreme Court ruled that frozen embryos are “children,” temporarily throwing fertility treatments, such as IVF, into uncertainty and igniting a national debate.

Meanwhile, anger and fear unleashed citizen-driven ballot initiatives around the nation that sought to protect abortion access, and in some cases, competing efforts to codify no right to abortion in some state constitutions.

And amid all of that, emergency room physicians in Idaho and other states nationwide are still waiting for the U.S. Supreme Court to decide whether they are subject to criminal penalties for providing an abortion even during a medical emergency.

It has been two years since the U.S. Supreme Court overturned the landmark Roe v. Wade decision after 50 years and ushered in the Dobbs era, allowing states to freely regulate abortion access for the first time since 1973. Dobbs triggered confusion and chaos in the reproductive health care landscape as patients and providers attempted to parse an ever-changing patchwork of laws around the country during considerable legal wrangling.

Some trends have emerged with particular salience and offer a possible preview of what is to come before and after the November election.

Ban states see as much as 26% reduction in medical residency applications

One of the most significant effects of Dobbs is among obstetric providers in the 14 states with abortion bans. The Association of American Medical Colleges published data in May showing fewer new graduates of U.S. medical schools applied to residency programs in states with bans. The decreases were particularly noticeable in ban states such as Tennessee and Alabama, with decreases of about 20% in both between 2023 and 2024.

Missouri showed one of the largest decreases at 25.7%, a drop from the previous year, which was still down almost 11%. Arizona experienced an even steeper decline of 26.4%, even though it is a state with a 15-week ban rather than a near-total ban.

Kendal Orgera, lead research analyst at the Association’s Research and Action Institute, said the data is collected between September and May 31 each year, and overall, there was an increase of just eight applicants for OB-GYN specialties nationwide.

“The biggest thing is the areas that already have problems with access to care are going to feel the impact first and foremost,” Orgera said.

Some ban states, such as Idaho and Mississippi, do not have residency programs specifically for OB care and have to rely on outside recruitment. That can make it especially difficult to fill positions in those states, Orgera said, in part because many people who match with a residency program tend to stay in that state to practice full time.

“People (who are in residency programs) are in their 20s and 30s, and they want to choose a home for the long term,” she said. “These are people who want to settle down and have families. Would a physician who wants to become pregnant choose a state with ban laws?”

It was the reason Dr. Leilah Zahedi-Spung left her job in Chattanooga, Tennessee, after her fellowship. In January 2023 she moved to Denver, Colorado where abortion is legal. “It became abundantly clear I had a giant target on my back as the only person doing this kind of care,’’ she told Tennessee Lookout last year. “There was nothing that anyone, including the hospital, could do to protect me from criminal prosecution.”

For now, Orgera said she can’t say with certainty whether the restrictive abortion laws are actually the reason for the drop in applications, but the Association is working on a survey that would be given to prospective residency applicants in September asking them to give those reasons.

“I’m hoping the sample size is large enough to give us some good data to work from,” she said.

Infant, maternal mortality rates expected to rise in states with restrictions

Prior to the Dobbs decision, maternal and infant mortality rates were already higher in states that attempted to restrict abortion access as much as possible without outright bans, including placing limits on who could provide an abortion and instituting waiting periods.

Now, as physicians in some states struggle to determine sometimes vague language in the law about when an abortion is deemed acceptable, pregnant patients have been forced to wait to receive care, resulting in near-catastrophic consequences. A doctor in a rural area of Idaho said in a brief to the U.S. Supreme Court that after a patient of hers experienced a very premature rupture of membranes, when the amniotic sac breaks, she felt forced to wait until the patient developed a serious infection called chorioamnionitis before she felt safe to intervene and terminate the pregnancy.

Florida resident Anya Cook had a similar story of her water breaking at 16 weeks — just after the deadline of 15 weeks for an abortion that existed in Florida at the time — and she was sent home. She later miscarried and hemorrhaged so much blood she nearly died.

A group of women in Texas sued the state over its abortion ban because they experienced serious medical complications and said they couldn’t receive proper treatment. The Texas Supreme Court rejected the lawsuit at the end of May, but similar lawsuits are still pending in Tennessee and Idaho.

Maternal mortality rates across the country decreased between 2021 and 2022, the last year of available data from the Centers for Disease Control and Prevention, but it remains much higher among Black women and higher in states with more abortion restrictions. As of 2022, the rate for Black women was 49.5 deaths per 100,000 live births, compared to 19.0 among white women and 16.9 for Hispanic women.

Cumulative data from the CDC between 2018 and 2022 showed Tennessee with the highest maternal mortality rate of 41.1 deaths per 100,000 live births, followed by Mississippi with 39.1 and Alabama at 38.6. All three states have high Black populations and are often classified as maternity care deserts, with entire counties that do not have hospitals or providers for obstetric care. Research has shown that maternal mortality increased between 1995 and 2017 in states that increased their abortion restrictions.

The numbers are much lower in states with broad abortion access, including California with the lowest number at 10.5 deaths per 100,000 live births, followed by Minnesota at 12.3.

The data for post-Dobbs years is still undetermined, but experts have predicted those numbers will increase further now that the procedure is criminalized for providers in 14 states. Some experts have also speculated that the data in states with bans may become less reliable as well because of fears of prosecution.

Numbers for infant mortality are consistent with the maternal mortality trends as well. The same set of CDC data between 2018 and 2022 shows the highest infant mortality rate in Mississippi, with a death rate of 8.7 infants per 1,000 births. The next highest is in Arkansas, with a rate of 7.63, followed by Louisiana with 7.56. Inadequate access to prenatal care is again cited as a contributing factor, and one recent study from the American Journal of Preventative Medicine linked abortion restrictions with an increase in unintended pregnancies among families that already struggle to access adequate health care.

“With the widening gap in comprehensive reproductive care access across the U.S., it is very concerning to consider that the current disparities in maternal and infant health outcomes will likely be exacerbated,” the study said. “Unless policies are implemented to improve the equitable access to and provision of comprehensive reproductive care, birthing individuals will have very different experiences of care and health outcomes depending on geography. This includes not only access to abortion facilities but to health insurance and access to care in rural areas.”

‘We are still in the very nascent stages’ of abortion ballot initiatives

With lawmakers and special interest groups continuing to pass abortion bans and restrictions, some citizens have taken matters into their own hands and asked voters to weigh in on what state policy on abortion should be.

So far, four state ballot initiatives meant to enshrine abortion access have officially qualified for the November ballot, in Colorado and Maryland, where access is already broadly legal, and in Florida and South Dakota, where a six-week ban and near-total ban are in effect, respectively. As of Friday, the organizers working to ensure abortion access remains in Montana said they collected more than enough signatures to qualify for the ballot there as well.

Arizona, Arkansas and Nebraska face deadlines for signatures in July, according to the Fairness Project, a ballot initiative-focused group that has been assisting volunteers with financial and organizational resources in Arizona, Florida, Montana and Missouri. The Project also worked on the successful ballot initiatives in Michigan and Ohio over the past two years.

Kelly Hall, executive director of the Fairness Project, said the initiatives require significant financial resources. Even if it looks like abortion-rights advocates have a lot more funding than the anti-abortion rights side, as was the case in Ohio and Kansas, the resources required to pass an initiative are vast in order to gather enough signatures and reach out to voters ahead of the election.

“They aren’t in a place where they’ve had to show any of their cards,” Hall said. “Their side is just getting to sit on whatever war chest they have to use later this year.”

Kansas was the first testing ground for a ballot measure focused on abortion in the wake of the Dobbs decision. That election took place on Aug. 2, 2022, less than two months after the opinion was released. It would have amended the state constitution to say there is no right to an abortion and given the legislature authority to then pass laws regulating and potentially banning it. It was resoundingly defeated by a nearly 59-41 point spread, and abortion is still legal in Kansas until 22 weeks.

However, legislators in Kansas have continued to pass anti-abortion measures, including a bill in April that requires providers to ask patients for the “most important reason” for their abortion before the procedure. The Center for Reproductive Rights and Planned Parenthood Great Plains are suing the state over the law.

Although some could take that as a negative sign of the effectiveness of successful ballot initiatives, Hall said that initiative was different because it was not affirming access to abortion. In Ohio, voters gave explicit approval to add reproductive rights to the state constitution.

“Ohio had a six-week abortion ban that was poised to go into effect,” Hall said. “The courts dismissed that ban and now … Ohio lawmakers (are) saying, ‘The voters have spoken, and you need to recalibrate your expectations. So Kansas is not the right comparator, because their lawmakers still do feel that they have a lot of wiggle room about what they can do because there’s no explicit constitutional protection.”

Hall said for as many states as there are already going after initiatives, she thinks this is just the beginning.

“We are still in the very nascent stages of reproductive rights ballot measures being a thing in this modern era,” she said.

Litigation overload is a strategy for a national ban, ACLU attorney says

One thing that’s certainly been difficult to keep track of in the post-Dobbs era is how many cases are pending in courts nationwide at the state and federal level, including two recent cases before the U.S. Supreme Court involving access to mifepristone and emergency abortion care.

Jennifer Dalven, director of the Reproductive Freedom Project at the American Civil Liberties Union, said the firestorm of litigation is part of the overall strategy of anti-abortion activists.

“In the Dobbs majority opinion, there was this notion that the decision would somehow end litigation, and the briefs on our side certainly said that wasn’t true, that wasn’t going to happen, in part because the other side — this was never their endgame,” Dalven said. “The endgame is to ban abortion nationwide and not to stop there. Abortion is obviously at the forefront of what we’re seeing most often but we’re seeing other aspects of reproductive care, including IVF and contraception, under threat.”

While the mifepristone and ER abortion care cases are examples of anti-abortion litigation, many more lawsuits are taking place at the state and district court levels to challenge the bans and other abortion-related laws that have passed since 2022. Many challenges to the overall abortion bans have been unsuccessful, while others are still pending. Other lawsuits are still underway to preserve access to the abortion pill, to challenge abortion laws meant to restrict interstate travel, or to clarify that an abortion is permitted in medical emergencies to preserve a patient’s health, not just to prevent death. Another recent lawsuit is challenging Kansas’ recent law requiring providers to gather information about a patient’s “most important reason” for getting an abortion.

If former President Donald Trump wins in November, Dalven said she expects anti-abortion litigation and lawmaking to increase, especially if Trump follows the outline of the Heritage Foundation’s abortion and reproductive health care wish list in Project 2025.

“It’s incredibly important that people know that when they are thinking about casting their ballot in November,” she said.

Some advocates find silver linings in the past two years

Some reproductive rights scholars, even those who have been researching the issue for more than 30 years like Tracy Weitz, have found reasons to hope in the post-Dobbs era.

“I think what’s inspiring is the extent to which the resilience of the abortion delivery system has shown up,” Weitz said.

During the COVID pandemic, access to medication abortion through the mail rapidly expanded, she said, and it made it easier to ramp up that system further when the Dobbs decision came in June 2022. Now, about 18% of all abortions in the U.S. are obtained through telemedicine, particularly in states that have passed shield laws to protect providers from prosecution by other state governments where abortion is banned.

“Many of us knew that before Dobbs, access was terrible,” Weitz said. “Even in states where access was good before Dobbs … we’re seeing increased utilization of abortion because some of the barriers in those states have been reduced.”

She added that more people are realizing there is more than just one type of abortion patient — not just those who don’t want to have a baby — and both populations are hurt by abortion bans.

“I think people who banned abortions really thought you could distinguish between the kind of OB care that’s necessary when someone has a wanted pregnancy and the kind of OB care that you do in abortion, and they didn’t understand that it’s the same medical intervention,” Weitz said. “You can’t ban one without impacting the other.”

A blanket given to Anne Angus at the Boulder Abortion Clinic in Colorado, one of the only clinics in the country that offers termination after the second trimester. Angus said a former patient makes the blankets, called Bananas for Annie, for others who had to terminate for medical reasons.?(Courtesy of Anne Angus)

This is the fifth installment of an occasional States Newsroom series called When and Where: Abortion Access in America, profiling individuals who have needed abortion care in the U.S. before and after Dobbs. The first installment can be found here, the second installment is here, the third is here, and the fourth is here.

Anne Angus has been ready to start growing her family for years now.

She got pregnant on her first try and felt lucky to escape the morning sickness and extreme fatigue that often comes with the first trimester of pregnancy. She quit her job in anticipation of being a full-time mom.

“It was so exciting, I was so ready,” said Angus, who lives in Montana.

She’d bought a few items off Facebook Marketplace by the time she was close to the halfway point, including a bassinet, some toys, a bouncer — and the teddy bear onesie that she holds onto when she tells the story of her doomed pregnancy.

At her routine 19-week anatomy scan, Angus’ doctor said something didn’t look right with the abdomen. But that could mean any number of things with varying degrees of severity, according to her doctor, and they wouldn’t know more until further tests could be completed. And those tests would need to be done by a team of specialists almost 700 miles away, at a children’s hospital in Denver, Colorado. Her appointment was four weeks out from the anatomy scan.

At the end of a series of tests, she met with a team of doctors at the children’s hospital to discuss the diagnosis and next steps. It was called Eagle-Barrett Syndrome, a rare genetic defect that can cause the partial or complete absence of stomach muscles, urinary tract malformations and abnormalities of the testes.

“The little glands running from the kidney to the bladder — his were three times the size of an adult’s,” Angus said. “You’re not even supposed to be able to see them at an ultrasound, let alone have them be very obvious.”

There’s a 50-50 chance her future pregnancies would have the same mutation, which led her to decide in vitro fertilization was the safer way to get pregnant and be able to test embryos prior to implantation in the uterus. But like abortion, access to IVF treatments is becoming another political argument at the state and federal level, leaving Angus to worry that her remaining option for having a child is also at risk.

Following Dobbs decision, clinic was overrun with patients

Before arriving in Denver, Angus had told her husband that even if the diagnosis was severe, she didn’t want to terminate. He understood and supported whatever decision she wanted to make, she said.

But after determining the status of the fetus’ condition, the Denver doctors started to discuss dialysis, kidney transplants, and a variety of other courses of treatment that would be needed after birth.

“All of which sounded to me like they would just be experimenting on my baby, with the experiment being, ‘How long can we keep him alive?’” Angus said. “That did not feel loving and compassionate to me.”

While talking it over with her husband, Angus said they discussed a family member who had a terminal illness.

“It has been devastating to the family to watch this person’s pain increase as they slowly fall apart over the years,” she said. “We didn’t want that for our son.”

It was at that time that they made the decision to let him go without the medical interventions and the idea that he might just slowly slip away in a neonatal intensive care unit, she said.

By that time, it was mid-October 2022, four months after the Dobbs decision that allowed states to once again regulate access to abortion and the ensuing legal and legislative chaos. One of the only places in the country where Angus could terminate at her stage of pregnancy was a clinic in Boulder, Colorado. Montana has a gestational age limit of 21 weeks for termination, so she knew she couldn’t go back home.

“That clinic (in Boulder) was overrun because all of the states that used to have access now didn’t have it, or they were being pushed until much later,” Angus said. “We had a two-week wait from when we made the decision.”

By the time she got to the intake appointment, she was at 26 weeks. There were protesters outside of the clinic, so an escort with an umbrella covered Angus and her husband as they walked inside.

“I remember feeling so much anger and rage at them. You have no idea what’s going on,” she said. “You don’t care at all about my baby’s suffering if he’s born.”

The termination was a few days later. Angus said it was difficult to face the reality of letting go of any shred of hope she had left.

“That was probably the most scared I’ve ever been. Nobody talks about what it’s like to get an abortion at the end of your second trimester. What am I supposed to feel? What’s going to happen? Who do I talk to about this?” she said.

After the procedure, the doctor told her it was a difficult process because of the amount of water retention in the fetus’ body. Angus said she could tell just by looking at him.

“I didn’t see his whole body just because of how medically fragile he was, but you could just tell that it would’ve been a really ugly death for him earthside,” she said.

Insurance didn’t cover the costs. With the travel, lodging and the price of the procedure, Angus and her husband spent $10,000 of their savings.

Frustration continues for Angus as IVF becomes new political target

Throughout 2023, Angus had many appointments for egg retrievals, but she said the process has been emotionally and financially draining.

“We are extremely lucky that my husband has benefits through his work, but we’re also at the end of (those benefits), which is why this is our last IVF retrieval cycle,” she said.

She has a planned embryo transfer in September, but if it’s not successful, she worries about future political decisions around IVF limiting her options. There is only one clinic that offers IVF treatment in Montana.

The Alabama Supreme Court ruled in February that embryos are “children” and several IVF clinics in the state closed their doors over liability concerns. In the months since, some states have taken steps to ensure access to the treatment, but congressional bills to protect IVF federally have failed to advance and a politically influential religious sect came out against it for ethical reasons, potentially igniting more ideological battles.

The new political fight over IVF on top of her experience getting an abortion has made Angus fearful about not having explicit protection for the treatment in her state. It has also made her passionate about telling her story, including at the Montana Legislature in early 2023, when legislators did not advance a bill that would have eased some of the remaining restrictions to abortion access in the state.

Although access is still broadly available in Montana, Republicans have tried to change that since the Dobbs decision. Gov. Greg Gianforte signed several anti-abortion bills in 2023, including a 20-week ban, but they’ve so far been blocked in the courts. Gianforte continues to use executive authority to try to limit Medicaid funding and who can perform abortions.

Republicans in the legislature have also made it clear they don’t support a November ballot initiative to amend the state constitution with a right to abortion access, and at least one candidate endorsed by a national anti-abortion group is running for a congressional seat.

“I’m so angry that politicians are inserting themselves into an extremely intimate part of my life. I am trying to grow my family in a way that I can and in a way that is loving and sustainable, and they think they know better than me, and I am so insulted by that,” she said.

Mifepristone, FDA-approved for pregnancy termination up to 10 weeks gestation, is used in about 63% of U.S. abortions. (Photo by Chris Coduto/Getty Images)

In the aftermath of the U.S. Supreme Court’s unanimous ruling Thursday to maintain current access to the abortion medication mifepristone, abortion-rights advocates and opponents vowed to continue their respective battles over the drug.

Mifepristone is one of two drugs used to treat miscarriages and terminate a pregnancy during the first trimester, and is the most common method of abortion in the U.S. Anti-abortion groups, in conjunction with conservative religious law firm Alliance Defending Freedom, sought to revert the FDA guidelines to 2016, when the prescribed gestational time frame was three weeks shorter and there were more requirements around who could prescribe it and where and when provider visits had to take place. The case made its way to the nation’s highest court after outspoken anti-abortion U.S. District Judge Matthew Kacsmaryk in Texas ruled that mifepristone’s approval should be revoked, followed by a Fifth Circuit Court of Appeals opinion that agreed in part, saying the restrictions should revert to pre-2016 rules.

In a unanimous decision rejecting the anti-abortion groups’ challenge to the U.S. Food and Drug Administration’s regulation of the drug, justices agreed that the case lacked standing, saying there was no clear injury to the plaintiffs to warrant reinstating the restrictions.

“The plaintiffs do not prescribe or use mifepristone. And FDA is not requiring them to do or refrain from doing anything. Rather, the plaintiffs want FDA to make mifepristone more difficult for other doctors to prescribe and for pregnant women to obtain,” Justice Brett Kavanaugh wrote in the opinion. “Under Article III of the Constitution, a plaintiff’s desire to make a drug less available for others does not establish standing to sue.”

Wendy Heipt, attorney for advocacy organization Legal Voice, said the fact that the unanimous ruling is focused on standing is helpful, because that’s an area of law that has been in question in many reproductive rights-related cases since the Dobbs decision in 2022.

“I’m not relaxing; it’s not over. But the fact that this one rogue judge in Texas opened the courthouse doors to people who had no right to be there was a real challenge to the way our judicial system works, so I am reassured that there are still rules,” Heipt told States Newsroom.

Many reproductive rights and medical organizations issued statements following the ruling, including the Guttmacher Institute, a reproductive rights research organization that has closely tracked abortion pill use in the two years since the Dobbs decision.

“We are relieved by this outcome, but we are not celebrating,” said Destiny Lopez, acting co-CEO of the Institute, in a statement. “From the start, this case was rooted in bad faith and lacking any basis in facts or science. This case never should have reached our nation’s top court in the first place and the Supreme Court made the only reasonable decision by leaving access to medication abortion using mifepristone unchanged.”

Nikki Madsen, co-executive director of the Abortion Care Network, said she wasn’t surprised by the ruling, but noted it only preserves the status quo.

“It’s just not enough,” Madsen told States Newsroom. “We know that the anti-abortion extremists are relentless, and their goal is to truly chip away at any abortion access. So today’s decision just preserves access, but it’s really not enough for the people across the country who are truly navigating a human rights crisis right now.”

Three intervenor states expected to continue fight at district court level

Alliance Defending Freedom, the conservative law firm that argued the case, is the same organization that argued in favor of the Dobbs decision that returned abortion regulation to the states. In a statement, ADF attorney Erin Hawley said the ruling was disappointing, but that they will continue to “advocate for women’s health.”

“The FDA recklessly leaves women and girls to take these high-risk drugs all alone in their homes or dorm rooms, without requiring the ongoing, in-person care of a doctor,” Hawley said, adding that ADF is grateful to attorneys general in Idaho, Kansas and Missouri who successfully intervened in the case at the district court level with Kacsmaryk’s approval, because they intend to keep litigating the case there.

In a statement posted on X on Thursday, Missouri Attorney General Andrew Bailey wrote, “Today’s ruling only applies to standing; the court did not reach the merits. My case is still alive at the district court. We are moving forward undeterred with our litigation to protect both women and their unborn children.”

Bailey’s spokesperson did not give any further details about what that case would look like, and Idaho Attorney General Raúl Labrador’s office did not respond to a request for comment.

According to Susan B. Anthony Pro-Life America, a national anti-abortion organization, those attorneys general will move forward with the case “based on harms suffered by women in their states.”

Abortion opponents target abortion drugs from multiple angles?

Anti-abortion opponents have been fighting against the expansion of access to medication abortion since the FDA first approved the regimen in 2000, and they say they are not deterred by Thursday’s ruling.

“The Justices simply discussed the issue of legal standing and did not reach the merits of the case,” Carolyn McDonnell, litigation counsel at national anti-abortion policy shop Americans United for Life, told States Newsroom in a statement. “It’s still an open question whether the FDA unlawfully deregulated mifepristone.”

Longtime anti-abortion activist Rev. Pat Mahoney, chief strategy officer for the Stanton Public Policy Center, said the Supreme Court’s decision in this case was instructive, if not what abortion opponents wanted.

“There’s, I think, a misconception that a loss is a loss, and that isn’t always the case,” Mahoney told States Newsroom. “Sometimes a loss helps define the parameters for bringing the next case and next case, and believe me, there are going to be next cases on medical and chemical abortions. So now we know this isn’t a route to go.”

Mahoney said that like past legal defeats for the anti-abortion movement, this ruling offers at least a partial road map, such as the one abortion opponents followed after the Supreme Court ruled in 1992’s Planned Parenthood v. Casey that abortion until fetal viability was a federal right but that states could pass regulations that didn’t create an “undue burden” for people seeking abortions.

That ruling led to hundreds of restrictions and regulations around the country that kept nudging the viability and undue burden lines — limiting abortion access even before Roe v. Wade was overturned. Mahoney said his organization and others are pursuing various legislative proposals, such as regulating the disposal of embryonic and fetal remains following a medication abortion, which most people have at home or in private settings.

Americans United for Life said in a statement following the ruling that it “will continue to offer legal prescriptions for the strengthening of protections for unborn children from abortion pills through action on the federal and state levels in both executive and legislative branches of government, including through executive enforcement of the Comstock Act and RICO Act.”

Ever since Roe v. Wade was overturned, resurrecting the long-dormant Comstock Act to ban the mailing of abortion drugs and equipment (something legal scholars and historians say is an inaccurate interpretation of the law and how it was applied) has been the long-term focus of East Texas pastor Mark Lee Dickson and his partner Texas attorney Jonathan Mitchell.

They have been pushing various legal and legislative strategies to prevent people from obtaining abortions in states where it’s still legal. They have helped pass dozens of local ordinances in Texas and other states with restrictions that challenge current federal law, such as banning interstate travel to obtain an abortion. In New Mexico, where abortion is legal and largely unrestricted, a challenge to two local ordinances based on the Comstock Act await a ruling from the New Mexico Supreme Court.

The U.S. Supreme Court did not address the Comstock Act in its opinion, but Kascmaryk cited the old law in his initial ruling last year. Major conservative groups are pushing former President Donald Trump, if reelected this fall, to enforce the Comstock Act along with other federal abortion regulations. Trump has stayed silent about what he will do.

In the meantime, anti-abortion groups have not stopped pursuing other cases.

“I can confirm that there are several attorneys in the pro-life movement that are planning on bringing a number of different lawsuits relating to abortion-inducing drugs and the harm that they cause to mothers and their unborn children,” Dickson told States Newsroom.

Mahoney also said groups like his are working with attorneys on a potential class-action lawsuit against abortion-pill manufacturers. He said they are “actively gathering testimony and information from women who have been hurt through medical chemical abortions.”

“We’re working on it,” said Mahoney, adding, “It took us 50 years to overturn Roe.”

As states pass laws mandating more information, experts warn of privacy concerns. (Getty Images)

Years before the Dobbs decision, providers like Dr. Kylie Cooper were already uncomfortable with some of the reporting requirements for abortion procedures in states where they practiced.

Cooper was a maternal-fetal medicine specialist for several years in Idaho before she reluctantly left the state in 2023 because of the near-total abortion ban that is now in place. But when abortion was still legal, she was required to fill out a form and submit it to the state with information about the patient and the procedure, including the physician’s name and when it occurred. While the law said that the information would be aggregated and could not identify individual patients, Cooper never felt sure about how it would be used or how secure the data would be kept.

“It was supposed to be anonymous, but they asked for patient identifiers on it, so I was like, ‘Could this get tracked back to them?’” she said.

In April, TIME magazine interviewed former President Donald Trump, who is the presumptive Republican nominee for president, about his goals in office if he is elected. He was asked whether he would be comfortable with states monitoring women’s pregnancies to determine whether someone may have received an abortion despite a ban. Trump responded that it didn’t matter if he was comfortable with it or not, because the U.S. Supreme Court’s Dobbs decision allowed states to dictate abortion policy.

Although it was posed as a hypothetical and limited to states with abortion bans, there are efforts underway at the legislative and congressional levels — and in the blueprint for the next Republican presidential administration — to track abortion and pregnancy data. Some have already become law, and some are pending in the U.S. Congress, including a bill that would mandate that the Centers for Disease Control and Prevention collect more abortion data from all 50 states. At the same time, there are renewed concerns about deceptive practices around data privacy at crisis pregnancy centers nationwide, which are receiving large infusions of taxpayer dollars from some state governments such as Louisiana, Arkansas and Kansas.

“I don’t think most people recognize the way that we are currently being surveilled in our health care system,” said Jennifer Driver, senior director of reproductive rights for a policy advocacy organization called State Innovation Exchange. “People need to be talking to their providers about what information is shared, how it’s shared, and start reading the forms.”

Patients misunderstand how protective HIPAA is, researcher says

Carmel Shachar, a Harvard law professor with research experience in data privacy and health policy, said people typically think of the Health Insurance Portability and Accountability Act — better known as HIPAA — as fully protective of medical records, but that’s not the reality.

“HIPAA is protective of what’s in your medical records, but it’s a little more like Swiss cheese than I think people understand. There are a lot of exceptions,” Shachar said.

Two of the big exceptions are for law enforcement, when it is conducting an investigation, and the other is for public health reporting, she said. Public health data reports can be positive in terms of understanding what’s happening in hospitals and clinics, but on the law enforcement end, the exception in the law could be used by state governments with anti-abortion laws to prosecute those seeking and facilitating care in other states. That’s the loophole that President Joe Biden’s administration sought to close with a recent rule that was enacted after the Dobbs decision to address patient privacy specifically around procedures related to reproductive care. It does not allow law enforcement to seek those records for that particular type of care if it was obtained in a state where it was legal.

But that hasn’t stopped one attorney in Texas from trying. Jonathan Mitchell, the state’s former solicitor general, has filed two petitions seeking legal action against women he says traveled out of state to obtain an abortion. Courts are still considering whether he can proceed with depositions against those women.

Meanwhile, 17 Democratic-led states and Washington, D.C., have passed laws protecting providers and patients from out-of-state investigations for reproductive health care and gender-affirming care. Governors in Arizona, Michigan, North Carolina, Pennsylvania and Rhode Island have also issued executive orders declaring that state agencies won’t cooperate in extraditions or investigations involving reproductive care.

Shachar said some laws are also made under the guise of public health reporting when they’re more about political tactics.

One example is a recent law passed in Kansas, where voters overwhelmingly rejected abortion bans in a 2022 referendum. Lawmakers overrode Democratic Gov. Laura Kelly’s veto at the end of April to pass House Bill 2749, which Kansans for Life asked a legislator to introduce. It requires providers to ask patients for the “most important factor” in their decision to terminate a pregnancy. Kansans for Life is the same group that led the failed referendum.

On May 20, the Center for Reproductive Rights and Planned Parenthood Great Plains announced it is challenging the law in court, adding it to an ongoing case from 2023, according to Kansas Reflector.

Although the bill says a patient can decline to answer the questions, Center for Reproductive Rights staff attorney Alice Wang said that isn’t enough, because it doesn’t require the provider to tell the patient they don’t have to answer. Especially now that patients are coming to Kansas for an abortion from states where the procedure is banned and criminalized, Wang said, the bill is designed to intimidate providers in particular, since they are the ones subject to criminal penalties, not the pregnant person.

“When patients are confronted with these questions, then that raises questions of what this deeply personal information is going to be used for in an atmosphere where anti-abortion extremists have already threatened to come after activities that should be perfectly legal,” she said.

The list of reasons includes whether the patient already has “enough, or too many, children,” whether they cannot provide for another child, that the pregnancy was a result of rape or incest or that it threatens their health to be pregnant. The data must be reported biannually to the legislature.

Shachar said the reporting of abortion procedures is not in itself shocking, but asking for reasons why is alarming.

“It feels like it’s trying to lay the groundwork to separate out ‘good’ or ‘permissible’ abortions from ‘bad’ abortions,” she said.

One of the reasons listed is that “The child would have a disability,” but there is no reason in the list for a pregnancy with a fatal or severe life-limiting fetal anomaly. Organizations such as Susan B. Anthony Pro-Life America and Live Action often refer to severe fetal abnormalities as “disabilities,” even if the patient chose to continue the pregnancy and the infant died hours after birth.

Abortion survey bill advances in New Hampshire legislature

While Kansas’ law is one of the most recent, it is not a new concept. According to the Guttmacher Institute, 15 states already require providers to gather information about a patient’s reason for seeking an abortion, with varying degrees of specificity. Many of those states now have near-total abortion bans or six-week bans, which is before many people know they are pregnant.

In Oklahoma, before its ban went into effect, reporting requirements included a list of 40 reasons that could be identified, whereas the Kansas list is 11 reasons. Seven other states that asked for reasons in their reporting requirements now have a near-total abortion ban or severe restrictions, including Arizona and Florida.

A similar reporting bill is advancing in the New Hampshire legislature, where abortion is still broadly legal, and another failed to pass in the Michigan legislature in 2023. In Indiana — a state with a near-total ban — an anti-abortion group is suing the state to make abortion records public information.

Another misunderstanding of HIPAA, according to Shachar, is that people can’t be identified through public health information as long as enough data points are removed.

“That theory is totally wrong,” she said.

She pointed to a story from 1997, one year after HIPAA became law, when a computer scientist named Latanya Sweeney was able to identify the medical records of the governor of Massachusetts at the time even though the dataset she was working from had been de-identified.

“It makes it more difficult to figure out who we’re talking about, but it doesn’t make it impossible, especially if someone is motivated to re-identify the data,” Shachar said.

Heritage Foundation outlines steps to federal abortion regulation

There are also national policy advocates prescribing the next actions to take in the fight over abortion rights. A document produced by conservative interest group the Heritage Foundation called Project 2025 details a wish list of priorities and approaches for many sectors of the federal government to be carried out by the next Republican president. The document, called “Mandate for Leadership, The Conservative Promise” is 920 pages and references abortion nearly 200 times.

Project 2025’s advisory board includes staff from the Alliance Defending Freedom, a religious conservative law firm that represented the clients at the center of the Dobbs decision overturning Roe v. Wade, and is arguing for the U.S. Supreme Court to restrict access to mifepristone, part of a two-step drug regimen to terminate a pregnancy. The firm’s senior counsel, Erik Baptist, is listed as a contributor to the document.

The board also includes anti-abortion groups such as the Family Research Council, the Family Policy Alliance and Susan B. Anthony Pro-Life America. As part of its overall guidance, the document calls for the next Republican president to remove all references to abortion and reproductive health and appears to suggest a nationwide abortion ban.

Driver, senior director of reproductive rights for State Innovation Exchange, said Project 2025 is the foundation for the recent state-level legislation.

“It would be na?ve to think this was not a design behind those with Project 2025,” Driver said. “Even if there’s not this conservative federal administration that comes, we’re already seeing Project 2025 elements and have for a long time at the state level.”

The plan states that federal abortion reporting data is “woefully inadequate.” California, Maryland and New Hampshire, where abortion access is broadly legal, do not submit abortion data to the federal government at all. The plan’s authors contend all 50 states must mandatorily report to ensure reliable public health and policy.

“Because liberal states have now become sanctuaries for abortion tourism, (the agency) should use every available tool, including the cutting of funds, to ensure that every state reports exactly how many abortions take place within its borders, at what gestational age of the child, for what reason, the mother’s state of residence, and by what method,” the plan states.

Project 2025 suggests rescinding HIPAA rule regarding abortion investigations?

Republican South Carolina Rep. Ralph Norman introduced a bill in Congress in January 2023 — about nine months after the Heritage Foundation established Project 2025 — that would require the Centers for Disease Control and Prevention to fulfill those data-tracking plans. It’s titled the “Ensuring Accurate and Complete Abortion Data Reporting Act of 2023,” and contains the exact language used in Project 2025’s outline. The bill has 29 co-sponsors and the support of the anti-abortion organizations on Project 2025’s advisory board. It has not advanced in the Subcommittee on Health. In a statement, Norman said current data collection “severely underestimates the number of abortions taking place” and tax dollars are being allocated to family planning programs without clear data.

Mandatory factors for reporting would include the pregnant person’s age, race, ethnicity and state of residence, the “abortion method type,” the person’s marital status, and the number of times they have been pregnant, including the number of previous live births, induced abortions and miscarriages.

Those factors — except for the number of previous abortions and miscarriages, which was less common — have been part of the data the CDC collected for many years, but the reporting was voluntary. What’s new is that the required data would also have to indicate “whether the child survived the abortion.” The agency head could also add questions at any time, according to the bill text. All states would have to report this data or lose federal Medicaid funding for family planning services.

The document’s authors also call for the federal government to rescind the HIPAA rule protecting those who seek abortion procedures in legal states from law enforcement action. Project 2025 calls the rule a “politicized statement in favor of abortion and against Dobbs.”

Crisis pregnancy centers imply they are subject to HIPAA law, but most are not

Amid the passage of new laws like the one in Kansas, an organization called the Campaign for Accountability filed complaints in April with attorneys general claiming that crisis pregnancy centers in five states — Idaho, Minnesota, New Jersey, Pennsylvania and Washington — are using deceptive language about HIPAA. Crisis pregnancy centers are often formed as nonprofit organizations with a stated mission to support pregnant women who are unexpectedly pregnant and a goal of dissuading them from seeking an abortion. Many of the centers have been criticized for promoting or providing false information related to abortion, such as claims that having an abortion increases a person’s risk of cancer or future fertility issues, or that the abortion pill is dangerous.

The centers almost always offer their services for free, which means they do not bill insurance providers and are therefore not subject to penalties under the federal HIPAA law for disclosing a patient’s health information. However, some of the centers claim on their websites that they are required by law to keep health information protected.

One of the clinics named in a complaint filed with the attorney general’s office in Pennsylvania uses the same type of language in the notice of privacy practices portion of the website. There are links to the federal HIPAA informational page, with one reference stating a person can file a complaint with the HIPAA office if they feel their data privacy was violated. Another section states the organization is “required by law to maintain the privacy and security of your protected health information” with a link to the HIPAA website.

The Pennsylvania clinic is part of a network of crisis pregnancy centers called Heartbeat International, one of two organizations targeted by the complaints, with Care Net being the second. Heartbeat has more than 2,000 affiliates in the U.S., and Care Net has 1,200.

Heartbeat International told States Newsroom in an email that while the organization could not speak for individual affiliates, all affiliates in the network adopt a commitment to hold client information in “strict and absolute confidence” and is only disclosed when required by law or “when necessary to protect the client or others against imminent harm.”

“Pregnancy help centers provide that protection to their clients, even when the law does not explicitly require them to do so,” said Andrea Trudden, vice president of communications for Heartbeat International. “Confidentiality is of the utmost importance to pregnancy help centers, and the forms women sign before receiving services provide them legal protection of their confidential information. Pregnancy, abortion, STDs/STIs, and other circumstances that might bring a woman to a pregnancy help center or abortion facility should be handled with the greatest confidentiality.”

Trudden added that the Next Level CMS system uses the same software platforms used by hospitals and doctor’s offices nationwide.

Michelle Kuppersmith, executive director of the Campaign for Accountability, said some of the centers state they can disclose health information for “moral reasons.” Heartbeat International also maintains a data management system called Next Level CMS for all of its centers, which it says follows privacy standards according to HIPAA law.

“Our fear is that the data collected at these centers are laddering up to much more sophisticated operations,” Kuppersmith said. “Every single woman who is thinking about going to one of these places because it seems like a friendly place should know that their personal health information is not required by any federal medical law to be protected, and they should be enormously careful what information they give to these places.”

It’s been one year since the U.S. Food and Drug Administration approved the first over-the-counter birth control pill, Opill, and less than two months since it hit store shelves. Advocates celebrate its availability but say access is still lacking in terms of cost barriers and insurance coverage. (Justin Sullivan/Getty Images)

Sriha Srinivasan remembers how surprised her mom was two years ago when she learned that birth control pills weren’t sold in stores without a prescription in the United States.

“My parents are immigrants from India, and it’s been over the counter there since my mom can remember,” said Srinivasan, a recent graduate of University of California Los Angeles.

More than 100 countries were already selling birth control without a prescription before the U.S. Food and Drug Administration Advisory Committee?recommended approval of the birth control pill for over-the-counter use in May 2023. Though?Opill was approved in July the same year, it didn’t reach online retailers or the shelves of major drug stores across the United States until a couple of months ago.

Opill is a progestin-only birth control pill, which is slightly different from the typical prescription of a progestin and estrogen combination pill. Dr. Kristin Lyerly, an OB-GYN in Green Bay, Wisconsin, said that means the oral contraceptive is still very safe and 98% effective, but the user has to be more diligent about making sure it’s taken at the same time every day. If the time window is missed by three hours or more, there is a higher chance of unintended pregnancy, so she recommends that people use a backup form of protection for the next 48 hours while they get back on schedule.

Srinivasan, 21, gets health care coverage through her parents’ private insurance, but she said when she called clinics to see if she could get a birth control prescription last year, the first appointment that was available was six months out.

She happened to be working with Free the Pill, a group of reproductive health advocates and health care providers, on getting Opill approved by the FDA, so she decided to hold off.

“Almost out of spite, I was like, ‘I’m going to wait and get this over the counter.’”

On March 22, just after Opill hit the U.S. market, Srinivasan drove with a friend to a nearby Walgreens to buy their first packs, which cost about $20 each. The two recorded a TikTok of themselves taking their first doses.

“It was a very joyous and empowering moment to be able to take that for the first time,” Srinivasan said.

Contraception access is key post-Dobbs, researcher says

Dr. Daniel Grossman, director of research at the Advancing New Standards in Reproductive Health program at the University of California San Francisco, has been at the forefront of the effort to get FDA approval for an over-the-counter birth control pill since 2004, leading Free the Pill. His research efforts included a study showing that women who had direct access to the pill in areas like Texas border towns where people could cross into Mexico to get it directly stayed on it longer than those who needed a prescription. His research also found that people generally didn’t support age restrictions, and the FDA approval for Opill does not have an age restriction.

Grossman said more access to contraception is important for overall reproductive health, but it’s especially important in the wake of the Dobbs decision in 2022 that overturned Roe v. Wade and led 14 states to enact near-total abortion bans.

“Improved access to contraception isn’t going to solve the crisis of abortion access that we’re currently facing, but that said, in this moment — when people in half of the states have very limited options for abortion care and there are growing threats on access to contraception — I think it’s important that we do everything we can to expand access to all methods of birth control where that’s possible,” Grossman said.

Aside from a few expected and manageable side effects, including headaches and light bleeding, Srinivasan said she’s had a good experience with the pills and their availability so far. But there’s room for improvement, she said, and Free the Pill is advocating for more cost assistance support and coverage from national private insurance companies.

Free the Pill launched an online petition this week to pressure President Joe Biden and his administration to require insurance plans to include coverage for Opill. It had 35,000 signatures as of Thursday afternoon.

Srinivasan said she tried to apply for assistance but wasn’t able to because she has insurance, and only those without any form of private or public insurance can apply. Qualifying applicants also have to have a household income at or below 200% of the federal poverty line, which is $15,060 for a single person. A 2022 survey from Advocates for Youth found that 1 in 3 of those surveyed cited affordability as one of the biggest barriers to accessing contraception.

“At a $20 price point, it’s something I can afford because I have a job and I live in California, where the minimum wage is over $17 an hour, but it’s definitely not something my peers in other states can afford that easily,” Srinivasan said. “I hope they adjust that, because it’s definitely not reaching the people that it should be reaching right now.”

Protesters gather outside the U.S. Supreme Court on Wednesday, April 24, 2024, while justices hear oral arguments about whether federal law protects emergency abortion care. (Sofia Resnick/States Newsroom)

This story has been updated

U.S. Supreme Court justices spent two hours Wednesday morning debating whether a federal law about emergency treatment encompasses abortion care even in states with strict abortion bans, with no clear indication of how they may ultimately rule.

A decision could come as soon as the end of June whether Idaho’s near-total abortion ban means doctors who might need to terminate a pregnancy during a health emergency would be protected from prosecution under the Emergency Medical Treatment and Labor Act, or EMTALA, a federal law that requires hospitals to treat patients who come to an emergency room regardless of their ability to pay. That includes treatment to prevent serious damage to bodily functions.

If the court decides the law does not provide that protection, then hospitals and doctors in Idaho have said they will have to continue transferring patients out of state for that treatment. Since January, when the court decided to take the case and struck down an injunction that provided protection under EMTALA, transfers out of state for pregnancy complications that may require termination increased from one in 2023 to six over the course of four months.

The court’s liberal wing — Justices Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson — ??questioned Idaho Deputy Attorney General Josh Turner about what EMTALA explicitly says about stabilizing treatment and whether abortion procedures fall into that definition when complications occur before a fetus can survive outside of the womb.

Turner argued that Idaho’s law should supersede federal law in the case of abortion procedures, even if it goes against commonly accepted medical care standards.

Sotomayor rejected that argument.

“There is no state licensing law that would permit the state to say, ‘Don’t treat diabetics with insulin. Treat them only with pills,’” Sotomayor said. “Federal law would say you can’t do that.”

She said federal law requires treatment of a person who is at risk of serious medical complications without that treatment, but Idaho’s law does not provide that much leeway.

“Idaho law says the doctor has to determine not that there’s really a serious medical condition, but that the person will die. That’s a huge difference, counsel,” she said.

Idaho’s abortion ban went into effect in August 2022, a few months after the U.S. Supreme Court issued its Dobbs v. Jackson Women’s Health Organization decision that overturned Roe v. Wade, ending federal protection for abortion access and allowing states to regulate it instead. Providers who are prosecuted for performing an abortion are subject to two to five years in prison plus the loss of their medical license, and they are also subject to civil enforcement laws by any family members related to the person who had the abortion.

Doctors are subject to prosecutorial discretion in Idaho, deputy AG says

The justices repeatedly asked Turner to identify situations where a doctor might provide an abortion as part of stabilizing care and it would not be allowed under Idaho law. He continued to point to the state’s exception to save a patient’s life and referred to a doctor’s “good faith medical judgment” being enough to avoid prosecution.

The government listed nine emergency medical conditions where termination of the pregnancy may be the recommended treatment to stabilize a patient’s condition, including when the water breaks before a fetus is viable or when a patient experiences uncontrolled high blood pressure or bleeding. Idaho doctors identified one recent “traumatic” case when a patient had to wait until advanced infection set in before the doctor felt secure enough to end the pregnancy. Others are sending patients out of state as soon as termination might be needed to avoid having to wait until they meet qualifications under Idaho’s exception to prevent death.

Justice Amy Coney Barrett, considered one of the court’s more conservative members, said Turner was hedging in his answers and asked what happens if another doctor or prosecutor reaches a contrary conclusion about what the appropriate medical treatment should have been.

“That, your honor, is the nature of prosecutorial discretion,” Turner said.

Barrett also asked if Idaho had released any legal guidance about its abortion laws, the way a federal health agency might issue guidance. Turner said the “guiding star” is the Idaho Supreme Court’s opinion from August 2022 interpreting the abortion statute, where it said the law does not require imminence of death or medical certainty for a physician to intervene. The Idaho court also said another doctor’s opinion would only be considered if they accused the doctor who performed the abortion of acting in bad faith.

U.S. Solicitor General Elizabeth Prelogar said for those reasons, women in Idaho are not getting the treatment they need, often in already-tragic situations where a wanted pregnancy is lost because of complications.

“They are getting airlifted to Salt Lake City and to neighboring states where there are health exceptions in their laws,” she said. “The doctors can’t provide the care until they can conclude that a prosecutor looking over their shoulder won’t second guess that maybe it wasn’t really necessary to prevent death.”

Conservatives ask about conscience objections

The more conservative justices offered mixed questions to Prelogar, who argued on behalf of the government. Justice Neil Gorsuch posed questions related to the federal Supremacy Clause about when federal law can override state law in the context of medicine, while Barrett asked whether conscience exceptions exist for doctors who don’t feel comfortable terminating a pregnancy even in emergency situations. Or if a hospital did not want to provide the procedure, such as a Catholic hospital, would be exempt under EMTALA for conscience reasons. One of Idaho’s largest hospital systems, Saint Alphonsus, is a Catholic hospital.

Prelogar confirmed that yes, individual doctors and entire medical entities qualify for those conscience objections and are therefore not required to perform an abortion under EMTALA. But at a hospital that did not have a blanket objection, they would take individual objections into consideration for appropriate staffing so that there is always someone available to provide that care if necessary.

“If the question is, could you force an individual doctor to step in over a conscience objection, the answer is no, and I want to be really clear about that,” Prelogar said.

Justice Sam Alito also asked Prelogar if EMTALA could be understood to apply to other emergency situations such as a mental health emergency, if someone was expressing suicidal thoughts and wanted to end their pregnancy to resolve those thoughts. Idaho’s legal representation, conservative religious law firm Alliance Defending Freedom, argued in its brief to the court that a ruling in favor of EMTALA protection would allow such situations to occur. Prelogar said no, the proper treatment would be to administer medications to alleviate the suicidal thoughts.

“There can be grave mental health emergencies, but EMTALA could never require pregnancy termination as the stabilizing care … because that wouldn’t do anything to address the underlying brain chemistry issue that’s causing the mental health emergency in the first place,” Prelogar said. “If she happens to be pregnant, it would be incredibly unethical to terminate her pregnancy. She might not be in a position to give any informed consent.”

Demonstrators, legislators from Idaho comment on court case

Hundreds of abortion rights advocates, medical professionals and two Idaho legislators gathered outside the U.S. Supreme Court building in Washington, D.C., on Wednesday morning before the arguments advocating for the court to uphold EMTALA as a guiding principle regardless of state abortion laws. On the anti-abortion rights side, Idaho-based crisis pregnancy center Stanton Healthcare argued the case was about forcing states with abortion bans to perform them. Danielle Versluys, the organization’s chief operating officer, said women with complications should deliver a baby naturally, regardless of the circumstances.

“The outcome is the same — a dead baby — but the difference is one is natural, and the other is not,” she said. “And one allows the woman the natural process to give birth and to grieve, and the other one is unnatural.”

Rep. Ilana Rubel, a Democrat and the legislature’s minority leader, told States Newsroom the case is a waste of state taxpayer dollars.

“It is, frankly, stunning that leaders in our state think that this is something they want so badly they were willing to take it to the Supreme Court to deprive women of appropriate care in medical emergencies,” Rubel said. And with the Idaho Legislature adjourned for the year, she added, “If the Supreme Court does not give us EMTALA back, there will be no lifeline for women at least until 2025.”

States Newsroom reproductive rights reporter Sofia Resnick contributed to this report.

Because of Idaho’s abortion ban and a court decision that does not protect emergency room physicians from prosecution under that law, some Idaho physicians are advising their pregnant patients, or those trying to become pregnant, to purchase memberships with companies like Life Flight Network or Air St. Luke’s in the Boise area to avoid potentially significant costs if they need air transport in an emergency. (Courtesy of Life Flight)

Since the U.S. Supreme Court decided in January to consider a case about whether a federal law regarding emergency medical treatment supersedes an abortion ban in Idaho, air transports out of state for pregnancy complications at one of the state’s largest hospitals have increased from one in all of 2023 to six in the past four months.

St. Luke’s Chief Medical Officer Dr. Jim Souza said if that pace continues, that number could be 20 patients before the year is over.

“We have limited resources in terms of helicopters, fixed-wing transports and ambulances. If we occupy an air transport with a patient who could completely receive the totality of her care right here, safely, it’s potentially dangerous for other patients,” Souza said.

Idaho’s abortion ban went into effect in August 2022, a few months after the U.S. Supreme Court issued its Dobbs v. Jackson Women’s Health Organization decision that overturned Roe v. Wade, ending federal protection for abortion access and allowing states to regulate it instead.

That rise has prompted some Idaho physicians to advise their pregnant patients, or those trying to become pregnant, to purchase memberships with companies like Life Flight Network or Air St. Luke’s in the Boise area to avoid potentially significant costs if they need air transport in an emergency. With or without private insurance, the cost can be thousands of dollars.

“The thought of this becoming the new normal — I don’t want it to be the new normal,” said Blaine Patterson, director of the Air St. Luke’s program, which reported the recent increase in transports by air.

The court will hear oral arguments Wednesday over whether the near-total abortion ban means doctors who may need to terminate a pregnancy to stabilize a patient in a health emergency will have to continue to transfer patients out of state or risk jail time and the loss of their medical license. The U.S. Department of Justice sued Idaho in 2022 over the ban, saying it violated the Emergency Medical Treatment and Labor Act, or EMTALA, which mandates that Medicare-funded hospitals provide stabilizing care for patients who come to an emergency room regardless of their ability to pay.

In a brief submitted to the court leading up to oral arguments, the Department of Justice cited States Newsroom’s reporting from January that without EMTALA protection in place, doctors said they would have to transfer more patients out of state for abortion care rather than wait for conditions to become life-threatening.

A pregnant patient might come to the ER for a variety of reasons, including high blood pressure, bleeding, or one of the most common occurrences, when the patient’s water breaks before a fetus can live outside of the womb, even with medical intervention. It happened 54 times at St. Luke’s Boise in 2023, or about once a week — though not all of those cases occur before a fetus is viable, which is generally considered to be about 22 weeks of gestation.

After the water breaks, there is often still a fetal heartbeat, even though the fetus ultimately won’t survive without amniotic fluid. And in the meantime, infection can quickly spread throughout the body and turn septic, which is life threatening, or it can lead to hemorrhage. Without the ban in place, a doctor would likely recommend termination of the pregnancy to avoid further complications.

But with the ban, maternal-fetal medicine specialists like Dr. Stacy Seyb of Boise aren’t taking any chances by trying to wait until the law’s exception for saving the patient’s life might apply. If termination needs to be considered, he said it’s better in his judgment to send someone to a facility out of state that can freely offer termination before it’s too late. The longer an infection or other complication persists, the greater risk it poses to a patient’s health and ability to get pregnant again in the future.

“And there are times they may not even need the procedure. But we can’t predict that, and we can’t predict how quickly their status might change,” Seyb said. “I think it’s a great hardship, it’s an extra expense to our medical system, and it doesn’t make sense why something that I’ve been doing for 30 years of my career is now taboo.”

Transport has financial, emotional and potentially physical costs

In a brief filed earlier this month by the Alliance Defending Freedom, a religious conservative law firm that has argued several abortion-related cases before the U.S. Supreme Court, including the Dobbs decision, attorneys argued on behalf of Idaho that transport out of state for an emergency termination is in line with EMTALA’s requirements.

“If state law allows a doctor to provide a particular treatment, then that service is available at a hospital for EMTALA purposes. But if state law prohibits a particular treatment, then the facility cannot provide it to anyone, no matter the circumstances,” the attorneys wrote.

Typically, only one support person at most can accompany a patient during air transport. That often means other family members must drive hours away from home in this region of the country, and find a place to stay. Seattle or Portland are seven to eight hours away, while Salt Lake City is about a five-hour drive from Boise. Utah has an 18-week abortion ban with an exception to preserve a pregnant patient’s health.

“It’s tough enough losing a pregnancy, but then to go through this in a foreign land,” Seyb said. “I feel very bad for these patients.”

There are also some patients who simply go home and wait it out, he said, because they don’t have the money or resources for air transport. Those patients may end up back at the emergency room later in worse condition.

According to the National Association of Insurance Commissioners, the average cost of these flights is between $12,000 and $25,000 before insurance is applied, based on an average 52-mile distance. Salt Lake City is almost 340 miles from Boise. Depending on the patient’s insurance plan details, 20% of that cost could still fall to them to pay out of pocket.

The median cost calculated by the Centers for Medicare and Medicaid Services is even higher at $36,000 to $40,000.

Besides the emotional and financial toll, Seyb said, there are delays in care caused by first having to make the decision to transfer and decide where the patient should go, then prep the patient for transport and make the journey while hoping no complications occur en route.

The aircraft is equipped to try to handle those situations, but by definition, it is not as well-equipped as a hospital. The specialty care teams that have to ride along for those transports in case of complications are also tied up for many hours and therefore unavailable to other hospital patients who may need them.

There are also considerations around weather in a mountainous region, said Patterson. In a time-sensitive situation, if there is a severe storm or low visibility for other reasons, it will inevitably delay care further.

“If it’s below weather minimums, we aren’t going anywhere. And those apply to everybody,” Patterson said.

‘You should think about’ membership if pregnant in Idaho

Natalie Hannah, spokesperson for the Life Flight Network, said they have not seen an increase in transports for maternal complications, nor have they seen an increase in membership requests. Life Flight has a reciprocal agreement with Air St. Luke’s and many other regional medical facilities around the West, she said, so coverage would be widespread. A membership with Life Flight costs $85 for one year for a household, while Air St. Luke’s charges $60 for one year. A member is required to have private insurance to qualify.

Patterson said a membership with Air St. Luke’s will cover copays and deductibles, and while he might only have recommended it before for those who recreate outdoors in remote areas or who ride motorcycles, he now would advise people to add pregnancy to the list. Seyb agreed that it made sense as a precautionary measure.

“You should think about it,” Patterson said.

A collection of mementos, including footprints and handprints, were provided by a hospital in Richmond, Virginia, to Kelly Shannon of Alabama after she had to terminate a pregnancy because of fatal anomalies. (Courtesy of Kelly Shannon)

Kelly Shannon was grieving a pregnancy she would need to terminate because of multiple fetal anomalies when she got the call that Alabama doctors wouldn’t approve an abortion procedure despite exceptions in the law. That meant she would have to leave the state.

This is the fourth installment of an occasional States Newsroom series profiling individuals who have needed abortion care in the U.S. before and after Dobbs.

Shannon, 36, was about 16 weeks along in January 2023 when genetic testing – and confirmation from an amniocentesis – showed her fetus likely had Trisomy 21, better known as Down syndrome. It didn’t take long for the doctor to determine the fetus likely wouldn’t survive to term. There was fluid buildup in the head and body, evidence of a heart defect, and a tumor on the abdomen that was roughly one-third the size of its entire body.

“There was so much decision-making and processing, and you’re still feeling the baby kick the whole time,” Shannon said. “And every time she would kick, I was just sitting there like, ‘I’m so sorry. I wish I got to be your mom, but I don’t get to be your mom.’”

Three years before the U.S. Supreme Court issued the Dobbs decision in June 2022 and returned the ability to regulate abortion to the states, Alabama had already passed an abortion ban. Gov. Kay Ivey said at the time she signed the bill that even though it was likely unenforceable since abortion was still legal nationally, it was a signal to the courts to overturn Roe v. Wade. A group of physicians challenged the Alabama law in court and received a preliminary injunction that had barred its enforcement for years. But when Dobbs took effect, the injunction was lifted. Doctors are now subject to felony charges with punishment of up to life in prison.

Alabama is one of few states with an abortion ban at any stage of pregnancy that also contains an exception for lethal fetal anomalies. In the law, it’s defined as a condition from which the fetus would die after birth or shortly thereafter, or be stillborn. There are also exceptions for performing an abortion to save a pregnant patient’s life or preserve their health. However, according to the latest WeCount report of abortions performed since Dobbs, Alabama has recorded zero abortion procedures. Activists have argued that exceptions in abortion bans are meaningless because there is too much fear and uncertainty about what circumstances will qualify for an exception.

Down syndrome is the most common chromosomal abnormality, and more often occurs when the pregnant person is over the age of 35. According to the Centers for Disease Control and Prevention, infants with Down syndrome and a heart defect are five times more likely to die in their first year of life than those without.

Each abnormality on its own would possibly have been manageable, Shannon said, but the maternal-fetal medicine specialist told her the combination meant she would likely either miscarry at some point during the pregnancy or her daughter’s life would be short and punctuated by multiple surgeries. Shannon and her husband made the difficult decision at that point to terminate.

“That made the decision easier because it was like, well now if I know I’m going to lose her regardless, I can lose her on a controlled timeline, protect my health, start the grieving process, get healthy and then still be able to have another child,” she said.

Shannon filled out paperwork and made a termination appointment pending approval from the other maternal-fetal medicine specialists at the University of Alabama at Birmingham. Her doctor felt confident that given the severity of the anomalies, the abortion would be allowed.

‘I don’t think I would’ve taken that risk on me’?

A few days later, in the car on her way to meet her husband and toddler at a local dog park, the doctor called back.

“I knew why she was calling me. I knew that was the day the (second) committee was supposed to meet and she’d be calling me with their decision,” Shannon said.

Shannon scheduled the Jan. 24? termination date, made arrangements to take leave from work and had decided on cremation. But with one phone call, all the decisions she’d made had to change.

The termination had easily been approved by the first committee, and it seemed like the higher-level committee would sign off too. But in a halting manner, the doctor explained the committee had decided since each condition by itself was survivable, it didn’t meet the criteria for termination. She told Shannon it was the hardest phone call she’d made in her professional career.

The only way the committee might approve the request was if the fetus also developed a condition called hydrops fetalis, an excessive buildup of fluid that is often fatal. Shannon said that put her in a strange place of having some kind of hope that her pregnancy was even worse than originally thought. But she wasn’t upset with the doctors themselves.

“I mostly just felt sorry for them, even at the time,” she said. “As angry as I was that I wasn’t going to get to handle my pregnancy and my termination in the way that made the most sense to me … if I had been in their shoes and thought well, is this one case worth my license and jail time and prosecution? Her life’s not in danger, her baby’s probably going to die. I don’t think I would’ve taken that risk on me.”

The manager of public relations at the University of Alabama at Birmingham said no one was available to speak with States Newsroom for this story.

She had one more ultrasound at 17 weeks, where her providers checked for hydrops, but there was no presence of it. As the pregnancy had progressed further since the last ultrasound,? multiple holes between the chambers of the fetus’s heart were clearly visible, and the tumor had grown .7 centimeters. Despite the increased severity of those issues, without hydrops, she still had to go out of state.

A scheduling error meant Shannon had to wait two more weeks before she could get an appointment at a hospital in Richmond, Virginia — an 11-hour drive. Rather than bring her husband and toddler along for the ordeal, Shannon’s parents accompanied her. It was the first night she’d ever spent away from her toddler.

She chose to be induced for the procedure. After a long day of waiting, Shannon gave birth a few minutes before midnight and got to hold her daughter.

“I kept her with me until about 2 or 3 in the morning,” she said.

The logistics of what to do with the remains became more complicated since she was now more than 700 miles away from home and wouldn’t be able to visit a burial site in Virginia the way she could have in Alabama. She opted to have her daughter buried with other babies that had died because of miscarriage, termination or other premature causes.

Baby boy born in mid-March?

In mid-March, Shannon gave birth to a healthy baby boy that was a surprise pregnancy. She had been aiming for her next pregnancy to happen over the summer, when she wasn’t teaching.

“When I found out I was pregnant, I just started crying. Instead of being excited, the trauma came back,” she said. “And I felt like, I want to be excited and happy, but I’m not there yet because I don’t know if we get to keep this one yet either.”

She said she wants her story to make a difference, in hopes that another person doesn’t have to go through the same pain.

“I get angry whenever I see people with the ‘choose life’ bumper stickers and license plates, because they’re not thinking about me. They’re not recognizing that it’s not a black and white issue, it’s nothing but shades of gray when you’re dealing with pregnancy, particularly high-risk pregnancy,” Shannon said. “I am a married, white, straight, Christian, grew-up-in-the-church woman who was attempting to grow her family within the bounds of marriage, and I just keep thinking, if anybody is going to be able to change a mind about this issue, shouldn’t it be me?”

According to March of Dimes, nearly 7 million people of reproductive age live in a county that is considered a maternity care desert as of 2022.?About 2.2 million of those people live in an area with no hospital providing obstetric care, no birth center and no obstetrics providers. (Getty Images)

The U.S. Department of Health and Human Services announced Thursday a $25,000 increase in loan forgiveness available to primary care providers in designated underserved areas. That means qualifying individuals are eligible for up to $75,000 in forgiveness if they commit to two full-time years of service.

The amount is available to medical and osteopathic doctors, including OB-GYNs, pediatricians, nurse practitioners and midwives, and physician assistants who practice in areas with shortages of primary care providers. The move is meant to help rural and historically underserved communities provide primary care services.

It could also help areas that have been deemed “maternal care deserts” after clinics closed because adequate staffing levels could not be maintained, leaving care limited or completely absent and forcing people to travel long distances for standard appointments.

This has especially been a problem in states with abortion bans since 2022, including Idaho, Mississippi and South Dakota. Idaho has lost 22% of its practicing OB-GYNs since a near-total abortion ban went into effect in late 2022, along with half of the state’s maternal-fetal medicine specialists, and three clinics across the state closed their labor and delivery units in the same time frame. Doctors have said it has been difficult to recruit new physicians to fill those positions — one doctor said Wednesday that out-of-state applications for openings have dropped significantly.

According to March of Dimes, nearly 7 million people of reproductive age live in a county that is considered a maternity care desert as of 2022, or about 35%. That number has reportedly grown in the past two years. About 2.2 million of those people live in an area with no hospital providing obstetric care, no birth center and no obstetrics providers. The 2022 report showed more than 97,000 Ohioans were affected by reductions in access to maternity care, the highest of any state.

Another 11.4%, according to the report, live in an area considered to have low access to maternity care, meaning fewer than two hospitals or birth centers providing maternity services and fewer than 60 OB-GYN providers. Research also notes challenges finding care in rural and medically underserved communities disproportionately affect people of color, particularly Black patients.

Medical school costs have grown, and associated debt has increased four-fold over the past 30 years, according to HHS, but the maximum loan forgiveness had remained at $50,000 until now. The Health Resources and Services Administration division of HHS is responsible for the program.

An additional maximum of $5,000 in loan repayment will be available for those who pass an oral exam showing they are fluent in Spanish and practice in high need areas with patients who have limited proficiency in English. Research from the American Medical Association has shown those patients have worse health outcomes and provider experiences.

HHS is also working to create new primary care residency programs in rural communities, which would provide 540 openings for physicians in specialty care, once operational, according to the release. It is also conducting more than 25,000 training sessions for practicing primary care providers, including OB-GYNs, nurse midwives and other maternal care providers to diagnose and treat mental health conditions among pregnant patients, new moms, children and adolescents.

The National Health Service Corps Loan Repayment Program is accepting applications until May 9.

House District 75 Democratic candidate Allie Phillips collects signatures for her ballot petition from neighbors Paula Lyles, right, Danielle Davis, center, and Theron Lyles. (Photo by John Partipilo/Tennessee Lookout)

NASHVILLE, Tenn. — Candidates for political office often have personal reasons motivating them to run, even if those reasons don’t always end up as part of a stump speech or a talking point of the campaign platform. But when Allie Phillips knocks on the doors of strangers in Tennessee, she is leading with the story of one of the worst things that has ever happened to her — when she was forced to leave her home state to terminate a nonviable pregnancy.

For many people who have had an abortion, the intimacy of the experience and the stigma that often comes with it makes them reluctant to share, even among their closest friends and family, especially now that the procedure is illegal in 14 states. But not Phillips, even before she decided to run for office.

She has agreed to virtually any media request for an interview that has come her way over the past year, including stories about her pending lawsuit against the state of Tennessee. A Google search of her name returns more than 54,000 results, with headlines in the highest echelons of American media and abroad.

She has been through the story so many times with so many people that going door-to-door and relaying it to strangers with no idea of their political persuasions and asking them to support her candidacy was only a little bit nerve-wracking. Phillips needed 25 qualifying signatures from registered voters in her district, which includes her home city of Clarksville.

“I’m running because this time last year I was 19 weeks pregnant at my anatomy scan, when my doctor told my husband and me that it was no longer viable, and we made the very hard decision to terminate the pregnancy,” Phillips told her neighbors at each stop. “Because of Tennessee’s laws, I could not do that here, and on March 7, I had to travel out of state to receive the care that I needed.”

Tennessee has a near-total abortion ban that has been in effect since August 2022, two months after the U.S. Supreme Court issued the Dobbs decision that returned the ability to regulate abortion to individual states. The law contains an affirmative defense if an abortion is performed to preserve the pregnant person’s health or prevent the person’s death. It’s the law Phillips is suing over, along with six other Tennessee women and two physicians, to clarify that doctors can provide an abortion to pregnant patients who need one for medical reasons without fear of criminal prosecution. Similar lawsuits are still pending in Idaho and Oklahoma, with representation from the Center for Reproductive Rights. A hearing is scheduled to take place Thursday morning in Tennessee district court.

Since June 2022, the average number of abortion procedures per month in Tennessee fell from 1,205 to 44, according to a report from the Society of Family Planning. The law contains exceptions to save a pregnant patient’s life and to prevent substantial health problems, but without greater clarity in the law, few physicians are willing to risk performing the procedure with potential felony charges and up to 15 years in prison.

Phillips, who is vying for the House District 75 seat,? is one of the first candidates to run for office with her own personal story of seeking an abortion in a state where it is banned since the Dobbs decision, and she’s one of few who has ever run with such an emphasis on her own abortion story, as far as she and her campaign manager can determine. With each door knock, she and her team weren’t quite sure what kind of reaction they would get.

‘I started blaming myself immediately’

The story Phillips, 29, tells at the door is much simpler than the one she tells at length when given the opportunity.

She announced her pregnancy in November 2022 on the TikTok account she started two years earlier. At that time, she had about 275,000 followers that she had built largely through sharing videos about her weight loss after bariatric surgery, when she dropped close to 150 pounds in nine months. In between those videos, she danced with her daughter and made memes to the music of her favorite artist, Taylor Swift. It’s also where she announced the name she and her husband, Bryan, had chosen for their first child together —Miley Rose.

The couple brought 6-year-old daughter, Adalie, to a routine anatomy scan when Phillips was 19 weeks pregnant in February 2023. About five minutes into the scan, which examines the fetus’ internal organs, limbs and other aspects of the pregnancy to check for any developmental issues, the technician stopped and told Phillips she needed to talk to the doctor because she was seeing “some pretty serious things.”

“And of course, as soon as she says that my heart starts beating fast, I get a knot in my throat,” Phillips said.

When the doctor came in, she told Phillips the fetus was lacking amniotic fluid, which is essential to continued development, and both of the kidneys were not functional. The doctor referred Phillips to a specialist, but didn’t give her a prognosis.

During the four days before her high-risk appointment, Phillips said she googled every possible diagnosis she could find and told herself based on that research that it was fixable. But the follow-up appointment dashed those hopes. The fetus had stopped growing about a month earlier, the bladder and stomach had not formed correctly, the lungs were not developing, and only two of four chambers of the heart were working.

“And so in my mind I’m like … we can get stomach transplants, or feed her with a tube. We can get a kidney. I’m just going through all these things in my head, like, this is fixable,” Phillips said. “Lungs, I don’t know how we’re going to go about that, but I’m sure we’ll figure it out.”

But then the doctor continued the ultrasound imaging to the head.

“That’s when I felt a giant weight on my chest,” Phillips said. “Once you hit the brain and there’s something wrong with the brain, you’re done.”

The brain had failed to fully split into two hemispheres, a condition that results in live birth about 3% of the time, and of those, many die within the first year of life. There was also extra fluid present.

With all of that, the doctor told Phillips her second daughter was not compatible with life outside of the womb.

“And it was just quiet for a minute,” she said. “I didn’t look at her. My eyes were fixated on the (screen), like a million things running through my mind. … How could I have avoided this? Is it because I didn’t drink enough water? Is it because I didn’t get enough vitamins? I started blaming myself immediately.”

The doctor told her and her husband they had two options — to continue the pregnancy with risk of miscarriage, stillbirth or other complications, or terminate the pregnancy.

“She continued to say that because of Tennessee’s ban, you cannot do that here. You would have to look out of state, and I cannot offer you any resources,” Phillips said.

To avoid risking her future fertility or health, especially since she already had a daughter dependent on her, she decided termination was the right choice.

The next morning, Phillips recorded a TikTok video about the outcome of the appointment. That video has more than 3 million views and 28,000 comments. Many were supportive and kind, but thousands urged her not to “kill her baby.”

For various reasons, she chose New York City for a termination appointment the following week. Her husband had to take off work, she had to close her in-home daycare, find child care for her daughter, and somehow come up with about $5,000 for the procedure, the flights, lodging and meals. Her followers asked her to set up a GoFundMe so they could help, and they raised $8,000 — double her goal.

‘I’m more than just a one-issue candidate’

The day Phillips went canvassing in late February, her campaign planned to target certain houses based on voting records, but the application that campaigns use to identify those voters wasn’t working. Campaign manager Megan Lange decided they would wing it and hope for the best. The canvassing team included Phillips’ friend, Kathryn Rickmeyer, who has also had to leave the state for an abortion and is a vocal supporter of Phillips’ run for office.

Her Republican opponent for the seat, Rep. Jeff Burkhart, ran unopposed in the 2022 election. The district was newly drawn as of that year, but as far as Phillips and other Democratic operatives can tell, it is close to a 50-50 split with an edge to Republicans.

A conversation Phillips had with Burkhart a few months after her abortion was one of the driving factors behind her decision to run. She had approached him about crafting a bill to exempt fatal fetal anomalies from Tennessee’s abortion ban that would be called “Miley’s Law,” but the legislation never made it to the statehouse floor.

Burkhart’s legislative assistant told States Newsroom he was not accepting any requests for interviews.

During the two-hour meeting, which Phillips recorded, she said Burkhart told her he thought it was just first pregnancies that could go wrong, and he would encourage his daughter to continue a nonviable pregnancy even if her health was at risk rather than see her get an abortion.

Before that, she’d had no political ambitions. But several weeks later, she decided to take the leap, not just because of Burkhart.

“The idea to run was to turn my pain into purpose, to turn my tragedy into policy, so nobody else has to experience it,” she said. “But I’m more than a one-issue candidate, because Tennessee is more than a one-issue state. We have a lot of problems that need to be fixed.”

It hasn’t been easy just five months in. The family’s combined income is low enough that Phillips has said publicly she’s had months where she has to choose between paying the mortgage and buying groceries. She lost one daycare client because she was closed down for too many days for campaign-related events and interviews. It’s a talking point she uses while canvassing as well — that her opponent, a real estate developer, was able to loan his campaign $110,000.

“I’ve never seen that much money in my life,” she says to her neighbors.

Face-to-face interactions are more powerful than rhetoric, historian says

Over the course of the afternoon, few people who answered the door reacted to Phillips’ story of needing an abortion in either a negative or positive way.

Gillian Frank, a professor and historian who has studied reproductive rights history extensively, told States Newsroom there is a long history of women telling their abortion stories after they’ve been elected, but fewer who have campaigned on their own personal story.

Sen. Lorraine Beebe, a Republican in Michigan’s state legislature, spoke of the abortion she’d had during a debate on a bill to loosen restrictions on the procedure in 1969, four years before Roe was decided. The bill failed, and while her story gained national attention, she lost her seat in the next election, her house was fire-bombed, and her tires were slashed.

In the decades that have followed, entire organizations and activist groups have dedicated their missions to sharing abortion stories, such as Shout Your Abortion and We Testify. Some Democratic legislators have recently told their own stories as well, including Sen. Eva Burch in Arizona, who spoke about her experience being forced to hear about adoption and foster care and undergo a transvaginal ultrasound for a nonviable pregnancy before she could be granted an abortion, laws that were passed by state GOP lawmakers. Only one of the chamber’s 16 Republicans remained on the floor during Burch’s speech.

Frank said while Democrats have included reproductive rights as part of the party platform for decades, the support has often not been full throated or explicit, including from President Joe Biden, a Catholic whom activists have complained is too tepid in his support for abortion access.

Phillips’ experience of door-knocking, as relayed to him by States Newsroom, is what Frank says he would expect as a person’s standard reaction to someone standing in front of them sharing their story.

“‘I’m sorry that happened to you’ is just a fairly scripted, polite way to respond,” Frank said. “The lack of condemnation itself is interesting, but the default in an awkward situation is to offer a nicety and avoid discomfort.”

But there is a difference, he said, in a face-to-face conversation versus interacting with the anti-abortion rhetoric that has played out in campaigns and at protests and rallies over the years, especially since most Americans support some form of access to abortion and a right to privacy.

“The anti-abortion minority is both vocal and dramatic and prone to highly emotional displays, and that sort of hyped-up language is not where most people live their lives,” Frank said. “When we have these push polls and campaigning issues, dramatic commercials and reductionist devices, it’s a different experience than someone saying, ‘This is my story, I’m right here telling it to you.’”

Unregistered voter still thought Roe was intact

As of November 2022, the U.S. Census Bureau showed about 67% of Tennessee residents are registered voters, but that number is lower in Montgomery County, where about 127,000 residents were registered. According to state population estimates for 2023, that would be about 55%.

That seemed to ring true in Phillips’ neighborhood, where many of those who answered the door were receptive to her story but were not registered to vote and therefore couldn’t sign her petition. Some politely took her card and listened, but didn’t comment or agree to sign. One said he didn’t care if she was his neighbor and shut the door in her face.

A woman who hasn’t been a registered voter for many years was unaware that Roe v. Wade, the landmark case that made abortion access a constitutional right in 1973, was no more. She told Phillips she was sorry about her baby, and agreed that Phillips should have been able to terminate her pregnancy in Tennessee.

Two neighbors, including the one across the street who displays a large “Trump 2024” flag on his front step, signed as well, saying they supported her decision to run even if they didn’t agree politically.

As part of her pitch, Phillips mentions she’s committed to making sure public schools are fully funded and talks about her support for Medicaid expansion, infrastructure and gun safety. One woman did not comment on the abortion story but asked if Phillips was in favor of charter schools. When she said no, the voter agreed to sign. Another man said he would sign based on her abortion story alone, but he had to make sure she was still in favor of the Second Amendment when she started talking about gun safety.

Her last signatures of the day, and the ones that helped her hit her goal, were from three voters who were largely concerned about growth in the community and having their voices heard at the local level.

A woman next door came out of her house as Phillips was leaving and offered deep sympathy for her experience. She said God would give her another baby.

“We aren’t sure about trying again while the laws are the way they are, because we don’t know what my body can handle,” Phillips told her.

‘She went on her own’

The clinic in New York City only allowed the patient inside for the procedure, so Phillips went to the initial appointment while Bryan stayed at the hotel. She was looking forward to seeing Miley one last time before saying goodbye.

But when the ultrasound began, instead of hearing the quick thud of a heartbeat and seeing a wriggling form on the screen, there was only silence.

“I was like, ‘Is there not a heartbeat?’ and she slowly started to shake her head,” Phillips said. “And it just hit me like a train.”

No matter how many dozens of times she’s told the story, Phillips always starts to cry when she talks about telling her mom that Miley was already gone by the time of the ultrasound.

“(She said) I think this is the best gift Miley could have given you, because you were going to New York with so much guilt, and so much heartache, you were blaming yourself, you had all these ‘what ifs’ you were dealing with,” Phillips said. “She went on her own, so you didn’t have to make that choice.”

On her mantle now sits a tiny pink urn containing Miley’s ashes, onesies and binkies purchased for a full-term baby, and framed tiny footprints. Everyday, she plays the recording of Miley’s heartbeat inside a stuffed bunny.

‘I will just fight fire with fire’

As of March 26, Phillips has qualified to appear on the Aug. 1 primary ballot in Tennessee. So far, she has no Democratic opponents.

Since the canvassing in February, Phillips has spoken before the U.S. Senate about her experience, and she visited the White House on March 18 as part of a Women’s History Month event with Vice President Kamala Harris.

Win or lose in November, Phillips feels she has already made a difference by helping others who have been through similar experiences feel less alone and more empowered to work for change. Telling her story over and over again has its challenges, but they have been outweighed by the positives, including keeping the promise she made to Miley that she wouldn’t let her name die with her. Before she was running for a legislative seat, Phillips said she told her story to share the pain and hurt that it caused, but she shares it now as an example of why she thinks a nationwide 15- or 16-week ban on abortion is a bad policy, because she was 19 weeks before she found out she would need to terminate.

“Part of me doesn’t like politicizing my story,” she said. “I feel like I’m using my life for a political purpose. But unfortunately, our government has made our wombs a political topic. So I will just fight fire with fire at this point and use their own ammunition against them, in hopes that I win the battle at the end.”

Jennifer Vollstedt was pregnant for the second time in 2016, ?after her first?pregnancy was?diagnosed with a fatal chromosomal condition. Her son is now 6. (Courtesy of Jenn Vollstedt)

Jennifer Vollstedt and Ariel Cavanaugh-Okhah have never met, but they are connected by fatal chromosomal abnormalities that affected their wanted pregnancies, and the stress and heartbreak that come with it.

Their experiences of needing to terminate their pregnancies were quite different. One took place before the Dobbs ruling overturned Roe and the federal right to abortion while the other occurred just a few months after.

The two women are separated by nearly 1,500 miles. Vollstedt lives in Wisconsin. Cavanaugh-Okhah is in southern Florida. In some states, like Wisconsin, abortion restrictions were already in place before Roe fell, but the procedure was still accessible.

After June 2022, patients and providers found themselves trying to navigate a patchwork of laws in 14 states that implemented strict or near-total abortion bans, some from any gestational age. Access suddenly became largely dependent on location, with some clinics in bordering states less than an hour away and others more than a 12-hour car ride.

Vollstedt got pregnant for the first time at 27 in December 2014, not long after her wedding. She couldn’t wait to tell friends and family. She called her grandfather to share the news over FaceTime, just weeks before he died.

“He was really excited, he loved babies,” Vollstedt said.

Her doctor ordered standard blood work and other lab tests. But while she was on a family vacation in Florida a few days later, a geneticist called.

“They said my results from the blood test were actually very concerning,” she said.

The test indicated her fetus could have a rare condition called triploidy, which means it has 69 chromosomes instead of the normal 46, and causes many developmental issues such as heart, kidney and neural tube defects. In almost all cases, the pregnancy ends in miscarriage or stillbirth. The few babies that make it to delivery die within hours or days.

“I was just absolutely devastated, because I really wanted this pregnancy,” Vollstedt said.

To confirm the diagnosis, Vollstedt had to wait until 16 weeks for an amniocentesis because of the position of her placenta. Although Roe was still in effect, that year then-Gov. Scott Walker signed a law scaling back abortion to 20 weeks. The clock was ticking.

“I had no doubt that I would get an abortion for this pregnancy, that I did not have any interest in carrying it to term,” Vollstedt said. “I knew this baby, if she survived to term, would experience suffering and then pass away.”

Now with confirmation of the diagnosis, and the termination appointment scheduled, Vollstedt said she avoided leaving the house.

“People could see I was pregnant, and would comment on my belly, and that would just send me into instant tears,” she said. “Everything is going on with your body that you don’t want to be going on, and it’s just really frustrating and disappointing. … I wanted to not be pregnant anymore, and I didn’t have 100% control of when that happened.”

For the abortion, she returned to the same hospital where she had already been receiving care for her pregnancy, where she was already familiar with the nurses and doctors.

“I felt really cared for, and it felt really comfortable to be able to get my abortion in a hospital setting where I knew everybody,” she said. “It was just treated like regular, normal health care.”

Diagnosis came after Florida’s 15-week cutoff?

Cavanaugh-Okhah learned she was pregnant in early October 2022, when her son was about 18 months old. That was the age gap she and her husband, Zachary Okhah, had hoped for.

“We were at that time with my first child when you finally start to sleep, and thought, ‘Okay, we can try again now,’” she said.

Everything went well at her first ultrasound, and she decided to go ahead with genetic testing. Her doctor told her that following the Dobbs ruling, if the test results flagged anything that might cause her to want to terminate the pregnancy, she would have to do it by 15 weeks according to the new Florida abortion law. He wrote the details on a sheet of paper with the name of a clinic and the deadline.

“I remember thinking, ‘Thank you for the information, but that’s not a me problem,’ and just walking out the door,” Cavanaugh-Okhah said.

The test results came back with a high risk of Trisomy 21, better known as Down syndrome. It is the most common chromosomal abnormality, affecting about 1 in every 700 pregnancies, and it has a higher survival rate than several other disorders. But it can come with other severe defects that decrease those odds.

At first, Cavanaugh-Okhah was in denial that the results were accurate. Her doctor seemed to indicate it was probably wrong, she said, and her husband was convinced they were part of the small percentage of people whose babies end up being perfectly fine.

“That was a little too painful, to sit in that place of hope for weeks,” she said.

The doctor ordered an additional diagnostic test just before Cavanaugh-Okhah and her husband left on a trip overseas — her dream vacation to Switzerland at Christmas. But they received the phone call not long after arriving confirming the condition.

“I just fell into my husband, and I was weeping,” she said.

Zach Okhah is a plastic surgeon, and he called in a favor with a friend in Germany who helped them schedule an appointment with an OB-GYN who was willing to perform another ultrasound. That doctor found fluid present in the fetus’ brain, a heart defect, and a gastrointestinal tract that was so poorly developed, the doctor said termination was worth discussing for that abnormality alone.

At that point, Cavanaugh-Okhah was right around 15 weeks, so she wouldn’t be able to get an abortion at home. In Germany, they didn’t offer the type of procedure she preferred to have. And if she wanted her husband to be able to come with her, it needed to happen within the next week. So on Dec. 23, 2022, Cavanaugh-Okhah first called an abortion hotline to figure out her options, then called as many clinics as she could back in the states to find an appointment.

Massachusetts was one of the options on the list, and since she met her husband in Boston, they still had family there who could offer support. But that meant disclosing the whole story to more people than she wanted to tell.

“We hadn’t told those family members we were pregnant, so (my husband) called them and said, ‘Hey, we’re pregnant, and we need an abortion, a place to stay, and child care,’” Cavanaugh-Okhah said.

She contacted her doctor to get all of the ultrasound images and medical documents sent to the clinic, she said, because it felt like no one back home in Florida wanted to be involved with it at that point.

There was one appointment available. They changed their flights and flew straight from Stuttgart, Germany, to Boston.

“It’s so painful getting on an airplane knowing you’re flying to end your pregnancy,” she said. “I kept on saying, ‘I don’t know that I can do this.’”

The hospital was calm and quiet the day of her appointment, and Cavanaugh-Okhah said the doctor who cared for her helped give her the emotional support she needed to make it through the procedure.

“I wanted someone to tell me how many people go through this, because I couldn’t find it anywhere,” she said. “I’ll never forget, she just rolled her little chair closer to me and said, ‘I don’t have that number, but I can tell you there’s a lot of you.’ And then I think she placed her hand on me and said, ‘I know what you’re doing today is done with absolute love and compassion for your child.’”

‘We can love that pregnancy … and still make that decision’?

By the end of 2016, Vollstedt was pregnant again with her son, who is now 6. To process her grief and start to move forward took more than a year, she said, and she’s not sure if she ever would have wanted to get pregnant again if she had been forced to carry that pregnancy to term.

“(When Roe fell) I just thought so much about where I would’ve been had all this happened after that, what other people who are going to be in my situation or similar situations are going to experience,” Vollstedt said. If she had faced the same situation after the Dobbs decision, she would have been forced to look out of state for help, since Wisconsin had a full abortion ban in effect for more than a year.

“To have to do that many extra steps to get to Illinois or Michigan is so challenging when you’re already in this really fragile mental state,” she said.

Cavanaugh-Okhah knows she was able to get the care she needed because she had the means to book a last-minute overseas flight, but that didn’t make the experience any easier or less frightening. Even wealthy people can still lose their lives because care is too far away or otherwise inaccessible. As someone who had an ectopic pregnancy before her abortion and two miscarriages since, Cavanaugh-Okhah is all too familiar with potential complications.

The Florida Supreme Court has yet to decide whether the state’s 15-week ban should become a six-week ban after Republican Gov. Ron DeSantis signed a bill into law in 2023 to further restrict reproductive care.

“We’re in Miami, and if this thing passes and it’s a six-week ban, what’s going to happen if something goes wrong?” she said.

“I really want for people to see the humanness of us women, and that we can love that pregnancy and have so much compassion and connection, and still make that decision. Both can exist at the same time. We’re not heartless monsters.”

Amanda D'Angelo and husband James honeymooned in Hawaii in 2021. The rainbow is widely regarded as a symbol of having a living child after losing one during pregnancy. (Courtesy Amanda D'Angelo)

Amanda D’Angelo only had a few weeks to get used to the idea that she was going to be a twin mom, before her eight-week scan revealed one had died.

It’s a relatively common occurrence early on in twin pregnancies, and while it was upsetting, she took comfort in still being pregnant. She went on her honeymoon with her husband to Hawaii in July 2021, and the newlyweds smiled for a photo on the beach with a double rainbow behind them — a rainbow being the widely regarded symbol of having a living child after losing one during pregnancy.

She didn’t know just how symbolic that rainbow would become until a few weeks later.

D’Angelo went to a clinic in Manchester, New Hampshire, for a routine 12-week scan on her lunch break, without her husband, James, who had to work. But when the ultrasound technician began looking in detail, she told D’Angelo, “I don’t like the look of the head.”

The technician went to talk to the doctor, and D’Angelo was left alone in silence for about 20 minutes, staring up at an orange-brown overhead light, repeating to herself, “There’s no way two bad things can happen.”

Before and after Dobbs, questions of ‘when and where’ affect abortion access

The doctor’s look said it all. ‘“I wish I was meeting you on better terms,’” she recalled him saying. She started to cry.

“I was beside myself.”

The connection of mental health and abortion is a talking point used by anti-abortion and abortion rights advocates alike, for different reasons. Research shows that most women do not experience significant emotional harm after an abortion and do not regret the decision, and those denied an abortion are more likely to have anxiety, low self-esteem, and fewer aspirational goals for the future.

For mothers whose pregnancies have been diagnosed with fetal anomalies, there is a high risk of traumatic stress and depression at the time of the diagnosis and over time.

D’Angelo’s doctor told her the fetus suffered a defect of a neural tube that never closed, leading to a condition called anencephaly, where the skull and large sections of the brain do not form. The condition affects 1 in 4,600 pregnancies, according to the Centers for Disease Control and Prevention. Many cases end in miscarriage or stillbirth. Those that make it to delivery die shortly afterward. It’s more common in females, which is what D’Angelo was carrying.

“I knew right away I mentally could not handle carrying a baby that was going to die,” D’Angelo said. “I knew that prolonging the suffering for myself and for her was not going to be a good environment.”

She walked out of the appointment in a daze, along the skywalk at the hospital to the parking garage.

“I kept looking over the edge, and I remember thinking, ‘I could just throw myself off of here right now,’” D’Angelo said. “What made me stop, and cry even harder, was that my husband would have no answers as to why I did that.”

Abortion stigma still exists in places like New England

A study from Saint Martin’s University in 2022 showed about 2.4 million deaths occur every year in utero or by stillbirth, which is four times greater than the annual number of deaths from cancer. That type of loss was not recognized by many health care professionals as an emotional trauma prior to 1970, the research said, but is now considered a traumatic event that can lead to post-traumatic stress disorder. Symptoms can be debilitating, and include depression, substance abuse and suicidal ideation.

D’Angelo’s diagnosis came nearly a year before the U.S. Supreme Court’s Dobbs decision to overturn Roe and return the right to regulate abortion to the states. In New Hampshire, access to abortion is legal until 24 weeks. Both sides of the abortion rights debate have tried to change that, but as recently as Feb. 1, members of the state’s General Court are in a stalemate. Representatives voted on a proposed constitutional amendment that would have asked voters to guarantee a right to abortion until 24 weeks, but it needed 226 votes to pass and received 193.

A competing bill would have banned abortion after a fetus has reached 15 days of gestation, which is before a menstrual period is considered “late” if gestational age is counted from the last menstrual period. Representatives voted 363-11 to indefinitely postpone the bill, according to the New Hampshire Bulletin.

Unlike in 14 other states, D’Angelo’s doctor was free to refer her to another clinic for termination. Within a week, she was able to get an appointment at a Dartmouth facility in Lebanon, New Hampshire, about an hour and a half away, at almost 14 weeks. Her husband didn’t question the decision, she said, and gave his full support.

She acknowledged she lives in an area of the country where abortion access is widely available, but said that doesn’t stop societal stigma. A 2020 study of 4,000 abortion patients found nearly two-thirds thought people would look down on them if they knew they had an abortion. A 2012 survey of college students in New England found 87% of participants agreed there is a stigma around women who have abortions, and 23% felt they had to withhold their beliefs about abortion from people they were closest to.

“In New England, a lot of places are very liberal and open about abortion, but that doesn’t mean there aren’t a ton of people around here that judge someone for that,” D’Angelo said.

Although in favor of abortion rights, she called herself the black sheep of a family where her father was very religious and conservative, including vehement stances against abortion.

“It was definitely something in the back of my mind, that religious guilt and knowing they would judge me over this,” she said.

Termination allowed her to go on to have a living child

Following her termination, D’Angelo said her obstetrician referred her to a perinatal therapist, and that therapy helped her feel prepared to try again a few months later. By December of that year, D’Angelo was pregnant with her now 18-month-old son, Jacob — her rainbow baby. He was due about a week after the year anniversary of her abortion.

During her pregnancy with Jacob, the Dobbs ruling happened in June 2022. She worried for every person whose mental health might go by the wayside during a termination experience because they couldn’t receive care first for their physical health.

“It makes me so upset and distraught for these women and families and what they’re facing, because I know how I felt in that situation, I felt very alone,” she said.

By sharing her story, D’Angelo said she hopes to increase understanding of why people need abortions.

“I cannot let this just go on and have people think that people just get abortions left and right,” she said. “Even if that’s the case, who is that for you to judge? But also, it happens to people who are trying to start families and want to have a baby.”

If she had been forced to carry the pregnancy to term, D’Angelo said she is unsure if she would have made it through her suicidal thoughts to be able to go on and have her son.

“I hope middle-of-the-road people that are undecided, and people who are conservative, look at this and say, ‘Oh my gosh, this is a really hard situation, and I don’t know what I would do in their situation,’” D’Angelo said. “And I hope they realize a woman’s mental health does matter. A woman’s health matters in general.”

A bipartisan bill introduced in Congress last July to expand the child and dependent care tax credit, which is meant to offset the cost of child care for working families, has not yet had a hearing. (Getty Images)

The U.S. House of Representatives voted overwhelmingly Wednesday evening to assist low-income families through an expansion of the child tax credit and the bill now awaits approval in the Senate. But some organizations are also highlighting a separate tax credit for child and dependent care, which they say is not providing adequate assistance to families and providers amid rising costs.

The National Association of Tax Professionals supports expansion of the child and dependent care credit, said Tom O’Saben, the organization’s director of tax content and government relations. As it is, the credit has not kept up with inflation, he said, and Congress is currently not discussing its expansion alongside the child tax credit.

It’s easy to confuse the two credits, but advocacy groups such as the First Five Years Fund say it’s important to know the difference and understand why both are needed to help families. The child tax credit is meant to support families with the costs of raising a child, and it is commonly used to assist with everyday expenses.

The child and dependent care tax credit is meant to offset the cost of child care for working families, and only the cost of formal child or dependent care qualifies, not informal arrangements for care with family members or others.

“More and more people are having the discussion of, is it worth it to me to work outside the home when I’ve got to pay $25,000 in child care?” O’Saben said. Some clients he sees as a tax professional are paying as much as $35,000 per year for two children.

Right now, his only recommendation to help those clients is to take advantage of pre-tax flex spending accounts through their employers if they have them, but those are capped at $5,000 per year, so it can only provide a fraction of what many families need.

A report from Bank of America in October showed the average child care payment per household has increased 30% since 2019, with families earning between $100,000 and $250,000 experiencing the largest increase. A January 2023 report from the U.S. Department of Labor also called monthly prices across the country for child care “untenable” and said counties with more expensive child care prices had lower rates of maternal employment.

According to data from the Bureau of Labor Statistics, child care costs have increased 214% since 1990, while the average family income has risen 143%.

Expansion bill with bipartisan authors has not received a hearing in Congress

Congress temporarily increased the child care tax credit through the American Rescue Plan Act in 2021. It was the first time the credit had been adjusted since 2001, during former President George W. Bush’s administration. Instead of $3,000 for one child and $6,000 for two or more children, the credit increased to $8,000 and $16,000, respectively, for qualifying expenses. The amount of the credit varies based on the taxpayer’s adjusted gross income.

During that time, the credit was also refundable, so a taxpayer could claim the full credit even if it exceeded the amount of taxes owed to the federal government and receive the remainder as a refund.

“It was coming to be more in line with reality, but it lasted for one year,” O’Saben said. “If I was to bet on this back at the end of 2021, I would’ve bet that Congress would’ve extended that provision, because it was so family positive.”

But Congress couldn’t reach a deal to extend either the child care credit or the general child tax credit, and only one is up for expansion now, if it clears the Senate.

There is a bill that has been introduced in Congress to address the expansion of the child care credit, sponsored by Democrat Rep. Salud Carbajal of California and Republican Rep. Lori Chavez-DeRemer of Oregon. It was introduced in July, but has not received a hearing. A group of 85 child care providers and employers and business leaders from states across the country also sent a letter to members of the Senate Committee on Finance and House Ways and Means expressing their support for expansion of the child care credit. The states included Kansas, Kentucky, Idaho, Texas, Utah and Ohio, among others.

State and local government must step in too, advocacy group says

Michael Cassidy, director of policy reform and advocacy at the Annie E. Casey Foundation, told States Newsroom both credits are important, but it may take time to reach both goals, and it will require more than just federal investment.

Some states have made efforts to continue the same level of assistance that the federal government provided through the pandemic, such as Minnesota, where Democratic Gov. Tim Walz approved a $1.3 billion package to assist child care providers with wage enhancements and allow more families to qualify for financial assistance with costs. But in other states, such as Texas, $2.3 billion in federal aid went unused, and in Missouri and Louisiana, the amounts budgeted from federal aid didn’t make significant inroads in helping providers and families.

“The pandemic and our recovery out of it have revealed the huge challenges we have in this country regarding child care. I think everybody saw that,” Cassidy said. “It’s a policy thicket that has vexed this country for decades … so transitioning from this faltering child care system to a functioning one is going to take some investment at the state, local and national levels.”

DakotaRei Frausto, 19, traveled 11 hours from their hometown of San Antonio, Texas, in April 2022 for an abortion after their contraception failed. (Courtesy of DakotaRei Frausto)

DakotaRei Frausto was 17 years old and 12 weeks pregnant when they had to travel 11 hours by car from San Antonio, Texas, to New Mexico to terminate a pregnancy after contraception failed them.

The appointment was April 1, 2022, about six months after Senate Bill 8 initially took effect in Texas, banning abortions after about six weeks. “I had a lot of health issues that played into me wanting to get an abortion, but those very issues made it difficult for me to realize I was pregnant in the first place,” said Frausto, who was eight weeks along by the time they discovered they were pregnant.

Among them: chronic nausea, anemia that causes dizziness and fatigue, and premenstrual dysphoric disorder — better known as PMDD — which causes severe mood swings and other symptoms often associated with premenstrual syndrome, including a missed period.

“Those are big signs of pregnancy early on, and I did not see those at all,” they said.

Although Roe v. Wade established a federal right to abortion prior to fetal viability in 1973, obtaining an abortion over the next five decades was still difficult for many, depending on where they lived. Abortion can be a complicated decision fraught with health issues for both the pregnant person and the fetus, and individuals often need emotional and financial support.

The stigma around making that decision can be especially heightened in certain regions of the country — prior to Roe’s passage, Texas consistently had the highest illegal abortion death ratio and rates in the United States, according to research.

States have had varying levels of access since 1973, but following the Dobbs decision in June 2022, when regulation of abortion changed from a constitutional right to a procedure that could be restricted at any stage at the state level, the fragmented nature of access became much more significant. Fourteen states have banned abortion in nearly all cases, while others expanded rights through constitutional amendments and other state laws. But even over the past year and a half, those restrictive laws have shifted, sometimes multiple times, through legislative action and ongoing court cases at the state, appellate and federal levels, creating confusion and chaos for patients and providers alike.

Today, States Newsroom begins “When and Where? Abortion access in America,’’ an occasional series that will profile individuals who have navigated the patchwork of laws around reproductive health care in the U.S. before and after Dobbs.

Health care environment in Texas didn’t feel welcome to all

Texas’ laws were at the heart of the Roe court case, and in the years following the original U.S. Supreme Court decision, the state continued to pass laws meant to limit access, including the requirement of parental notification for minors seeking abortions, requiring admitting privileges for providers, and then the 2021 law allowing lawsuits from family members against anyone who provided or “aided and abetted” an abortion after fetal cardiac activity could be detected.

For Frausto, being a nonbinary, Indigenous person seeking care in Texas presented even more challenges. They told States Newsroom the general attitude toward reproductive health care where they live played a major role in the unwanted pregnancy, because they wanted to be tested for any complicating health conditions, such as endometriosis, before starting hormonal birth control and got the brush-off from their provider. They also got the message that only one type of person was welcome in the clinic.

“You walk into the waiting room and it’s just pictures of babies and mothers everywhere, and at the one I went to there was even Christian music playing,” Frausto said. “It just felt like I was boiled down to my reproductive organs, and told that my job was to be a mother (rather than being treated as a whole person). That played a major role in not accessing hormonal birth control and having my contraceptives fail.”

A 2016 survey from the National Center for Transgender Equality showed 23% of more than 27,000 respondents said they did not seek health care due to fear of mistreatment, and 33% reported incidents of mistreatment from a provider within the past year. A 2020 study found that transgender and nonbinary people in the South experience increased oppression and stigma, with as much as 50% of trans people reporting suicidal ideations. Texas also passed a law that went into effect Sept. 1 banning transgender youth from accessing gender-affirming care.

Frausto and their partner had been together almost two years at that point and talked about safe sex. They talked about not wanting children, and using contraceptives to ensure that didn’t happen. It was never treated as a taboo with their family either — but the contraceptives failed and Frausto ended up pregnant anyway.

“As much as I knew I wanted an abortion, I of course still considered the possibility … but I cannot in good conscience bring a child into this world with these social and political conditions,” Frausto said.

Two-day trip and procedure cost nearly $1,500

Frausto called Planned Parenthood and remembers being told several states that normally would have been an option for them were hesitant to take out-of-state patients because there were fears that abortion access nationwide would soon be overturned by the nation’s highest court. The two best options seemed to be New Mexico and Oklahoma. They chose New Mexico because of family ties.

Between Sept. 1 and Dec. 31, 2021, Planned Parenthood clinics in Oklahoma experienced a 2,500% increase in patients from Texas compared to the previous year, according to Axios, while Colorado saw a 1,000% increase and Louisiana took in nearly 350% more. New Mexico saw a 100% increase in patients from Texas during that time.

The first appointment Frausto could get in New Mexico was four weeks out, putting them at 12 weeks of pregnancy. Oklahoma likely would not have been an option as the state passed its own abortion ban that started at conception during the same timeframe.

“I found out that the day I was having my abortion … people who were in the waiting rooms of those clinics were told they could no longer be given the procedure and had to leave,” Frausto said. “I felt extremely grateful to be in a place where it was still accessible to me.”

The procedure was $600, discounted to $525 through donor support. Food and gas cost between $600 and $700. Lodging for the night was somewhere around $300. Through the goodwill of strangers online, Frausto raised $400 to help offset the costs.

Frausto was still in high school, as was their boyfriend, and their mom was a full-time student as well, so they couldn’t afford a longer trip. They drove out on Thursday, arriving at the hotel in the wee hours of the morning, went to the appointment at 9 a.m., then drove back to San Antonio a few hours later while Frausto dealt with the cramps, bleeding and nausea in the back seat of the car.

Every other person in the clinic who was there for an abortion was from Texas, Frausto said. Patients from Houston, Dallas, Austin, one of whom was also 17 years old and getting on a plane right after her appointment.

“In the recovery room there was this girl who was talking to me after her abortion, and she was saying she came there alone, she flew there alone, and immediately after she had to catch a flight back to Texas all by herself,” Frausto said.

‘My abortion saved my life’

Two months later in June 2022, the U.S. Supreme Court issued its decision to topple Roe v. Wade, and more than a dozen states implemented near-total abortion bans. Frausto started telling their story through Planned Parenthood’s Patient Advocacy Storytelling Program, and in February 2023, they started an abortion support group on Facebook to help dispel myths around abortion, decrease its stigma and connect people with resources. The group gained 531 members over the course of four months, but toward the end of the year it was shut down by Meta, the owners of Facebook. Frausto said they weren’t given a reason for the action, but their other chats that did not have the word “abortion” in the title went untouched.

But Frausto continues to be active with advocacy work and open about their story, which they said breaks apart a lot of stigmas around abortion.

“When people think about me and see me, their immediate thought is, ‘promiscuous young woman,’ and I am able to tell them that I stayed with my fiancé and it made us stronger,” they said. “I tried to take the steps to be proactive about my reproductive health care, and I was dismissed.”

It’s important to Frausto that people see they are confident and fearless about telling their story, because it wasn’t until the experience at the New Mexico clinic that they actually felt seen, cared for and embraced. At the same clinic, Frausto was offered a hormonal birth control implant to be placed for free, which was possible because of state funding that wasn’t available in Texas.

“I never really felt like I was treated as a human until I got my abortion, which was the craziest experience for me,” they said. “Even before I was pregnant, just living here in Texas, I was told abortion was horrible, and painful, and the worst experience of your life, but then I would say my abortion saved my life and showed me that it was possible to have compassionate and adequate health care.”

Family physicians practicing in places where there are no other medical professionals should be able to provide reproductive health care, says Dr. Christine Dehlendorf. (Getty Images)

More than a year after the U.S. Supreme Court overturned Roe, many have raised concerns about training for obstetrician-gynecologists, particularly in states with civil and criminal penalties for providers if they perform abortions. But researchers from the Person-Centered Reproductive Health Program at the University of California San Francisco have found there is reason to be concerned about training for family physicians in ban states as well.

A study published in the November-December issue of the Annals of Family Medicine found that 29% or 201 of 693 accredited family medicine residency programs in the U.S., are in states with abortion bans or significant restrictions on abortion access. The study used publicly available data from the American Medical Association to conduct the analysis, and found 3,930 residents out of 13,541 were in states where abortion is banned or heavily restricted.

This has implications for family physicians who are often tasked with helping patients manage early pregnancy loss, or miscarriage, the researchers said, as well as patients who self-manage an abortion at home with medication. Any of those patients might need follow-up care from a family physician, the study said.

States Newsroom spoke with one of the lead researchers, Dr. Christine Dehlendorf, about the results of the study. Her responses have been edited for clarity and conciseness.

States Newsroom: Why did you think it was important to conduct this study?

Dr. Christine Dehlendorf: We really just wanted to be descriptive about what the reality was. It was less than what was seen in previous analyses of OB residencies (which showed about 45% were in ban or heavily restricted states), but that was based on the assumptions of what bans would look like post-Dobbs. It is an evolving map — we know the abortion policy landscape is changing on a daily, weekly, monthly basis, so this is a moment in time that tells us already a substantial portion of residents are having their training influenced.

The residents that are in those programs are not going to have access to comprehensive reproductive health training because they’re not experiencing it within their state context. They cannot see abortions, cannot perform them, cannot learn how to care for patients after abortions in the same way they would be able to if they were working in a state where abortion was unrestricted.

SN: What does that mean for those residency programs?

Dehlendorf: What that means is that residency programs need to be very intentional about their curriculum and seek out ways for residents to get experience with reproductive health care, including ways they can get that training out of state.

In typical family medicine residency programs, you have your routine primary care curriculum, and then also specialty rotations (e.g., dermatology or other specialties), where you get more dedicated time with that topic. Having abortion be restricted will influence training in both of those contexts. You won’t see people who recently had an abortion and be able to help manage post-care, like bleeding, and you will not be able to provide abortion medication. You won’t be able to see patients who have abortions in hospital settings.

So residency programs will have to think about how, in the absence of this natural way people would be exposed, how they can substitute and supplement the curriculum to make sure people have that exposure. The experience of residency is a moment in time, and the reality is they will be taking care of these patients regardless of whether they’re in states with abortion restrictions.

SN: What supports can family physicians provide to those experiencing a miscarriage or who are self-managing an abortion?

Dehlendorf: People need to be able to go to their primary care doctors with any questions they have, including about bleeding or other side effects. Early pregnancy loss is a very common experience, and the skill set for caring for that and first trimester abortion are very similar.

SN: How concerned are you that these programs won’t provide this training?

Dehlendorf: I’m very concerned that programs will not pay adequate attention to this newfound gap in their curriculum, and therefore that their residents will not be comprehensively trained, and their future patients will be negatively impacted by that.

Patients are going to receive less patient-centered care. Ideally, primary care providers should be able to take care of people throughout the reproductive health cycle. If we can’t do that, what that means is care will be fragmented in a way it doesn’t have to be. It also means some of those patients won’t receive care at all, and some will receive lower quality care.

SN: Who might be affected the most by this lack of training?

Dehlendorf: We know that family physicians provide care in areas where there are no other health care professionals, and they are the safety net for underserved communities, rural or urban, where there is no access to specialty care. Those providers need to be able to provide the full scope practice of family medicine, including the full scope of reproductive health care. Those are the communities that are most likely to be impacted.

SN: What can be done to help support those training opportunities?

Dehlendorf: From an educational lens, people in states with abortion access funding training opportunities for people in states without it is something that is absolutely essential.

SN: What other implications might this have on family medicine?

Dehlendorf: Prior to Dobbs, there was a lack of recognition of the critical role that abortion access played in many aspects of our medical institutions and health care system, and that includes the fact that we prescribe medications that can cause birth defects with the knowledge that abortion could be available to the patient if needed. There have been cases of people being denied those medications because access is not available.

All of those things are affecting our lives and health. It’s multi-faceted, and we’re just beginning to see the impacts that are going to influence the system, and how it will fail to meet people’s needs in places where abortion is restricted.

Experts have said that a U.S. Supreme Court ruling on the use of mifepristone, a key abortion medication, could have implications for drug approval by the U.S. Food and Drug Administration. (Getty Images)

This year will end on a major cliffhanger for abortion access.

Last November, anti-abortion activists via a powerful conservative Christian law firm asked a federal court to effectively ban or widely restrict the abortion drug mifepristone. Finally on Wednesday, the U.S. Supreme Court agreed to take the case, making Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration the high court’s first abortion-related case since overturning the federal right to an abortion in June 2022.

As abortion access advocates, providers, people of reproductive ability and anti-abortion proponents wait until mid-2024 for the results of this case, other ongoing abortion litigation (a Texas woman left the state after her request for an emergency abortion was granted before being blocked by that state Supreme Court) and a presidential election, uncertainty and fear about the future of reproductive health access remain high.

Abortion via a two-step medication process of mifepristone and misoprostol has become the predominant way Americans terminate pregnancies post-Dobbs, particularly those living in states with bans or in areas with no providers. Mifepristone blocks the progesterone hormone, which is necessary to continue a pregnancy.

“We should never be in a position where judges are deciding whether people can get effective medicines,” said Elizabeth Ling, an attorney for the legal advocacy group If/When/How, in a statement. “Mifepristone access is essential to people’s ability to determine their own future and actualize self-determination by ending a pregnancy, including self-managed abortion.”

Though the anti-abortion plaintiffs in this case asked the Supreme Court to fully reverse the FDA’s 2000 approval of mifepristone for first-trimester abortions, the high court is expected to review questions around restrictions that were lifted during the last decade because of mifepristone’s proven safety record. Depending on how the court rules next year, mifepristone will likely remain legal but could prove much harder to access, especially if the court strikes down the ability to obtain the drug via telemedicine. Legal and pharmaceutical experts have said this case could have far-reaching implications on approval for medications beyond abortion drugs.

“The future of telehealth for medication abortion care now hangs in the balance,” said Dana Northcraft, founding director of Reproductive Health Initiative for Telehealth Equity & Solutions, in a statement. “Telehealth for medication abortion is safe and effective and helps people overcome barriers to care, whether it be long travel distances or getting time off from work or school. Everyone deserves compassionate, accessible, and inclusive abortion care.”

Mifepristone is also used for miscarriage management but has become harder to access, doctors report.

For providers who spoke with States Newsroom on Wednesday, it’s not just about what restrictions will or won’t stand after a ruling from the U.S. Supreme Court, but the fact that the case got this far in the first place.

Dr. Erin Berry, an OB-GYN in Seattle who works at 15 Planned Parenthood clinics around the West, said it’s hard to sit with the idea that nine judges are making a decision about the medical science and safety of a drug.

“That’s just unprecedented, they are not to be the experts in that, and them getting to have a say on that, that’s a big deal to me,” Berry said. “And it has implications on all of our lives.”

Berry sees patients from all across the country in various clinics, including people from as far as Louisiana and Texas who travel to Seattle, often because they know someone who can help drive them home from an appointment and offer them a place to stay. But that alone is disruptive to a person’s privacy, she said, because if care was accessible in their home state, they might have been able to keep a very personal event to themselves.

Cynthia Dalsing, a retired nurse midwife in Sandpoint, Idaho, said restrictions have made local providers more wary about how they interact with pregnant patients, including how they reflect a patient’s demeanor in a medical chart. Abortion restrictions have made people second guess their decisions about evidence-based medical care out of fear, she said.

Dr. Caitlin Gustafson, an OB-GYN in a rural area of central Idaho, still regularly prescribes mifepristone for miscarriage management, and based on evidence, she said using it for that care results in fewer visits to the emergency room and a reduced need for procedures that empty the uterus. Access to the medication in Idaho is already more restricted because only providers can dispense it, not local pharmacies. Some people already have to drive more than an hour to get to a clinic in the case of a miscarriage, she said.

“As we lose providers (to other states) and then further lose access to this medication, if that’s what the Supreme Court does, it will make that experience harder,” Gustafson said.

In the year and a half since the abortion access landscape exploded into chaos and confusion, attorneys like Ling spend their days answering desperate phone calls on the Repro Legal Helpline, which is managed by If/When/How. Earlier this year, If/When/How joined a network of reproductive rights legal assistance groups and law firms called the Abortion Defense Network.

The helpline has been around for a few years, but the end of Roe v. Wade saw inquiries increase by 2,460%, If/When/How’s legal support director Kylee Sunderlin told States Newsroom earlier this year. Sunderlin said many people call before they ever see a provider about a suspected pregnancy or a pregnancy that’s turned into a health emergency because they’re scared about the legal consequences. She said most people don’t understand what is and isn’t legal these days.

On Wednesday, Ling reiterated that If/When/How is committed to helping people navigate these complex and ever-changing laws.

“This case is a further weaponization of the courts to deny people bodily autonomy,” Ling said. “But no matter what the court says, people will always have abortions. Myself and the rest of If/When/How are here to provide people the legal support they need to access the abortions they want and help them fight back against state violence.”

In states with extremely limited abortion access, like Idaho, some people are actively avoiding pregnancy.

Makayla Sundquist, 27, lives in North Idaho and said she has been with her partner for seven years and would consider having children if abortion access was available. She lives in Sandpoint, a rural area of about 9,000 people, where OB-GYN services are no longer offered at the county’s only hospital after the unit closed in March, citing staffing issues and the political environment of the state, where a near-total abortion ban has been in effect since 2022. The closest area with OB care is Coeur d’Alene, which is an hour-long drive both ways.

“We saw it when Roe fell, the number of vasectomies in young men rose dramatically, and I think so many people in red states are realizing that if they want children, this is not the place for them, and I fall into that demographic,” Sundquist told States Newsroom on Wednesday.

Sundquist said she can’t fathom a reason why the U.S. Supreme Court would further restrict a safe and well-tested medication when the other option for an abortion — a procedure that empties the contents of the uterus — is more invasive, but she thinks it’s a real possibility. According to the FDA, 28 deaths out of an estimated 5.6 million people in 23 years have been associated with mifepristone’s regimen for terminating a pregnancy, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. The FDA notes that a small number includes fatal cases “regardless of causal attribution to mifepristone,” including people who died from homicide, suicide, and pulmonary emphysema.

“I will be angry and scared for the people in my life that would need (an abortion), me included if it came to it, but I would not be surprised if that’s what happens, unfortunately,” Sundquist? said.

The vast majority of Americans — 82%, according to a recent Marist poll — support allowing abortions at any stage of pregnancy to protect the life or health of the pregnant person.(Getty Images)

In early October, an Idaho woman 20 weeks into her pregnancy went to the emergency room after her water broke about five months early.

When the water breaks prematurely, an infection can develop and infect the fetus, placenta and other fluids. At that stage of pregnancy, the threat of infection becomes a ticking clock for everyone involved.

And in this case, time was already running out.

At 20 weeks, there is virtually no chance a fetus can survive outside of the womb even with medical intervention — the heart and lungs are too immature. And once an infection reaches the uterus, it is systemic, so there isn’t enough time to allow the fetus more days in utero.

The condition can progress to a blood infection called sepsis within a matter of hours, then septic shock, which can cause organ failure in as little as 12 hours, according to medical research. More than one quarter of patients who develop sepsis die. And if the patient survives, merely having the infection can leave them with permanent organ damage and other long-term health effects.

In another state, a doctor would be able to induce labor and let the patient deliver if that was their wish, then offer palliative care so the parents could hold their child until it passed.

But in Idaho, a state with a strict abortion ban, the doctor had limited options. The law does not allow for termination to preserve a person’s health, only to prevent death. And hours could pass before the hospital’s legal, administrative and medical teams might approve the decision to terminate the pregnancy and properly care for the infection.

So rather than roll the dice, the doctor ordered the woman transferred in the hospital’s small airplane to Salt Lake City, Utah — a state that has an 18-week ban, but also an exception to preserve the pregnant person’s health.

It’s a scenario physicians have warned about in the year since the Dobbs decision, when 14 states implemented near-total abortion bans. Doctors in ban states, including those with health exceptions, have said the exception language is written so vaguely that it is essentially meaningless, and hospitals have adjusted their policies to protect doctors from potential criminal charges and loss of medical licenses. Several states with a general health exception don’t include fatal or life-limiting fetal anomalies.

On that day in October, the stakes felt especially high for ER physicians in Idaho, because it was during a limbo period when doctors were more at risk for state prosecutions after a court ruling. In the 12-day span of time between the initial ruling and the reinstatement of protection, 11 St. Luke’s patients were transferred for pregnancy-related complications, said spokesperson Christine Myron, which is a typical amount of pregnancy-related transfers in that time frame. Seven were within the hospital’s network and four were sent out of state.

The vast majority of Americans — 82%, according to a recent Marist poll — support allowing abortions at any stage of pregnancy to protect the life or health of the pregnant person. But five of the 14 states with bans — Idaho, South Dakota, Oklahoma, Arkansas and Mississippi — have an exception only to prevent death.

In all five states, legislation has been drafted to fix the issue, and in many cases, it is Republican lawmakers who offer such proposals. But with ongoing court battles, partisan fights at the local, state and federal levels, and arguments among anti-abortion advocates over policy details, those efforts failed during each state’s 2023 legislative session.

Opposition to health exceptions goes back to Roe-adjacent court case

In Arkansas, Democratic Rep. Denise Garner sponsored a bill in late March adding a health exception to the state’s ban. Garner, a retired oncology nurse, said during the committee hearing that several health care workers shared stories with her about the “devastating effects” on patient health after the ban went into effect. She told lawmakers about a 19-year-old college student who became pregnant while a contraceptive IUD was still inserted, causing the embryo to develop around the device.

Doctors delayed ending the pregnancy, hoping it would spontaneously discharge, Garner said, but four weeks later the IUD perforated the woman’s uterus, causing hemorrhaging and forcing doctors to remove the uterus entirely in a hysterectomy — ending her chances of giving birth to a child of her own.

“I can’t tell you how many times patients were diagnosed with cancer at the time of a pregnancy,” Garner said, and a pregnancy can make it difficult to continue chemotherapy treatments. “Let’s figure out a way to make sure that the specialists are able to do what they’re trained to do and take care of the health care of women who need these abortive treatments.”

The Arkansas Family Council immediately voiced its opposition, saying the legislation would effectively legalize all abortions in the state. During the committee hearing, Republican Rep. Marcus Richmond said he was “sympathetic” to the issue but voted no because he wanted the language to be more narrowly focused.

“It’s going to be such an arbitrary thing that anybody who’s wanting to perform an abortion will be able to make some claim somehow that their health is being affected, and they can find somebody who will support that,” Richmond said.

Jerry Cox, Arkansas Family Council president, told States Newsroom his organization believes cultural issues should have a biblical worldview, including abortion.

He said their opposition to health exceptions stems from the 1973 case of Doe v. Bolton, which was decided on the same day as Roe v. Wade. The U.S. Supreme Court struck down portions of a Georgia law that limited when and where someone could seek an abortion, namely that it had to be within a hospital with specific accreditations, and several layers of administrative and medical staff had to grant permission for the procedure if it met the exceptions for rape, a fetus with severe abnormalities or a life-threatening condition. The court said the requirements were unreasonable and ruled them unconstitutional on the basis of a right to privacy. That ruling invalidated many other state laws with restrictions.

Justices also said the Georgia law could not restrict the definition of “health” to physical health only, and said emotional, psychological, familial and age factors should also qualify.

To anti-abortion activists, the ruling effectively legalized abortion up until birth for almost any reason. The Doe ruling made clear, however, that a statute placing such limits on where abortions could be performed after the first trimester might hold up to constitutional scrutiny.

Prior to the Dobbs decision in 2022 that overturned Roe, less than 1% of abortions in the U.S. occurred after the 21st week of pregnancy. The ones that do happen after that stage are often related to fatal or life-limiting fetal anomalies.

“One would hope that doctors are not going to say, ‘OK, you’re going to start labor next week, but your health is bad, so we’re going to abort,’” Cox said. “I can’t name any cases where that’s happened, but that’s why over the years when people would say, ‘Well, we need a health exception in this abortion law,’ we’ve always resisted that, because it would pretty much then put it all back in the hands of the doctor.”

Cox said he knows doctors have to make judgment calls more often than the public is aware of, but since no doctors have yet been prosecuted under an abortion state law, then maybe the concerns are overblown.

“It makes me wonder if some people might think that’s a convenient way to justify doing the health exception, is to say that well, doctors won’t know what to do. It seems they’ve been able to figure it out pretty well,” Cox said.

Dr. Nisha Verma, an OB-GYN and abortion provider in Georgia, said even though her state includes medical emergencies in its six-week abortion ban, it’s impossible for a law to encompass the nuance and complexity of medical decisions in a patient’s life.

“There isn’t this line in the sand, there isn’t this moment in time where someone goes from totally fine to actively dying, it’s a continuum. It’s really difficult to determine where we can legally intervene,” Verma said.

In the case of a patient’s water breaking before fetal viability, Verma said the risk of maternal death increases by 50% if a doctor waits to treat until the person is sicker, which they often end up doing to protect themselves from legal consequences. One woman in Oklahoma named Jaci Statton was told to wait in a parking lot until her infection was more serious so she could be treated. Statton has filed a federal complaint over the incident, and she is one of several women in Idaho, Oklahoma and Tennessee who have taken action after being denied abortion care in their home states.

“I think these laws are establishing for people what risk is acceptable and what isn’t, and that component of it is really problematic,” she said. “And they’re using these non-medical terms to try to regulate the practice of medicine.”

Women in several ban states have sued over denial of care

Earlier this year, 13 Texas women sued the state after they were denied abortion care despite the fact that they were facing severe, dangerous pregnancy complications. Although Texas’ law includes an exception for the pregnant person’s health, the severity of the ban in place makes doctors feel uncomfortable relying on it, according to the lawsuit. One plaintiff, Amanda Zurawski, said she was forced to wait until her infection became septic to receive abortion care, causing one of her fallopian tubes to permanently close and affecting her future fertility. She spent three days in the intensive care unit.

A Texas district judge issued a ruling in early August saying doctors could use their own good faith judgment in emergencies, but the state immediately appealed it, which stopped the decision from taking effect. The Texas Supreme Court is scheduled to hear arguments on Nov. 28.

In August, a Texas Democratic lawmaker successfully passed a bill allowing doctors to legally terminate a pregnancy in two scenarios: When a pregnancy is ectopic, which is a nonviable condition, and when a pregnant person’s water breaks prematurely and the fetus is not yet viable. Republican Gov. Greg Abbott quietly signed the bill into law in August, and it took effect Sept. 1.

Exceptions in bans are ‘fake,’ Wisconsin Democrat says

For abortion rights advocates, even the states with health exceptions in their ban laws are causing harm, because often the laws lack clarity and do not account for instances of fatal or life-limiting fetal anomalies.

Jillaine St.Michel, an Idaho plaintiff in a lawsuit led by the Center for Reproductive Rights, was 20 weeks into her second pregnancy when her fetus was diagnosed with multiple developmental abnormalities of the organ and skeletal systems at a routine scan. It was so severe that the doctors asked St.Michel if she worked in a factory around any dangerous chemicals. She didn’t.

St.Michel had to spend three days in Seattle with her husband and 3-year-old child, which made her feel like she was doing something wrong.

“To have to go through that procedure and then go back to an unfamiliar hotel room, and have to heal and go through that process not in the comfort of your own home felt really degrading,” she said. “It felt really insulting that we had to go through that in such a demeaning way.”

Democrats in states like Wisconsin, which had a complete ban without exceptions until a recent court ruling prompted Planned Parenthood to resume its abortion services, think most Republican-proposed bills to add health exceptions are drafted in bad faith.

“The idea of exceptions to abortion bans, it’s absolutely fake, it’s false,” said Sen. Kelda Roys, a Democratic legislator in Wisconsin. “It’s intended to do one thing, and that is to give political cover to anti-abortion politicians who realize how deeply unpopular their position is and are desperately trying to scramble to appear less extreme.”

Wisconsin Republicans proposed legislation with a health exception in March, but Democrats immediately rejected it, calling it a publicity stunt that came just a few months after Republicans nationwide performed poorly in the 2022 midterm elections. It also came a little more than two weeks before a significant state supreme court election, which Justice Janet Protasiewicz went on to win in April. Protasiewicz openly campaigned in favor of abortion rights.

Wisconsin Gov. Tony Evers, a Democrat, also vowed to veto the bill if it passed, after which the bill died. While it passed the House, Republican Senate Majority Leader Devin LeMahieu said at the time that the Senate would not hear the bill because, “This is not a topic to use as a political football.”

As political minorities in ban states, Democrats sometimes protest exception bills

In most states with abortion bans, Republicans dominate the legislature in both chambers, and a lack of Democratic support for a bill typically won’t determine whether a bill advances or passes into law. For that reason, in places like Idaho and South Dakota, proposals to add health exceptions have drawn support and ire from Democrats at the same time.

In South Dakota, Democratic Rep. Erin Healy responded to a health exception proposal drafted by Republican Rep. Taylor Rehfeldt by saying she heard anecdotes from women in her life who had pregnancy complications and were affected by the vague laws, but health exceptions are just a small carveout to what is still a violation of individual privacy and doctor-patient relationships.

“Democrats really believe that there shouldn’t be just exceptions, that abortion should be an option for women, and that bodily autonomy is important,” Healy told the Mitchell Republic in January.

Rehfeldt did not respond to requests for comment.

In Idaho, Democratic legislators were angry after health exceptions were dropped from the bill that ultimately passed the legislature in April. Republican Rep. Brent Crane withdrew the version that included that language after opposition from Right to Life of Idaho and state Republican Party Chairman Dorothy Moon.

Rep. Brooke Green, a Democrat, said her caucus decided to walk out of the House chambers when the bill came up for a vote as a form of protest because it only included ectopic pregnancies and miscarriages as exceptions.

“It was one of those situations where we were damned if we do, and damned if we don’t,” Green told States Newsroom. “When you have an environment where you’re the super, super minority, these are the circumstances that play out.”

Crane said he is still working to find the right language for a bill that could pass during the 2024 legislative session, which begins in January. Rehfeldt has vowed to keep fighting for her bill in the next session as well.

National Right to Life helps guide legislative language to keep exceptions narrow

Ingrid Duran, director of state legislation for National Right to Life, also cited the Doe v. Bolton case as one of the reasons why the organization is typically opposed to legislation that adds a health exception to an abortion law. Because the court in that ruling said that a physician could use their own medical judgment to determine what qualifies as “health,” any exception related to health must be narrowly tailored if it is to earn the NRLC’s support.

From Right to Life’s perspective, during the time of Roe, doctors were providing abortions after viability for arbitrary reasons, even in states where the procedure was more tightly regulated after about 22 or 24 weeks of pregnancy.

“This is a tale as old as time, as far as the different medical associations — or maybe just a pro-choice senator or representative — that will introduce language that would make it not as narrowly tailored and kind of leave it open and vague to the person performing the abortion’s interpretation of what ‘health’ could mean,” Duran said. “I think when we do that, it is very akin to the wolf looking after the sheep.”

Right to Life was heavily involved in the passage of a narrow health exception in Tennessee’s abortion ban earlier this year. The Tennessee Medical Association supported an initial version of the bill that included fatal fetal anomalies and allowed physicians to provide an abortion if in their “good faith” judgment it would prevent serious health consequences.

After Right to Life’s objections, a different version passed without fetal anomalies and instead said the physician must act with “reasonable” medical judgment. Duran said that term is preferable because to her, it reflects a consensus of the medical community. Objections from the medical community must be taken with a grain of salt, in her view, because groups like Right to Life believe physicians profit from providing abortions.

“If you had a very terrible abortion doctor like Kermit Gosnell, you wouldn’t want to leave it up to him to determine what is his good faith medical judgment,” Duran said, referring to a former physician and convicted serial killer.

For attorneys like Peg Dougherty, deputy general counsel for St. Luke’s in Idaho, that distinction is important from a legal standpoint when advising medical staff. Dougherty would prefer to see “good faith” wording because in other areas of medicine, physicians are trusted to provide the appropriate training and expertise to a patient. If it is specific to a doctor’s “reasonable judgment,” she said, it is easier for prosecutors to find witnesses who might testify that a course of treatment wasn’t what they would consider reasonable.

“Doctors are treating patients and providing the best care for their patients that they can and they’re also working with their patient. They’re not trying to fabricate reasons for their patient to do something, ever.”

A demonstration for abortion rights outside the U.S. Supreme Court. (Getty Images)

A group of more than 600 Democratic legislators from 49 states have signed an amicus brief to the U.S. Supreme Court urging the justices to overturn an appellate court decision that would roll back access to mifepristone, one of two drugs used to safely terminate early pregnancies and treat miscarriages.

The amicus brief, also called a “friend of the court” brief, was organized by State Innovation Exchange’s Reproductive Freedom Leadership Council and assembled over the past week, said Jennifer Driver, the group’s senior director of reproductive rights. Driver said State Innovation Exchange, also known as SiX, provides tools and resources for state legislators to advocate for progressive public policies after being elected to office.

Driver said SiX did ask Republican legislators to sign on as well, but didn’t manage to garner any bipartisan support.

Every state, with the exception of Mississippi, had Democratic legislators who signed their names to the brief, with the highest number of participants from Illinois, followed by North Carolina, New York and Colorado. Driver said 13 state representatives from Arkansas also signed on.

“This statement should say that across the country, in almost every state, there are legislators that are saying their ability to protect their community should not be interfered with,” Driver said. “Even in ruby red states, there are legislators who are still fighting for abortion access, and they understand the ramifications of what happened in Dobbs and what could happen in this case.”

Upholding 5th Circuit would mean reinstating prior restrictions on pill ?

The Supreme Court has not yet accepted the Alliance for Hippocratic Medicine’s case against the U.S. Food and Drug Administration, but the court already involved itself in April by temporarily blocking the 5th Circuit Court of Appeals’ decision. If the high court declines to hear the case or upholds the appellate court’s ruling, the FDA’s rules that allowed expanded access of mifepristone would be struck down.

That would include the ability for providers to prescribe the medication via telehealth or send the medication in the mail, and it would decrease the time limit from 10 weeks of pregnancy to seven weeks. The results of most at-home pregnancy tests are not reliable until after an individual has already missed a period at four weeks of pregnancy.

It would also require patients to see providers at three separate clinic appointments in person, which would be especially difficult for those traveling from one of the 14 states with abortion bans to access care.

The Alliance for Hippocratic Medicine is a group of four anti-abortion organizations and four doctors that formed in 2022 and incorporated in Amarillo, Texas. U.S. District Judge Matthew Kacsmaryk, who is in Amarillo, made the initial ruling that would have revoked mifepristone’s approval in its entirety, leading some to conclude the plaintiffs chose to incorporate there for a favorable outcome in Kacsmaryk’s court.

The plaintiffs are represented by the Alliance Defending Freedom, a religious conservative group that recruits and trains attorneys to litigate cultural issue cases, including abortion, anti-LGBTQ legislation and what they consider violations of Christian religious freedom. The same organization was also involved in the U.S. Supreme Court’s Dobbs decision overturning the constitutional right to an abortion. The attorneys have argued the FDA illegally approved mifepristone in 2000, and have repeatedly contended that the drug is unsafe and responsible for many deaths — a claim that is not backed by credible sources. According to the FDA, 28 deaths out of an estimated 5.6 million people in 23 years have been associated with mifepristone’s regimen for terminating a pregnancy, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. And as the FDA notes, that small number includes fatal cases “regardless of causal attribution to mifepristone,” including people who died from homicide, suicide, and pulmonary emphysema.

Legislators in Minnesota, North Carolina take the lead on brief?

In the Dobbs decision, authored by Justice Samuel Alito and issued in June 2022, the justices in favor of overturning Roe v. Wade said the regulation of abortion should be left to the states, “in accordance with the views of its citizens,” just as it was prior to the Roe ruling in 1973.

“It is time to heed the [U.S.] Constitution and return the issue of abortion to the people’s elected representatives,” Alito wrote.

That’s one of the reasons why the legislators decided to submit the brief, said Minnesota Democratic state Sen. Erin Maye Quade, one of two lawmakers leading the effort. While the legislators who signed on aren’t saying they agree with the Dobbs decision or the Supreme Court’s interpretation of the law, the justices’ own logic for the decision demonstrates that federal courts should not come between state laws on the issue of abortion.

“This [case] gives them an opportunity to decide whether abortion is really going to be up to states or not,” Maye Quade told States Newsroom on Tuesday.

The representatives and senators also argue that elected officials rely on the FDA’s authority to approve medications on the market, and allowing the 5th Circuit’s ruling to stand would undermine that authority. In a state like Minnesota, which is almost entirely surrounded by states with abortion bans, access to mifepristone is vital, Maye Quade said. Following Texas’ implementation of its abortion ban prior to the Dobbs ruling in 2022, Minnesota started to see an increase in patients seeking care. Maye Quade said there was a 20% increase in the state in 2022, and in 2023, the numbers continue to increase.

The other lawmaker leading the case is Rep. Julie von Haefen, a Democrat in North Carolina’s General Assembly. The legislature in North Carolina passed Senate Bill 20 earlier this year, banning abortions after 12 weeks of pregnancy and requiring patients to receive counseling at least 72 hours before the termination is scheduled to take place. A report issued Wednesday by the Guttmacher Institute showed between June and July, when the law went into effect, abortions decreased by 31%. North Carolina was an access point for many people in surrounding states, von Haefen said, and that drop was jarring.

“We just believe that the Supreme Court made this decision in Dobbs, and they have to step in and say, ‘No more, we have to leave these decisions to state legislators,’” von Haefen said.

According to the U.S. Supreme Court’s docket, attorneys for the plaintiffs are scheduled to file their brief in opposition to the court taking the case by Nov. 9.

Jennifer Adkins of Idaho, who said she faced a complicated pregnancy, is suing the state over its near-total abortion ban. (Center for Reproductive Rights)

Women and physicians in Idaho and Tennessee have sued their home states after they say they were denied abortion care despite being diagnosed with serious, life-threatening medical conditions while pregnant.

The lawsuits are led by the Center for Reproductive Rights, an advocacy organization based in Washington, D.C., which also helped a patient in Oklahoma file a complaint against a hospital that denied her abortion care.

The filings come after 13 women sued the state of Texas for similar reasons and a judge in that case ruled that all the women should have been given abortions. That ruling has been appealed by the state and is now on hold, according to the Center for Reproductive Rights.

“It is clear that in filing that lawsuit in Texas, we hit the tip of a very large iceberg,” said Nancy Northup, president and CEO of the Center, on Tuesday. “Today, (plaintiffs) are holding their states accountable for the suffering they have caused.”

Idaho plaintiffs ask court to clarify medical exceptions

In Idaho, four patient plaintiffs, two physicians and the Idaho Academy of Family Physicians are suing the state over its near-total abortion ban, asking a court in Ada County to clarify when an abortion is acceptable under the law.

Idaho’s abortion ban applies to any stage of pregnancy, and narrow exceptions are provided for cases of rape and incest in the first trimester with an accompanying police report, and when an abortion is necessary to prevent a pregnant person’s death. Health care providers who violate the statute put their medical licenses at risk and face between two and five years in prison, along with civil penalties of at least $20,000 against individual providers if family members decide to sue.

“… Pervasive fear and uncertainty throughout the medical community regarding the scope of the exceptions to abortion bans have put patients’ lives and physicians’ liberty at grave risk,” the court document states.

One of the plaintiffs in Idaho is Jennifer Adkins, whose story was first reported by States Newsroom in May. At her 12-week ultrasound appointment, Adkins’ fetus was diagnosed with conditions that are almost always fatal, including a collection of fluid called a cystic hygroma and hydrops fetalis, and a missing chromosome. In 99% of cases, such a pregnancy ends in miscarriage by 12 weeks, but Adkins was still pregnant. As a result, she was at risk for developing high blood pressure that could lead to seizures, stroke and organ damage.

Knowing the prognosis and health risks, and with a toddler at home to care for, Adkins made the decision to travel to Portland for an abortion.

“It isn’t safe to be pregnant in Idaho,” Adkins said during the press conference Tuesday. “People in Idaho must be able to make informed decisions with their doctors without intrusion from politicians.”

Other plaintiffs like Adkins are Jillaine St.Michel, Kayla Smith and Rebecca Vincen-Brown. According to court documents, St.Michel learned at her 20-week ultrasound appointment that her fetus’ organ systems showed “severe developmental conditions.” Smith learned her fetus had a severe congenital heart condition that made survival after birth very unlikely and increased her risks of developing preeclampsia, a condition she experienced during her first pregnancy. Both women traveled out of state to receive abortion care.

Vincen-Brown found out at 16 weeks that her fetus had a serious genetic condition that made it unlikely to survive at birth, court documents said, and risked her health as well. She drove seven hours with her husband and child to a clinic in Oregon and ultimately “passed the pregnancy in the hotel bathroom as her daughter slept on the other side of the door.”

Idaho’s ban, the lawsuit contends, endangers pregnant Idahoans and risks their fertility and potential for injury or death.

Two doctors in Idaho’s case include Drs. Emily Corrigan, an OBGYN, and Julie Lyons, a family physician. Corrigan said Tuesday that there is widespread confusion in the medical community in Idaho about when the law allows an abortion to be performed, even a full year after it went into effect. Many physicians have already left the state over the law, she said, particularly after the Idaho Legislature failed to pass a bill in the 2023 legislative session that would have allowed abortions to be performed to preserve a pregnant person’s health, not just to save their life.

The final plaintiff in the case, the Idaho Academy of Family Physicians, represents 656 physicians, residents and medical students across the state.

“All of the above-described impacts on Idaho’s already strained medical system are likely to worsen if the abortion bans, in their current form, remain in effect,” the court document says. “A collapse of the system seems inevitable and will result in grave danger to all Idahoans needing any form of health care—not only those who may need abortion care in the future.”

Oklahoma woman was told to wait in the parking lot while health deteriorated

In Oklahoma, Jaci Statton filed a complaint with the U.S. Department of Health and Human Services under the Emergency Medical Treatment and Active Labor Act, a federal law that requires medical facilities that accept Medicare funding to provide emergency stabilizing treatment to patients. According to the complaint, Statton learned she was pregnant early in the year, but began experiencing pain, dizziness and severe nausea mere weeks into the pregnancy. She then learned she had a partial molar pregnancy, a non-viable pregnancy that can cause hemorrhaging, infection and death if left untreated.

Statton went to the University of Oklahoma Medical Center in March in severe pain, the complaint says, but the staff would not provide abortion care and instead moved her to the Oklahoma Children’s Hospital.

“Jaci and her husband begged staff at Oklahoma Children’s Hospital to perform an abortion, even asking to speak to a hospital ethics board and explain why Jaci should be permitted to access life-saving care,” the document says. The staff instead told her she could not receive an abortion “until she was actively crashing in front of them or on the verge of a heart attack.”

Until then, according to the complaint, they told Statton to sit in the parking lot, so she was close to the hospital as her condition worsened.

“As her condition grew more dire, Jaci fled the state to receive an abortion, traveling three hours by car during a medical emergency,” the complaint says.

Attorneys for Statton argue there was no legal basis for the children’s hospital to deny her medical care, since Oklahoma’s existing ban had exceptions for active medical emergencies. The complaint asks the Oklahoma region of the Medicare and Medicaid Services division to investigate the incident and find that the hospital violated EMTALA by failing to provide Statton with stabilizing care.

“The investigation and finding are necessary to safeguard access to emergency medical treatment for all pregnant Oklahomans who remain at risk that hospitals will deny them care in the event that they experience a pregnancy complication,” the complaint said.

Financial barriers forced Tennessee woman to give birth to stillborn

Three women and two physicians in Tennessee are suing the state in Davidson County court to clarify the state’s medical condition exception and issue a ruling blocking enforcement of the law “to protect the health and lives of pregnant Tennesseans with emergent medical conditions.”

The individuals are Nicole Blackmon, Allie Phillips and Katy Dulong. Blackmon discussed her experience during the Tuesday conference call, saying the Tennessee law forced her to carry a non-viable pregnancy that posed serious risks to her health.

Blackmon learned she was pregnant in July 2022, just five months after losing her 14-year-old son in a drive-by shooting in Alabama. Although it was unintentional, Blackmon said she and her fiancé were excited about the possibility of having another child. But she already had medical issues that could be exacerbated by pregnancy.

“We were excited, but worried at the same time, and at 15 weeks we learned there was an issue with the baby’s stomach,” Blackmon said. “Then at 24 weeks, a specialist confirmed our baby’s organs were not forming as expected or in the right places. … Doctors told us certainly that this pregnancy would not result in a living baby.”

At that gestational age, Blackmon’s only options were to wait and risk her health and life or travel to Washington, D.C., for an abortion. But even with financial assistance, the trip would have cost thousands of dollars that she couldn’t afford, especially as her health deteriorated and she was unable to keep working.

“Waiting to lose another child in the same year was bad enough, but then my health started to get worse,” Blackmon said. “My water broke in my seventh month, and after 32 hours laboring, I delivered our baby stillborn. Why won’t Tennessee politicians allow people to have abortions in terrible situations like mine? Something good must come out of my pain, that’s why I joined this case. What we went through was torture that no one else should ever have to face.”

Phillips was told at 15 weeks of pregnancy that her fetus’ kidneys, bladder, stomach and heart were improperly developed, and the brain had not developed into separate hemispheres, a congenital defect. All of those complications together made it extremely unlikely that the pregnancy was viable, according to court documents.

Phillips started a GoFundMe to raise enough money to obtain an abortion in New York City, but shortly after arriving at the clinic, the fetus’ heart had stopped beating.

“I went into surgery alone, and I sat in recovery alone,” Phillips said Tuesday. “The doctors were kind and compassionate, but I’d never met them before. I had to grieve the loss of my daughter in a city I’d never been to.”

Dulong experienced issues with her cervix and placenta that eventually led to serious medical complications, including the beginning of sepsis, an internal infection that can quickly become fatal. Her doctor spent two hours asking various legal and ethical personnel at the hospital for support to provide her with medication to induce an abortion, the court document said.

“(Dulong) was told that prior to Tennessee’s enactment of an abortion ban, even the Catholic hospital where her abortion was performed would have given her (abortion medication) when she was first diagnosed with an incompetent cervix, instead of risking septicemia or hemorrhaging at home,” the lawsuit said.

Drs. Heather Maune and Laura Andreson joined the lawsuit in Tennessee, saying they have seen widespread fear and confusion about the abortion ban and alleging it has had a chilling effect on obstetric care in general.

“Dr. Maune and her peers fear that prosecutors and politicians will target them personally if they provide abortion care to pregnant people with emergent conditions,” the court document states.

Andreson said in the lawsuit that many of her patients live in rural areas and drive more than an hour to see her, and sending those patients to clinics out of state could result in life-threatening situations.

CORRECTION: Jaci Statton in Oklahoma filed a complaint — not a lawsuit — about the Oklahoma Children’s Hospital with the U.S. Department of Health and Human Services, requesting an investigation. The complaint was incorrectly reported in a States Newsroom story on Tuesday.

Anti-abortion protesters gather outside A Preferred Women’s Health Center of Atlanta. (Ross Williams/Georgia Recorder)

The first time Tina Marshall heard anti-abortion protesters call themselves “abolitionists,’” she said she burst out laughing.

Marshall, a Black woman who lives in Charlotte, North Carolina, was counter protesting at an abortion clinic when a mostly white group — save one Black woman — surrounded her and told her they were abolitionists.

“I rolled my eyes and said, ‘Can’t you people ever think of anything original? Do you guys have to steal everything?’” Marshall said.

Anti-abortion demonstrators have told her she hates her own people. She’s seen the mostly white men and women put their fists in the air and say, “Black Lives Matter.”

Marshall started volunteering as a clinic defender, as abortion rights groups call it, about two years ago, and she was unfamiliar with some of the rhetoric around abortion until recently. Much like the rest of America, in her view.

“They’ve been doing this for years, and nobody cared, and it’s only because of Roe now that everybody’s antennas are up,” she said of last year’s U.S. Supreme Court decision that ended the federal right to abortion. “Even before that, I’ve been out here over two years, and nobody cared about all the jeering and heckling of Black women.”

The co-opting of imagery from slavery, the Civil Rights Movement and other Black experiences to argue against abortion goes back more than a century, depending on who you ask, but the so-called “abolitionist” sect of anti-abortion groups has gained more momentum in political circles and state legislatures in recent years. With statistics showing higher rates of abortion by Black people in some states and the Black community’s reverence to culture and religion, it’s easy to see why such anti-abortion groups are focusing on African Americans.

William Hart, a professor of religious studies at Macalester University in Minnesota, told States Newsroom in an email that from his research, most Black Christians and non-Christians tend toward cultural conservatism, but they don’t typically have strong feelings against abortion. Those who do think abortion should be illegal are often viewing it from the historical belief that family planning and abortion were forms of Black genocide, Hart said.

“The anti-abortion religious right is appealing to Blacks on religious grounds because they understand that Blacks are susceptible to the argument even if their reasons diverge,” he said.

Activists have also argued over how civil rights icon the Rev. Dr. Martin Luther King Jr. would feel about abortion if he was alive today. King’s niece, Alveda, has said she thinks he would be anti-abortion. Others point to his quotes about the importance of family planning to say he was an advocate of reproductive rights.

The slavery comparison has historically been used by both sides of the abortion debate, according to research published in 1994 by Professor Debora Threedy, who is now retired. While anti-abortion groups use the comparison as a civil rights argument, harkening back to the days when slaves were widely viewed as less valuable human lives, abortion rights activists point to the implied slavery of not having a choice whether or not to give birth to a child, sometimes referring to it today as “involuntary servitude” and invoking “Black Lives Matter” to argue for bodily autonomy.

Threedy said the comparison to slavery in particular allows people to argue from the side of moral certainty, because nearly everyone today would agree that slavery was wrong then and wrong now.

“From where we stand now, on the slavery debate, we’re all on the side of the angels,” Threedy said. “By co-opting that rhetoric, what you’re saying is, ‘I’m on the side of the angels. They’re not on the right side of history, they’re not occupying the moral high ground — I am.’”

While the terminology is invoked on both sides of abortion politics, the anti-abortion activists who call themselves abolitionists have adopted it more as an identity over the past decade, and it has caused rifts among groups with similar goals.

Abortion abolitionists draw comparisons to history

At a recent conference hosted by Operation Save America, an extreme anti-abortion and anti-LGBTQ organization with a history of physically blockading abortion clinics around the country, those rifts were openly discussed. The group’s director, Jason Storms, opened the conference on July 17 at Pray’s Mill Baptist Church in Douglasville, Georgia, by stating his organization would no longer associate with T. Russell Hunter, the leader of Abolish Human Abortion.

Hunter has frequently taken to Facebook, YouTube and other video platforms to imply or directly state that groups like Operation Save America, Students for Life of America, Live Action and others don’t always advocate from an exclusively “abolitionist” standpoint and are not as committed to ending abortion as he is.

Those who call themselves abortion abolitionists, such as Hunter, see that as an example of the difference between their views and that of the “pro-life” groups, which generally oppose criminal penalties for the pregnant person.

On a recent episode of a podcast called The Serrated Edge, Hunter said he researched abolition in the context of slavery when he was in graduate school, and he saw parallels between the immediate abolitionists and those who opposed slavery but were in favor of more gradual, incremental approaches to ending it. To him, the abolitionists took a more biblical stance by calling the practice a sin and calling on the nation to repent.

“I thought, these (abolitionists) are amazing, what they’re doing,” Hunter said. “They could’ve been anything, and instead, they saw the plight of their neighbors on these transatlantic vessels … and they decided to give themselves to that because they saw those men as their neighbors.”

The two sides of the anti-abortion movement have clashed more in recent years over legislation that would eliminate abortion entirely without any exceptions, including to save the life of the pregnant person, and would attach criminal penalties for the person who sought the abortion, which in some states would include the death penalty.

An “abolish abortion” bill introduced in the Louisiana legislature crafted in partnership with the Foundation to Abolish Abortion in 2022 did not advance after opposition from abortion rights groups as well as anti-abortion organizations, including the Louisiana Family Forum and Louisiana Right to Life. In Idaho, Rep. Heather Scott has introduced a similar bill for three years in a row, but it has not advanced to the House State Affairs Committee. Rep. Brent Crane, who is chairman of the committee, said in 2022 that he would not give a hearing to an “extreme” bill that would put a pregnant person on trial for murder.

During a panel discussion at Operation Save America’s conference in July, Storms was joined by six other men to talk about abolition versus incrementalism in approaches to ending abortion, and said his group staunchly believes in criminal penalties for those who seek out the procedure but shied away from labeling the group as abolitionist or “pro-life.”

Zach Conover, communications director of the national organization End Abortion Now, was also a panelist, and he described the failure of a similar bill his group sponsored in 2019 in Arizona as a result of the National Right to Life group’s opposition to it in a letter signed by more than 70 of its chapter members. He also referenced the Louisiana bill.

“What happened in Louisiana should’ve been national news,” Conover said to the panelists. “It was really the first time that the pro-life establishment had shown their cards to that extent.”

Gabriel Rench, a member of the extremist Christ Church in Moscow, Idaho, also compared abortion to slavery, saying if churches in America had taken a stand against slavery, the Civil War would never have happened.

“We ended slavery through the blood of people instead of through the blood of Christ. When you have a massive cultural sin like slavery in America, you end it through the gospel, you don’t end it through a war,” Rench said during the discussion. “We need to end abortion, which is awful — way worse than slavery, by the way. The slave trade had four, five million slaves max in America? And 600,000 people died. How much has abortion killed?”

According to historians, at least 12.5 million men, women and children were captured and enslaved from Europe and Africa between 1526 and 1857, and 10.7 million were taken to North and South America. That doesn’t include the unknown numbers of people who did not survive the journey on tightly packed ships across the ocean.

Historians say a little more than 300,000 slaves were brought to the United States.

The Centers for Disease Control and Prevention reported about 1.3 million abortions per year between 1980 and 1997, after which the numbers dropped to less than 650,000 per year since 2013.

‘They’re trying to hitch them together’

Amanda Roberti, an assistant professor of political science at San Francisco State University, has researched the rhetoric of abortion politics for more than a decade. She said the civil rights language is often invoked as one of many strategies to capture more audiences, as any cultural advocacy movement would do. But it doesn’t mean every group will take the same approach at the local, state and national levels.

“There is a widespread and widely cast approach going on here, but that is something that social movements can do, especially when they’re multi-faceted like the anti-abortion movement is,” Roberti said. “They have an overarching goal of the end of abortion, but I think there are other groups that have slightly different tactics and what they want to pursue.”

Anti-abortion groups have also used the names of feminist leaders from history along with the names of Black activists. In 2011, U.S. Congressional representatives considered a bill titled the “Susan B. Anthony and Frederick Douglass Prenatal Nondiscrimination Act,” to impose criminal penalties for abortions that were performed based on the sex or race of the child. It’s unclear to historians whether Anthony, an early feminist leader, or Douglass, a slavery abolitionist, were against abortion.

“There’s a whole psychology behind it, because they’re trying to usurp a tragic historical fact and rise abortion to that level, they’re trying to hitch them together,” Roberti said.

‘Black women are the most marginalized’

Mandisa Thomas, a Black woman who lives in Atlanta and volunteers with an organization called We Engage, went to counterprotest at a local abortion clinic when Operation Save America held its conference in July. Abortion is banned after six weeks of pregnancy in Georgia, but members of the anti-abortion group gathered outside A Preferred Women’s Health Center just outside Atlanta during the morning hours that week and attempted to stop individuals from going into the clinic, using microphones with amplified speakers to shout religious messages encouraging the patients not to go through with their appointments. Many of the patients who came to the clinic one morning were Black women.

Thomas said she has often heard the abolitionist language from anti-abortion protesters, and she finds it insulting.

“The fact that they think they are being abolitionists is offensive, because they’re not being liberating at all,” Thomas said. “It really undermines the movements of people who did sacrifice their lives to make sure that all of us do have the freedom of choice, especially when it comes to reproductive choice and reproductive health.”

Marshall, who founded the Black Abortion Defense League in North Carolina, was also at the Atlanta clinic in July. Marshall said she started her organization because she didn’t see many Black people on the abortion rights side.

“I just thought, being a Black woman who had an abortion so many years ago, there’s a common language that we can speak, Black person to Black person,” Marshall said. “Black women are the most marginalized if you ask me. Nobody loves Black women except for other Black women, and sometimes we hate each other too. We’re an easy target because nobody wants to jump up to really save us.”

According to data from the Centers for Disease Control and Prevention, as of 2020, 39% of abortions in the United States were among non-Hispanic Black people, while 33% were among non-Hispanic whites, and 21% were Hispanic. In states across the South, such as Alabama, Mississippi and Georgia, more than twice as many abortions occurred among Black people in 2020 than among white people. In all three states, the poverty rate among Black people is also two to three times higher than among whites, and maternal mortality rates among Black women are higher than anywhere else in the country. Anti-abortion groups often target clinics in communities where a majority of the population is Black, typically in the South, for protests.

The disproportionate rates of abortion by race in some states are often cited on websites and in the literature of anti-abortion groups as a crisis to be addressed. Right to Life of Michigan has an entire page on its website titled “Black Abortions By the Numbers.” Focus on the Family cites the rate of abortions among Black women on its website as well.

But a 2022 poll by the Pew Research Center found that 59% of white respondents and 68% of Black respondents supported abortion to be legal in most or all cases.

That disparity in support could be one reason for trying to persuade communities of color to turn against abortion rights, said Grace Howard, an assistant professor of political science at San Jose State University. But on the other hand, Howard said tactics like the billboard could also be directed at white people like herself, to motivate her to action.

Some groups have paid for billboard advertisements that make race-based arguments around abortion, such as one in New York City in 2011 with a picture of a young Black girl that said, “The most dangerous place for an African American is in the womb.”

The billboard was paid for by an anti-abortion group in Texas called Life Always and approved by the group’s founding board member Stephen Broden, a Black pastor in Dallas. Broden said at the time in a statement that, “Our future is in jeopardy as a genocidal plot is carried out through abortion.”

The billboard was placed in a largely white community to garner the most attention, Broden said.

For some, reproductive justice is the answer

Roberti said the history of violence against Black women should also be considered when people use language related to slavery and civil rights. Research shows women who were enslaved were often raped and forced to bear children that could then be sold to other slaveowners. They were also subject to forced sterilization and other reproductive control measures.

“Black women have been subject to a lot of reproductive violence, so in a way they’re (anti-abortion activists) tapping into an argument that is real, but then applying it to a policy output that’s not going to provide any kind of justice,” Roberti said.

Howard is also a scholar of the reproductive justice movement, a social justice concept formed by a group of Black women in 1994 that looks beyond the statistics and demographics of abortion and works to strengthen the infrastructure of social supports around marginalized communities. That includes increasing access to contraception, adequate health care during and after pregnancy, reducing poverty rates and other measures that would increase quality of life and provide real choice, according to Sister Song. Howard said it’s a solution that could lower the number of abortions obtained in the U.S. each year, including among communities of color.

“For some people, they are having abortions because they know they won’t be able to raise this child the way they want to,” Howard said. “If you want fewer abortions, then a social safety net might change things, if someone knows they might be able to care for their child with dignity.”

Operation Save America Director Jason Storms told a gathering of religious, anti-abortion attendees that the church must take the lead to end abortion, which could happen with civil war. (John McCosh/Georgia Recorder)

An all-male panel of anti-abortion religious leaders from around the country met Friday night to discuss the strategies that should be used to end abortion in every state at any stage of pregnancy, without exceptions for rape and incest, and with criminal punishment for the pregnant person in line with existing criminal penalties for murder, which includes the death penalty.

The panel was part of a week-long series of events hosted by Operation Save America, an anti-abortion, anti-LGBTQ and anti-Muslim religious group that wants all Americans to follow “God’s law” and their interpretation of the Christian gospel. Many of the?events were held?in Douglasville, Georgia, at Pray’s Mill Baptist Church, which?broke away?from the Southern Baptist Convention for supposed acceptance of liberal social justice views regarding race and gender. Tuesday through Friday, the group started its mornings by?protesting outside?of A Preferred Women’s Health Center, an abortion clinic near Atlanta.

Friday’s speakers included Wisconsin-based Operation Save America Director Jason Storms and former OSA director Rusty Thomas, along with Arizona-based?End Abortion Now?communications director Zachary Conover, Georgia Right to Life President Ricardo Davis, and Gabriel Rench, a member of the extremist?Christ Church?in Moscow, Idaho.

Speakers focused on equal protection bills in state legislatures?

The theme of OSA’s national event was unity, and highlighted divisions within anti-abortion circles over what they described as the proper approach and response to legislation that seeks to limit or entirely restrict abortion procedures. The moderator of the panel, Derin Stidd, opened by asking, “Why do you all hate women?” to which the men laughed.

Rench then joked about not giving the microphone to Conover and said, “We don’t give him a voice like women,” then added, “Bad joke.”

The comments were in jest, but in line with remarks from OSA speakers throughout the week, including another comment from Rench, who said the church was wrong to allow women to be preachers.

On Thursday, anti-Islam speaker Raymond Ibrahim said, “If you look at a country, and the best they can come up with for a president is a woman, there’s something wrong about that. That doesn’t mean women aren’t smart or capable, I believe that, but if the very best — the crème de la crème — is a woman, that tells me something about the men when it comes to positions of authority and leadership.”

The panel focused on legislation they call “equal protection” bills, such as Georgia’s House Bill 496, also called the?Georgia Prenatal Equal Protection Act, which was introduced in February but did not advance in the state’s House of Representatives. An “equal protection” bill, by their definition, is one that adds criminal penalties to a pregnant person for the intentional termination of a pregnancy at any stage, with no exceptions for rape or incest. The law would make an exception if the abortion was performed to prevent the pregnant person’s “imminent death or great bodily injury.”

Storms said OSA has advocated for similar bills in?more than a dozen states, including Alabama, Arizona, Missouri, Kentucky and Oklahoma. So far, no states have passed an “equal protection” bill, but several, including Georgia, did pass what anti-abortion advocates call “heartbeat bills” that ban abortion after six weeks of pregnancy, before many people know they are pregnant. Those who advocate for “equal protection” bills call themselves “abolitionists,” co-opting language from the movement to abolish slavery, while the “pro-life” community has advocated for more politically expedient bills like six-week bans. Storms and other panelists called the six-week bans weak, even though they expressed understanding of political environments that make “equal protection” bills unlikely to become reality.

Rench said that is the case in Idaho, where many members of the state legislature are part of the Church of Jesus Christ of Latter-Day Saints. The church has taken an?official position?that rape and incest exceptions are acceptable, and bills that have not included those exceptions, such as?one introduced?by OSA-endorsed?Sen. Scott Herndon of Sandpoint, have gone nowhere in the Idaho Legislature. Christ Church and its followers have taken an approach they dubbed?“smashmouth incrementalism,”?which acknowledges that change can be achieved through gradual reformation and repentance in the country’s culture.

But Rench said he intends to keep working with Herndon and others to bring equal protection bills back in the next legislative session to keep pushing for it. Davis, president of Georgia Right to Life, said his organization will push for their bill again in the next session as well, and said he’s confident they’ll get it done the next time around.

How is abortion going to end? Maybe with civil war, speaker says?

Thomas, who was a longtime director of Operation Save America before Storms, said incremental steps like heartbeat bills were “a lie from the pit of hell” from the very beginning, but the organization didn’t used to be politically involved because there was too much compromise and too much that needed to be changed.

Thomas said it wasn’t until pastor Matthew Trewhella, who co-founded the Milwaukee-based group Missionaries to the Preborn and is?Storms’ father-in-law, wrote “The Doctrine of the Lesser Magistrates” that he felt like there could be progress. The book references history and biblical theology to argue that governments deemed “tyrannical” and ungodly can and should be defied. Trewhella has said he has spoken to at least 11 state legislatures across the country about the book.

“That was the first time in my life I knew we had solid rock to stand on to fight this battle politically,” he said. “That was the game changer.”

Conover’s organization, End Abortion Now, creates model legislation that grants legal personhood to fertilized eggs, which would limit in-vitro fertilization procedures, and assigns penalties to people who have abortions in addition to doctors who provide them. Some of his legislative efforts have been defeated by organizations that are against criminal penalties for pregnant people.

“It’s a dirty little secret of the pro-life industry: Their heretical teaching that has informed the types of laws they’ve supported for five decades, the lie that women should be allowed to kill their own children with immunity and impunity because they themselves are victims of abortion,” Conover said. “It is a lie that says that they are never legally culpable, however willfully or intentionally they carry out the act of taking the life.”

Regardless of the legislative strategy, the panelists agreed changing the culture of America to take on a Christian biblical worldview, which will require all pastors to take the same position on abortion as their own.

“We must see that the church plays that role culturally, to create that social tension. That’s the standard, that’s the ideology,” Storms said. “But that’s when we have to say, ‘Well, how does that flesh out in the real world?’ It doesn’t always look so pretty when we actually see that applied. How is abortion going to end? I don’t know, maybe it’s going to be a civil war, maybe it’s going to be a whole variety of other means.”

States Newsroom reproductive rights reporter Sofia Resnick contributed to this report.

Opill, a progestin-only contraceptive pill, will be available without a prescription in the first quarter of 2024, according to its manufacturer. (Photo courtesy of Perrigo Company.)

The U.S. Food and Drug Administration announced Thursday it has approved the country’s first daily birth control pill that can be used without a prescription, a move that reproductive health advocates celebrated after more than 20 years of advocating for an over-the-counter option.

The contraceptive, called Opill, is a progestin-only oral pill that could soon become available in drug stores, convenience stores and grocery stores, as well as online, without requiring a visit to a health care provider.

Frédérique Welgryn, an executive at Opill’s manufacturer, Perrigo, said during a press conference Thursday that the company will work with its regional partners to build distribution plans nationwide, and said Perrigo is committed to making Opill affordable, but the retail price is not yet available. The company anticipates the pill will be on sale in major retail stores across the country and online by early 2024 and also plans to work to list Opill as an option with private insurance and Medicaid.

Other reproductive-focused organizations, including the American College of Obstetricians and Gynecologists, celebrated the announcement, as did the American Medical Association. But Dr. Jesse M. Ehrenfeld, president of the American Medical Association, said in a statement that it should be the first step of approval for a variety of oral contraceptive options for over-the-counter use.

“It is important that patients have options when choosing which type of birth control works best for them. We hope this is just the first of several to be approved,” Ehrenfeld said. “We must continue to remove barriers to affordable care for those in underserved, high-poverty and rural communities. We know barriers to oral contraceptives can lead to inconsistent or discontinued use.”

The FDA said Opill should not be used by those who currently have or have ever had breast cancer, and those who have had any other form of cancer should ask a doctor before use. It should not be used with any other hormonal birth control product, including other oral pills, patches or injections, vaginal rings or intrauterine devices. The most common side effects of Opill are irregular bleeding, headaches, dizziness, nausea, increased appetite, abdominal pain, cramps or bloating, according to the approval announcement.

Unintended pregnancy associated with poor outcomes

Welgryn said it took more than eight years to conduct the research for approval and complete the lengthy application process with the FDA.

“This has been a journey fueled by the passion of our team, researchers, health providers, advocates and women themselves, along with the unwavering belief that the women and people of this country should have greater access and fewer barriers when it comes to their reproductive health,” Welgryn said. “Today’s decision follows nearly 50 years of data and research showing that progestin-only pills such as Opill are safe and effective. It follows the joint FDA advisory committee’s unanimous votes recommending Opill … because the benefits of having access to Opill over the counter overwhelmingly outweigh the potential risks.”

Welgryn said an estimated 40 million women in America need contraception, and approximately 15 million of those are using a less effective method or no method at all, while 10 million are already using an oral contraceptive pill with a prescription.

According to research from the Guttmacher Institute, nearly half of the 6.1 million pregnancies in the U.S. in 2011 were unintended, and 18% of those pregnancies were considered unwanted. Further research has determined unintended pregnancy is significantly associated with higher incidences of depression during pregnancy and postpartum, along with higher rates of preterm birth and low infant birth weights.

Dr. Stephanie Sober, global lead of medical affairs for Perrigo, said during the press conference that the country’s current reproductive health landscape makes the pill’s approval all the more important. Fourteen states have near-total bans on abortion, and Iowa could soon join Georgia with a gestational ban at six weeks, before many people realize they are pregnant. Indiana’s abortion ban, which applies to all stages of pregnancy with exceptions for rape, incest, fetal anomalies and the life of the pregnant person, is expected to take effect Aug. 1.

“Opill over-the-counter paves the way for improved access by removing barriers for the people who struggle to access contraception most, particularly people working to make ends meet, people of color, young people, and those who live in rural areas,” Sober said.

“For some, the ability to secure insurance, find a provider, make an appointment, and then obtain child care and access reliable transportation, all can create an insurmountable obstacle to obtaining contraception. Being able to pick it up at a pharmacy knocks down those obstacles, and it’s truly game changing.”

Elevated Access has recruited more than 1,200 volunteer pilots to privately fly those in need of an abortion to states where it is accessible. (Isiah Holmes/Wisconsin Examiner)

Editor’s note: This report is part of a special States Newsroom series on abortion access one year after the U.S. Supreme Court decision struck down the federal right to abortion.

When the U.S. Supreme Court issued its Dobbs decision one year ago, people of childbearing age in states across the country suddenly faced what seemed like a new prospect — having to travel hundreds or even thousands of miles from home to get an abortion.

But historians say it is merely continuing a long tradition of pregnant people seeking out the sometimes lifesaving care they need wherever it can be found, and other people helping them along the way.

In the Midwest, Dr. Josephine Gabler operated an abortion clinic that served tens of thousands of people in Illinois, Indiana, Michigan and Wisconsin between 1930 and 1940.?Patricia Maginnis?kept a list of trusted physicians in Mexico, Japan and Sweden through the 1950s and ‘60s where people could be?referred from California?for safe abortion care.

The Clergy Consultation Service, made up of 3,000 religious figures across 38 states, helped 7,500 women find abortions from 1967 until 1973, when the U.S. Supreme Court ruled in favor of Roe and legalized the procedure nationwide.

Today, with 14 states that have implemented near-total bans on abortion, one organization called Elevated Access has recruited more than 1,200 volunteer pilots to privately fly those in need of an abortion to states where it is accessible.

Since the Dobbs ruling, states with abortion access have experienced an increase in out-of-state patient volume. In Illinois,?nearly one-third?of Planned Parenthood patients came from other states, compared to an average 6% prior to Dobbs. Similarly, clinics in Colorado reported out-of-state patients doubled from 14% in 2021 to 28% in 2022, with a large share coming from Texas, which has a strict abortion ban. At least one state, Idaho, has passed legislation aimed at restricting out-of-state travel for an abortion for minors who don’t have parental permission, but it’s unclear how that law will be enforced. Other states with bans have not successfully implemented any laws aimed at restricting travel.

“This is part of a long history of people seeking out ways to end their pregnancies and to get abortions, or ‘get their menstruation back,’ as they called it then, that often included travel,” said Leslie Reagan, a historian who wrote?“When Abortion Was a Crime”?and scholarly articles about women traveling for abortion throughout the 19th and 20th centuries. “They could be coming by train, driving, or taking a bus, depending on what time period we’re talking about and their circumstances.”

Groups across America ran underground networks that kept organized lists of trusted physicians who would provide abortion care. Sometimes those physicians operated covertly in communities within the U.S., but often they were located across the border in Mexico, or across oceans in Puerto Rico, Europe and Japan.

Overseas, people have also traveled where abortion was illegal. Irish citizens?traveled to the United Kingdom?for abortion care for many decades, and still do for pregnancies beyond 12 weeks’ gestation. Canadians traveled to U.S. cities like New York City and Chicago and Washington state prior to legalization in 1988. Between 2001 and 2017, Dutch Dr. Rebecca Gomperts used ships to ferry women from cities in Ireland, Poland, Portugal, Spain, Morocco, Guatemala and Mexico to international waters, where they could terminate their pregnancies legally aboard the ship and then return home.

“Sometimes people can’t control when they’re going to get pregnant, or if the timing is right, or you’re going to get kicked out of school,” Reagan said. “And really what I saw was not only were women doing it, they had a lot of support. There’s really a lot of moral support for this even though the laws might say it’s illegal.”

Volunteer pilot raised $15,000 to buy small seaplane?

A Midwestern pilot who goes by Mike Bonanza?started Elevated Access three days before the leaked draft opinion overturning Roe was released on May 1, 2022. He volunteered for the?Midwest Access Coalition, an abortion access fund in Chicago, and his background as a pilot led him to put the two together to help more people. The organization also flies those who need gender-affirming care, which is quickly becoming a larger need. As of June 1,?21 states?have banned gender-affirming care for minors, including all 14 states with abortion bans.

One of Elevated Access’ volunteer pilots is Adrian, who asked only to be identified by his first name, as all Elevated Access volunteers and staffers do to protect themselves from harassment and potential legal scrutiny. But he is one of the most outspoken individuals affiliated with the organization, and one of the only people who willingly shows his face on social media — his TikTok account has more than 115,000 followers.

“I stopped counting donations (to Elevated Access) once we crossed over $150,000,” he said.

When asked why he volunteers, Adrian speaks plainly about his mother, who was raped by an older man when she was 13 years old. Her parents, he said, were members of the Church of Jesus Christ of Latter-Day Saints in Utah and did not allow her to seek an abortion. She was forced to give birth to Adrian and his identical twin brother at the age of 14.

For the first eight years of their lives, Adrian and his brother lived with his grandparents, until his mother returned and took the boys to Georgia to live on a military base with her and a man she was dating. From that time until he left home, Adrian and his brother frequently experienced food insecurity and other abuse.

Now that he is married and living in Wisconsin, Adrian said he doesn’t have a relationship with his mother, stepfather or his brother, who has also struggled with substance abuse.

“A lot of people will say, ‘Oh well, my god, he’s doing so much for his mom,’” he said. “No, it’s not about my mom. Yes, my mom is an individual that perfectly embodies the individual that should have access to reproductive health care. It doesn’t mean I like her.”

His plane is a model from the 1980s, and one of less than 50 left in operation around the country. He opted for an amphibious plane for its versatility, especially after rumors that states with strict abortion laws such as Texas might try to interfere with people trying to leave the state for the procedure. According to the National Oceanic and Atmospheric Administration, about 2.1 million of Wisconsin’s 5.7 million people live in coastal areas of the state, or nearly 37%, and he could taxi through the water right up to their docks if needed.

Although Elevated Access has many volunteer pilots, Adrian said they need more who own their own planes.

“That’s our biggest hurdle, is actually pilots with planes,” he said.

Word of mouth spreads easily in the internet age

Some of the circumstances surrounding abortion access today are easier to navigate now than they were prior to 1973, according to historians. Katrina Kimport, a researcher at the Bixby Center for Global Reproductive Health at the University of California, San Francisco, said travel has historically been limited to those with the means and resources to do it. Wealthier people had the financial backing as well as more connections who could help lead them to the right people. In the internet age, information is readily available to many more people, she said, and there is often more financial support for those who can’t afford it.

Christabelle Sethna, a professor at the University of Ottawa who wrote a book called “Abortion Across Borders,” said the information network that exists today is an essential difference from history.

“In the past it was sort of underground, whispered information; you’d have to ask a whole number of people and maybe one would come through for you with the name of a doctor,” Sethna said. “It was much more disparate in the past, and now it’s much more organized because of the internet and the vast reach of the internet.”

That includes being able to access abortion medication through websites, Sethna said, which is another option that wasn’t available in the past. Another significant difference is that the procedure is legal at various stages of pregnancy in 36 states rather than banned nationwide, as it was between the late 1890s and 1973.

Despite those changes, Kimport said her research shows there are still many?logistical, emotional and financial burdens?placed on those forced to travel because of a lack of access in their own state. She pointed out that prior to the Dobbs ruling, abortion after 24 weeks was still heavily restricted, which provided a preview of what pregnant people are experiencing now at a much broader scale.

“Putting aside the cost of the procedure, travel itself is an additional cost,” Kimport said. “There’s also the logistical burden of having to seek out child care or pet care, time off work, getting reservations. Some people don’t have credit cards, some don’t have a car. This is a time and resource and organizational burden.”

Emotional costs are difficult to measure, she said, but are some of the most heightened effects, especially for someone leaving a rural area and traveling to an urban area if they have never traveled before.

“Even for people who have experience in travel, going to an unknown place can be extremely stressful and unsettling,” Kimport said.

Abortion access funds rely on each other to cobble together funds for travel

While Elevated Access is responsible for the pilots and the actual flights, it is partner organizations large and small that refer clients to them and help arrange lodging and other logistics, often providing additional financial support for meals and other expenses.

One of those partners is?New River Abortion Access Fund, which started in 2019 in rural Virginia, where it can take hours to drive to the nearest clinic. Sophie Drew, interim director of the fund, said barriers to access already existed prior to the Dobbs ruling, but at a much smaller scale. The initial budget for the fund was about $600 per week, she said, with maybe five calls for help during that week.

Now, the fund averages $20,000 per week with 60 to 70 calls on average in one week.

Gianna G., an intake coordinator for New River, said that might sound like enough funding, but with an average cost of $300 to $500 for first-trimester abortion care and as much as $20,000 for abortions later in pregnancy, abortion funds around the country rely on each other to cobble together enough dollars from donations each week to help all of their callers.

“Right now, we just don’t have the money we need in order to make this sustainable,” they said. “I think a lot of people support abortion care, but they don’t know the monetary need behind it.”

The vast majority of those who call New River seeking help can travel by car where they need to go, Drew said, but there are still instances when a flight is the best option.

Gianna G. said much of their job is identifying barriers, like someone who doesn’t have a car or driver’s license, or doesn’t have a support person who can come with them for a long car ride.

Both commended Elevated Access, and said the fact that the flights don’t come at additional cost, including for a support person, is incredibly helpful.

“We’ve gotten feedback from some callers about their experience and it’s been exclusively positive,” Drew said. “Even if someone was nervous about flying. Elevated Access has been a great support both logistically and emotionally.”

Pilots use their own funds to gas up their planes, which Adrian said typically burn 10 to 25 gallons per hour. With the typical average cost of fuel, it can range from $60 to $120 per hour in gas alone. Sometimes Elevated Access can help offset those costs, but that funding is limited.

“Any of these pilots actually volunteering their time and resources, they’re losing money,” Adrian said.

Most patients who need flights come from the South and Midwest

Elevated Access has a policy of not asking many questions about the patient or their circumstances to respect their privacy as much as possible, especially because the situations can be complicated and emotionally difficult. Some flights have even been one-way trips, for those fleeing abusive situations or other dire circumstances.

“By the time they get to Elevated Access, they have tried many, many approaches,” said Fiona, who acts as a volunteer media relations coordinator. Elevated Access volunteers and staffers go by their first names only to protect themselves from harassment and potential legal scrutiny. “We are often the end of a long road for them. They are often very desperate at that point. They know that they can’t carry the pregnancy to term for many reasons.”

The organization does not disclose how many flights it has completed through volunteers over the past year to avoid becoming a target of anti-abortion advocates. But it now has three full-time staff members, including the executive director and two flight coordinators, and nearly 2,500 people have donated in the past year, even without active fundraising campaigns.

The requests for flights come from all states with abortion bans, Fiona said, but the largest share come from the South and the Midwest, where 13 of the 14 states with abortion bans at any stage of pregnancy are located.

“There are states where we will get requests where technically there is access, but it’s eight weeks out to get an appointment, or it’s a very specialized need for care,” Fiona said. “That’s more the exception.”

Researchers: Stigma from community adds to stress

The stigma surrounding abortion remains, presenting an added burden, according to Kimport’s research. She interviewed 30 women who traveled for abortion prior to the Dobbs decision about their experiences and said many of them felt forced to disclose their situation to people before they were ready or lied because they had to explain their absences.

Being away from support networks, including children, family, pets, neighbors and friends is another difficulty, she said.

Those who have to travel for an abortion, especially if it is by plane, are often in more advanced stages of pregnancy, Kimport said. Sometimes that is because a lethal fetal anomaly was discovered and sometimes it’s because the person did not know of the pregnancy until it was advanced — or, in today’s environment, an appointment could take weeks to obtain, depending on the demand at available clinics.

Whatever the reason, Kimport said those late-term abortion seekers face added emotional, physical and logistical burdens, since the procedure itself is more intense and requires more time to recover.

“People with third-trimester abortions had to travel because their state said that care was not allowed, and they talked about how that particular fact made things additionally emotionally stressful,” Kimport said. “One woman said she felt cast out from her community, that the law was saying what she was doing was deviant and she felt stigmatized.”

One benefit of Elevated Access and its volunteer pilots, according to the organization’s leadership, is that it offers a private method of flying to a destination. Kimport said those who have traveled for later-term abortions are more visibly pregnant and have to interact with strangers who will compliment and congratulate them and offer unsolicited advice. For someone whose wanted pregnancy went wrong, she said, that can be devastating.

‘We shouldn’t get used to it being complicated’

At the moment, as is in the case in so many states, the reproductive rights landscape in Wisconsin is complicated. The state is currently operating under a criminal abortion ban that went into effect in 1849, banning all abortions except to save the pregnant person’s life. But it’s unknown if a law that dated can still be enforced, particularly since Roe was in effect for 50 years in between. The law passed to comply with Roe allowed abortions at any stage of pregnancy.

The question of enforceability is currently under consideration in one of Wisconsin’s circuit courts, after Democratic Attorney General Josh Kaul filed a lawsuit against the three district attorneys who would prosecute cases in the counties with abortion clinics.

“Whichever party loses, I anticipate they would file a notice of appeal to the court of appeals and then it would go up to the (Wisconsin) Supreme Court,” said Michelle Velasquez, director of legal advocacy and services for Planned Parenthood of Wisconsin. “But the circuit court’s decision is an important first step to potentially restoring abortion access.”

The state’s governor is also a Democrat, but Republicans have a majority in both chambers of the legislature, creating a split, stalemated government. Unlike other states that are using citizen ballot initiatives to try to codify abortion access, Wisconsin only allows the legislature to propose ballot referendums.

Even before Roe fell, access to abortion was restrictive. Only three of the state’s 72 counties had a health center that offered abortion care, and using telehealth for abortion medication was prohibited by law. To obtain mifepristone and misoprostol, the two-drug regimen used to terminate early pregnancies, an individual is required to complete two in-person visits with the same physician present.

But Wisconsin is an island in the upper Midwest in terms of access — its border states, including Minnesota, Michigan, Illinois and Iowa all continue to allow abortions.

By plane, Adrian can fly from Wisconsin’s eastern peninsula to a Minnesota clinic in about 45 minutes, but it would take someone living on the peninsula four hours to make the drive.

“That’s kind of how ridiculous this is,” he said. “I couldn’t imagine what it feels like to be told, ‘No, you can’t get the care you need.’ It’s also going to permanently rearrange your body, and you’re never going to be the same all because some a— h—- assaulted you or some tech bro didn’t want to wear a condom.”

Although the people working to connect pregnant people with abortion care are passionate about the work, New River’s Interim Director Sophie Drew said she hopes having to drive for hours or take a private flight to get an abortion doesn’t become normalized. In her ideal world, none of these resources would need to exist.

“People should be able to access abortion in their communities without all these hoops to jump through,” she said. “That’s the main thing I wish people knew, is that it can be a complicated process, and we shouldn’t get used to it being complicated.”

When Roe was overturned, Adrian posted a video to promote Elevated Access and recruit more pilots. His presence as “cheesepilot” on TikTok is how the leadership at Elevated Access found him and asked for his help in May 2022. The organization had barely started in April, and only had a few volunteers. He made a quick video on a break from his job as a pilot for a regional airline and came back several hours later to nearly 500,000 views and hundreds of people asking how to donate. The seaplane he bought last year was made possible with a $15,000 down payment raised by his TikTok followers.

The U.S. Food and Drug Administration approved mifepristone in 2000 as part of a two-drug regimen that’s currently used up to 10 weeks in a pregnancy. (Photo illustration by Anna Moneymaker/Getty Images)

America’s major medical institutions and drug policy scholars have roundly denounced as “pseudoscience” many of the claims brought by anti-abortion groups in a high-profile federal lawsuit asking the Food and Drug Administration to revoke its 23-year-old approval of mifepristone, one half of a two-drug regimen that has become the most common form of pregnancy termination post-Roe v. Wade.

But the three-judge panel of the 5th U.S. Circuit Court of Appeals that heard oral arguments Wednesday appeared to be persuaded not by the medical consensus in this case, but by some of the evidence brought forward by plaintiffs that consists largely of anecdotes, speculation, and cherry-picked studies brought by a handful of anti-abortion medical groups and doctors.??

Medical and public health societies led by the American Medical Association submitted a “friend of the court” brief before the 5th U.S. Circuit Court of Appeals, stating that the lower court’s ruling “relies on pseudoscience and on speculation, and adopts wholesale and without appropriate judicial inquiry the assertions of a small group of declarants who are ideologically opposed to abortion care and at odds with the overwhelming majority of the medical community and the FDA.”

While asking a question of U.S. Deputy Assistant Attorney General Sarah Harrington, Judge Jennifer Walker Elrod referred to mifepristone cutting off “nutrition” to the fetus, which is a false claim cited in the initial ruling written by Texas federal Judge Matthew Kacsmaryk in April. Kacsmaryk referred to mifepristone as a “synthetic steroid that blocks the hormone progesterone, halts nutrition, and ultimately starves the unborn human until death.”

According to Johns Hopkins Medicine, the progesterone hormone is produced in early pregnancy to help thicken the lining of the uterus to support implantation of a fertilized egg. Without that hormone stimulation, which mifepristone blocks, the lining breaks down and the pregnancy cannot continue. It is then followed by doses of misoprostol to induce contractions and expel the pregnancy.??

Former President George W. Bush appointee Elrod – like her fellow Donald Trump appointee Judges James C. Ho and Cory T. Wilson – shares ideological views on abortion with the plaintiffs’ anti-abortion coalition, which is represented by the Alliance Defending Freedom. So does Kacsmaryk, whose since-blocked decision to suspend FDA approval of mifepristone cites anecdotal evidence from plaintiffs.?

Mifepristone remains legal and on the market as the case winds its way through the legal system, and data from the FDA since the drug’s initial approval in 2000 shows it is overwhelmingly safe to use. Out of an estimated 5.6 million people in 23 years, 28 deaths have been associated with the FDA’s abortion medication regimen, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. And as the FDA has noted, that number includes fatal cases “regardless of causal attribution to mifepristone,” such as people who died from homicide, suicide, and pulmonary emphysema.?

If the plaintiffs prevail, health care providers, medical institutions and pharmaceutical industry organizations have warned of its potentially catastrophic consequences. In addition to radically reducing access to abortion nationwide, removing mifepristone from the market would reduce access for miscarriage treatment, public health experts say, and have far-reaching consequences beyond abortion.

“The implications of this case are extraordinary, and they include the potential termination of access to mifepristone, a precedent for court interference in the FDA’s rigorous and science-based testing and approval process not just for mifepristone, but for any drug,” said Joanne Rosen, a senior lecturer in the departments of Health Policy and Management and Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, during a media briefing hosted by the university Thursday. “This would be the first time in history that a court has abrogated the FDA’s approval of a drug over the objections of the FDA.”

Sympathetic, cynical and combative exchanges

The appeals court judges seemed sympathetic to the narrative brought by the plaintiffs that mifepristone is a dangerous drug, as they were in their previous opinion blocked by the Supreme Court, which would have restricted the use of mifepristone. A big question in this case has been whether the coalition of anti-abortion medical groups and four doctors, including Indiana state Sen. Dr. Tyler Johnson, have standing to sue. Plaintiffs have argued their doctors would suffer direct harm if mifepristone remains on the market.

Like medical and legal scholars following this case, Rosen said plaintiffs’ arguments for standing are weak, and if accepted would open the door to any group that wants to challenge the FDA’s approval of a drug for any reason.??

Plaintiff groups argue that their member doctors could be overwhelmed with a potential future influx of emergency room visits from mifepristone patients, or forced to treat an abortion patient against their will. These claims are based not on robust data but largely on the testimony of handful of plaintiff doctors, three of whom give mostly non-specific anecdotes about treatment they performed for women who allegedly had taken some form of medication abortion, but it’s not clear when the procedures took place and whether it was the FDA’s regimen.?

Harrington argued on behalf of the federal government that plaintiffs had not made claims of being forced to treat abortion patients against their will.?

“They claim injury from speculative downstream effects of choices made by a chain of other people who are not parties to this lawsuit,” Harrington said.

But Wilson pushed back.

“The declarants here said they’ve seen these patients, they’ve cared for them,” he said. “I take that to mean that they treated them and that they expect to see more in the future. How’s that not enough for standing if the doctor also has a conscience objection to doing so?”

The judges made a series of sometimes snarky and combative comments and questions aimed at the attorneys for the U.S. Department of Justice, representing the FDA, and the mifepristone manufacturer Danco Laboratories, and called into question trust in the FDA’s expertise and judgment.?

Echoing plaintiffs’ criticism of the FDA approving mifepristone as part of a particular category of drugs for serious illnesses, Ho said pregnancy is not a serious illness, quipping, “When we celebrated Mother’s Day, were we celebrating illness?”

A question of evidence

And they misstated non-scientific assertions by plaintiffs, such as claiming that non-fatal adverse reporting is no longer required by the FDA. Mifepristone manufacturers (but no longer medical providers) are still required to report non-fatal adverse reactions.

Much of the anti-abortion evidence submitted in this case was authored by researchers who work for the anti-abortion Charlotte Lozier Institute, whose role is to defend abortion bans and restrictions with research. Regarding mifepristone, Charlotte Lozier’s researchers have published articles that mostly speculate large amounts of under-reporting when it comes to abortion complications, and argue the true risk of mifepristone is unknown.?

Another anti-abortion organization, the Family Research Council, also submitted a 125-page amicus brief with false claims that the drug approval was expedited by former President Bill Clinton. It also cites research from the Charlotte Lozier Institute to back claims that the drug is unsafe.?

Judges echoed this sentiment and speculated on the safety of telemedicine abortion and questioned the FDA’s process of loosening restrictions over time. Elrod asked Harrington if a medical provider could examine someone via email rather than video, and if people could use telemedicine as an “intermediary” to send the medication to a state with an abortion ban. Elrod referenced amicus briefs that alleged individuals were engaging in those tactics to skirt state laws.?

Harrington said the statements referenced by Elrod in the briefs are unsupported and irrelevant to the central issue.

“None of that is dictated by the FDA, and none of that is relevant to whether the FDA’s determination that this drug is safe and effective with these conditions in place,” Harrington said.

Elrod pushed back, asking if it was a relevant factor to consider in issuing an injunction that would limit access to the drug.?

“If it’s violating other law, which we have to determine, perhaps, then we have to decide whether or not it’s appropriate to enter an injunction or not and that’s one of the factors we would consider,” Elrod said.

Public health experts say the appeals court’s attitudes toward the science in this case are deeply concerning.?

“Judges and lawmakers should not be substituting their own opinion for the experience, expertise, and authority of the U.S. Food and Drug Administration. Nor should they ignore the substantial weight of scientific evidence from hundreds of studies and millions of patients confirming the safety and effectiveness of mifepristone, which has been used for decades in both medication abortion and miscarriage management,” said AMA President Dr. Jack Resneck Jr. in a recent statement.?

Even if the appeals court rules to restrict or revoke approval of mifepristone, the federal government will most likely appeal the case to the U.S. Supreme Court. Regardless, the 5th Circuit Court judges’ reasoning could prove influential to the Supreme Court’s eventual decision.?

Oregonians gather outside the Multnomah County Justice Center to protest the June 2022 U.S. Supreme Court decision that overturned Roe V. Wade. (Alex Baumhardt/Oregon Capital Chronicle)

Oregon Gov. Tina Kotek announced the state will secure a three-year supply of mifepristone, one of two drugs used to terminate a pregnancy and manage miscarriages, amid lawsuits and an expected U.S. Supreme Court ruling on access to the medication.

“By challenging the FDA’s authority over mifepristone, the lower court decisions set an alarming precedent of putting politics above established science, medical evidence, and a patient’s health, life, and well-being with potential implications beyond this one medication,” Kotek said in a news release.?

The state government intends to partner with Oregon Health & Science University to secure the supply of 22,500 doses. Kotek’s office and the Oregon Health Authority first asked health care providers in the state for their thoughts on the ongoing court battles and whether additional state support was necessary, according to the news release.?

The health authority told the Capital Chronicle on Monday that it was not yet stockpiling mifepristone and was exploring “all options” to ensure access to safe, legal and effective abortion care.

The move comes one day before the U.S. Supreme Court is scheduled to announce whether it will allow a Texas ruling to strike down the approval of mifepristone by the U.S. Food and Drug Administration. The ruling would have taken effect on April 14, but the U.S. Supreme Court paused its implementation pending its own opinion.

Kotek’s office said she will also direct Oregon’s licensing boards to issue guidance clarifying that the state supports providers continuing to prescribe, dispense and use mifepristone regardless of the decision issued by the U.S. Supreme Court. Kotek has also pledged that Oregon government officials will not extradite individuals for criminal prosecution for receiving, providing or supporting patients seeking reproductive health care in Oregon.

“To our providers, to the patients who live in Oregon or have been forced to come to our state for care, and to those who are helping people access the care they need, know that I have your back,” Kotek said.?

Oregon is a plaintiff in a competing lawsuit led by Washington Attorney General Bob Ferguson’s office calling on the FDA to lift the restrictions placed on mifepristone’s use. A federal judge in Washington has not yet ruled on the case, but ordered the FDA not to make any changes to the approval or accessibility of the drug in the meantime. Including Washington and Oregon, 15 other states and the District of Columbia joined the lawsuit as plaintiffs and are not expected to be affected by the outcome of the Texas case while the Washington judge’s order is in place.

Kotek joins Democratic governors of several states across the country who took similar action, including in Washington and Massachusetts. The governors of New York and California stockpiled misoprostol, the second drug in the two-step regimen for abortion and miscarriage care. If misoprostol becomes the only drug patients can access for medication abortion after the court’s decision, they might experience more side effects, such as cramping, nausea, vomiting and fever, health care professionals warn.

Shown here, a colored composition scanning electron micrograph of human sperm traveling through a fallopian tube. After ejaculation sperm may stay alive in the female reproductive tract for about 48 hours. Companies are testing a male contraceptive option that would filter out the sperm while allowing other fluids to pass through. (Photo by Steve Gschmeissner/Science Photo Library via Getty Images)

Heather Vahdat has been advocating for male contraceptive options for nearly a decade, but she is the first to say it is a lonely space to occupy in the health science field.

Vahdat is the executive director of the Male Contraceptive Initiative, based in Durham, North Carolina, which has been working with a single donor to provide up to $1.5 million in grants per year for emerging male birth control technologies since 2017 — and that makes it the second largest funder of that type of research in the U.S., second only to the National Institutes of Health.

At the moment, the options for men are limited to condoms and vasectomies, Vahdat said, and while vasectomies can potentially be reversed, it doesn’t always work.

Vahdat says demand for male contraceptives was already stronger than most would guess, but the U.S. Supreme Court’s Dobbs decision in 2022 was a tipping point.

“After Roe fell, women looked around and said, ‘What can you do?’ and men looked around and said, ‘Crap, what can I do?’” Vahdat said. “Men are waiting for this; I think it’s really underestimated how much attention men are paying to this.”

Cody Romero, a 32-year-old single Idaho resident, said he will be happy to take any method of male contraception once it is available, especially in the current environment of abortion restrictions.

After all, even with the birth control methods that are available for women, a recent estimate showed half of the world’s yearly pregnancies are unplanned. In the United States, as of 2019 data from the Guttmacher Institute, there were about 45 unintended pregnancies per 1,000 women between the ages of 15 and 44.

“I don’t like the idea of getting someone pregnant. That’s scary,” Romero said. “I always feel bad for the ladies that do get on birth control and struggle with some of them. It’s like, ‘Well, this is my fault as well.’”

Romero had only heard of a study on hormonal pills for male birth control that was cut short after some of the participants experienced adverse psychological effects — that was in 2016. But he said he is open to any method, particularly since he does want children at some point and doesn’t want a vasectomy at his age.

Romero said among the men he knows, subjects like contraception are rarely talked about. But if more options became available, he thinks many of them would be interested in taking the contraception burden on themselves.

“Right now, it just feels like that’s not something they need to take care of, ‘It’s someone else’s problem’ sort of thing, that’s the impression I get,” Romero said.

?Potential 10 years of birth control with injectable gel

Although male contraceptives have been discussed and researched since as early as the 1950s, Vahdat said there has been little interest from pharmaceutical companies to invest in options for men. The Male Contraceptive Initiative has provided grant funding for research at institutes such as Emory University, Baylor College of Medicine, the University of North Carolina at Chapel Hill and Yale University.

The initiative also partnered with the Bill and Melinda Gates Foundation to produce research released in February that assessed the demand for potential contraceptives for men across various regions of the world, including the United States, India, Africa and Vietnam. Two thousand men were surveyed in each country, and in the U.S., 78% of those surveyed said they would use male contraceptive methods if available. That included options such as hormonal pills, a gel that is rubbed into the shoulder, a nasal spray and implants or injections.

The organization is planning to replicate the survey in the U.S. to assess interest after the fall of Roe and the return of abortion regulation to the states.

One of the grants the Male Contraceptive Initiative provided in the last few years was for a hydrogel developed by Virginia-based business Contraline called ADAM, which is a similar technology in development by a company called NEXT Life Sciences.

Contraline representatives could not be reached for comment, but the ADAM technology is in use in a clinical trial in Australia that is expected to be completed by 2025.

L.R. Fox, CEO of NEXT Life, said his California-based company acquired rights to vasalgel from the Parsemus Foundation. Vasalgel is a technology derived from a hydrogel that has been used in clinical trials in India for about 30 years called Reversible Inhibition of Sperm Under Guidance, or RISUG, according to Fox. NEXT Life is calling their product Plan A.

The non-hormonal contraceptive method involves the injection of a substance called vasalgel that forms a small, flexible filter inside the vas deferens — the duct that produces sperm — and filters sperm out while allowing other fluids to pass through.

The injection would take place during a quick doctor’s visit with local anesthetic, Fox said, and he said it could potentially provide up to 10 years of birth control that could be reversed at any time. He likened it to non-hormonal IUD implants.

The company will begin clinical trials with Plan A at the end of this year, so those numbers are preliminary, according to Fox, but they are based on data from trials in India and animal studies, which he said have been promising so far. That length of time, if it holds true in clinical trials, will be much longer than similar hydrogel formulations, Fox said.

“Since the overturn of Roe, the only effective contraceptive option for men is currently a vasectomy, which solves the long-lasting problem, but is designed to be permanent,” Fox said. “Therefore, it’s primarily only used by men who are child complete at 45 or often 65 and older, so what we see is this massive demand from men who are in their 20s and 30s who are in committed relationships and who are saying they want to be able to participate in the family planning process.”

Contraception takes two, initiative leader says

The lack of investment into the development of male contraception hasn’t gone unnoticed by Fox, who said he grew up in the foster care system and saw firsthand the “devastating consequences” that can occur when someone can’t choose when to have a child.?

“People aren’t recognizing the problem because they sit back and say, ‘Well, is it really needed?’ because women have a solution,” Fox said. “The assumption is we can just burden women with contraception that clearly is not sufficient.”

Fox said 50,000 people have expressed interest in the product, and if all goes as planned, he hopes Plan A will have approval from the U.S. Food and Drug Administration and roll out on the market by 2026, which is “just right around the corner,” he said.?

Fox believes Plan A represents the best option because of its simplicity and potential effectiveness.

“Of course, those (pills and creams) are incredibly valuable contributions to science, but at the same time, one of the big concerns is how can you ensure effectiveness and also how do we remove user error?” Fox said. “That’s why something long lasting and reversible is so key.”

From Vahdat’s perspective, it is unrealistic to expect an option to hit the market by 2026 given all of the bureaucratic hurdles involved in clinical trials and approval that can take years to complete. A 2018 study from the Tufts Center for the Study of Drug Development showed FDA-approved drugs and biologics spent an average of nearly 90 months — more than seven years — in the clinical trial phase, although Fox points out that Plan A is a medical device, which average a faster timeline of three to seven years.

But Vahdat does think the market in general is on a steady upward trajectory.

“What we can’t do is slow that momentum,” she said.

Vahdat said she’d love to see more investment from donors and organizations, but what will also aid the speed of bringing products to market is individuals demanding more options. Because in the meantime, the options remain limited.

“We have to stop looking at contraception as either for men or for women. Like conception, you need two people,” she said. “So with the onus being on women, we’ve kind of gendered that term, but really contraception is about two people preventing an unintended pregnancy.”

(Photo by Peter Dazeley/GettyImages)

A Texas federal judge with a history of anti-abortion beliefs has thrown into jeopardy the most common form of abortion since Roe v. Wade fell last summer.

U.S. District Judge Matthew J. Kacsmaryk released his decision on the cusp of Easter weekend to pause the Food and Drug Administration’s 2000 approval of the abortion drug mifepristone while a lawsuit against the agency proceeds. However, whether this ruling will ever be enforced remains to be seen. Legal experts have called into question the judge’s ability to suspend an FDA approved drug without going through agency protocol.?

Doctors and abortion providers around the country told States Newsroom the decision will likely exacerbate abortion care that has already been delayed and diminished following the U.S. Supreme Court’s decision to let states regulate abortion laws.?

The order is scheduled to go into effect by April 14, but that could change because of appeals. The U.S. Department of Justice launched an appeals process Friday within hours of Kacsmaryk’s ruling.

“Any delay in abortion care is unnecessary and cruel, and it’s a dangerous precedent to deny access to a safe medication that science tells us is safe,” said Dr. Mollie Nisen, a family physician and abortion provider in Washington state.

Nearly simultaneously on Friday afternoon, a Washington District Court judge issued a contradictory ruling preventing the FDA from taking adverse action on mifepristone. That ruling affects the plaintiff states who brought the case, which includes 17 Democratic-led states, while the Texas case has nationwide implications. It remained unclear how the two rulings might be resolved on Friday.

?As of 2020, use of mifepristone in conjunction with the drug misoprostol accounted for more than half of abortions nationwide. But in the eight months since Roe v. Wade was overturned and the FDA loosened certain regulations, the prevalence of medication abortion regimen has expanded, especially for women living in one of the 13 states that currently fully or mostly ban abortion.

?Nisen said about half of her patients seeking abortion use the mifepristone and misoprostol combination rather than a surgical procedure. She also knows of patients who have managed their own abortion care at home after obtaining the drugs by mail. Like abortion providers in so-called abortion-haven states, Nisen sees patients from everywhere and is bracing for a surge in new patients following this ruling. On a recent workday, she saw patients for medication abortion from seven different states.

?“People coming from as far as a seven-hour plane ride to get a five-minute procedure is what we’re looking at right now,” Nisen said.

?People seek medication abortion over surgical procedures for different reasons, including cost and allergic reactions to anesthesia. But for many, it’s the only accessible abortion method, given how abortion clinics are now scattered across the country and separated by vast distances, and many of them don’t offer the surgical procedure. Until now many people have been able to avoid traveling significant distances and other delays that lead to later abortions by taking advantage of the telehealth option allowed in some states.

?Additionally, doctors worry this ruling could have serious health consequences for women experiencing miscarriage, which can be life-threatening. Already providers around the country have reported that their state’s restrictive abortion laws have forced them to turn away pregnant patients even if they’re experiencing, or at risk for, serious health complications.

?Ruling has implications for miscarriage management, doctor says

In a “friend of the court” brief filed in the lawsuit in February, leading medical and public health societies that include the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the American Medical Association wrote: “Recent research has shown that prescribed mifepristone, in conjunction with misoprostol, improves safety outcomes for patients experiencing pregnancy loss.”

Mifepristone blocks the hormone progesterone, which a pregnancy needs to progress. It’s followed by the drug misoprostol, which has other indications but also causes the uterus to expel the embryo or fetus. The FDA has recommended it be used up to 10 weeks in pregnancy; the World Health Organization says 12.?

Dr. Loren Colson, a primary care physician in Idaho who is also a fellow with national advocacy group Physicians for Reproductive Health, is among those concerned for his miscarrying patients. Idaho has a near-complete ban on abortions at any stage of pregnancy. Doctors who provide abortions must prove they were trying to save the pregnant person’s life. (Similarly, survivors of rape and incest who want an abortion have to first file a police report.)?

Colson said he has seen many patients at his clinic seeking care for miscarriages since the ban went into effect, and while the clinic has had difficulties securing mifepristone, the doctors have been able to use it to help those patients.

When a pregnant person miscarries, which happens in as many as 26% of all pregnancies, the pregnancy often does not completely end for weeks if not months, Colson said. According to his estimates, about 80% of patients’ pregnancies will resolve within one month, while the remaining 20% could take six weeks or longer. Mifepristone and misoprostol taken in combination after an early miscarriage has a success rate of completing miscarriages by day two in 84% of Colson’s patients, according to his data.

Misoprostol alone – which is what many doctors currently prescribe for an early miscarriage, depending on the situation – will still be faster for some patients than using no drugs at all, Colson said, but by itself, the number of prescribed doses would increase, which creates more cramping and other side effects. The ruling bothers him because the medicine now pulled from shelves has fewer side effects than misoprostol and creates a better outcome for patient comfort.

“(Mifepristone is) an incredibly safe medication, and there’s no real reason to get rid of it except to inhibit access to a standard of care,” Colson said. “And for folks that are advocates of banning abortion, that means not getting the standard of care for an abortion, but the unintended consequence is for miscarriage management as well.”

Adapting to new challenges

Abortion-rights advocates and providers have been preparing for this legal outcome since plaintiffs sued the FDA last November. Some advocates have been forming an underground network of abortion pills and helping people access the medication outside of the U.S. legal system.?

Some abortion clinics have already promised to keep offering medication abortion, regardless of Kacsmaryk’s ruling.

Some doctors plan to recommend misoprostol alone for patients who want or can only access abortion via medication – something OB-GYNs sometimes did before the FDA approved mifepristone in 2000.

Dr. Deborah Nucatola, chief medical officer for Planned Parenthood Great Northwest Hawaii, Alaska, Indiana and Kentucky, has practiced abortion care in nine states for more than 25 years, which includes a stretch of about five years before mifepristone. When the drug was introduced, effectiveness and speed to complete an abortion rapidly increased, she told States Newsroom.

“Losing access means patients still have access to options, but it takes longer, and the risk of failure is higher,” she said.?

Nucatola expects more patients will have incomplete abortions and will need to return for the surgical procedure, called aspiration, which involves using suction to empty whatever tissue remains in the uterus.?

Time is the most important factor when it comes to optimizing women’s recovery from spontaneous or induced abortion, Nucatola said. Medication abortion works quickly, and has a low infection rate. She expects infection rates will remain low with misoprostol-only, but the longer it takes for a pregnancy to fully end, the higher the chances of infection and other complications.??

Misoprostol is still a safe and effective medication, she said, but the higher doses cause more side effects, such as chills, nausea, vomiting, gastrointestinal distress and fever. The recommendation is 12 misoprostol pills, as opposed to four for medication abortions before eight weeks.?

“(Patients are) just going to have a lot more discomfort for longer,” Nucatola said, underscoring that providers will continue to support patients amid the coming challenges. “We trust our patients to do the best thing for themselves, and we’re going to do everything we can to support them, whether or not we have access to mifepristone.”

But for anti-abortion lobbying groups, today is a huge victory, years in the making.

Students for Life of America (SFLA) – a national group that fights against abortion and birth control access on college campuses – has for years campaigned against mifepristone and against the FDA’s loosening of restrictions, which most recently included allowing retail pharmacies to dispense the medication abortion regimen directly to patients.

SFLA president Kristan Hawkins said on a recent webcast. “When I launched Students for Life more than 16 years ago, we knew we were going to need a trained army, ground troops ready to go in states and communities around the country the moment Roe versus Wade was reversed. And we began looking at this issue of chemical abortion five years ago.”

Like the plaintiff anti-abortion medical groups in this lawsuit, Students for Life uses the number 28 to argue that mifepristone should be banned. It’s the same number the FDA uses to argue that it’s safe: 28 deaths out of an estimated 5.6 million people in 23 years have been associated with the FDA’s abortion regimen, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. And as the FDA notes, that small number includes fatal cases “regardless of causal attribution to mifepristone,” including people who died from homicide, suicide, and pulmonary emphysema.??

But Hawkins did acknowledge that the procedure her movement is trying to ban terminates pregnancies early, in the first trimester – which is something most Americans favor, in public opinion polls.?

“We became very concerned that there were legislative advances to make chemical abortion pills the preeminent type of abortion that’s offered in our country,” Hawkins said. “Because the abortion industry reads the same polls that we read. They know that the majority of Americans oppose second- and third-trimester abortions.”?

A recent Public Religion Research Institute poll contradicts Hawkins, finding that 52% of Americans oppose restrictions that make it illegal to obtain an abortion after 15 weeks of pregnancy.??

Asked via email if SFLA expects an increase in second- and third-trimester abortions if this ruling makes first-trimester abortions harder to access and what the impacts of banning abortion drugs will be, Hamrick said, “Lives will be saved.”

Many doctors across the country disagree with her.

“Making mifepristone unavailable nationwide — even in states where abortion remains legal — will impose a severe, almost unimaginable cost on pregnant people throughout the United States,” write the American College of Obstetricians and Gynecologists and the other medical and public health societies in its brief.

“Medication abortion’s relative availability makes it more accessible to patients who otherwise face challenges to access medical care, including low-income patients and patients of color—the very people who are most likely to experience severe maternal morbidity and more likely to die from pregnancy-related complications.

Dr. Loren Colson, a primary care physician in Idaho and a fellow with national advocacy group Physicians for Reproductive Health, does not provide abortion services, as incorrectly reported in a story about a federal judge’s ruling on abortion medication.

Since Roe v Wade was overturned last summer, abortion medication has been under fire as the abortion drug mifepristone is the subject of a federal lawsuit and some states are attempting to restrict access by threatening legal action against retail pharmacies and suppliers of the drug. (Adobe Stock)

The pills came in a dark salmon-colored envelope sealed with a plastic covering that traveled more than 7,000 miles, over a dozen time zones from Nagpur, India, in almost exactly one week.

They were placed partially under the doormat of a home in a state with one of the most restrictive abortion bans in the United States, where zero clinics or pharmacies dispense the medication and the closest option for an in-person procedure is at least an hour to four hours away.

It is, advocates say, one of the only options left for those seeking abortions in one of the 14 states with criminal penalties for health care providers who perform the procedure.?

The process of ordering the medication from Aid Access, a nonprofit organization founded by Dr. Rebecca Gomperts in 2018, is cobbled together in segments. From the organization’s headquarters in Austria, Gomperts acts as the prescribing gynecologist for the person ordering the pills on the Aid Access website. It’s one of the only services that allows people to order the medication as a “just in case” option, as the pills don’t expire for two years with proper storage.

Payment of $105 (about 98 euros) is made separately via PayPal, and once payment is complete, Gomperts sends her prescription to the pharmacy. There is also an option for financial assistance.?

Mifepristone and misoprostol are used in combination to end a pregnancy, typically before 12 weeks of gestation, and the drugs are used to help manage early miscarriages. Mifepristone is taken first to stop the production of the progesterone hormone, which is needed to continue a pregnancy. Misoprostol is then taken to induce contractions in the uterus to expel the pregnancy.

Mifepristone was approved by the U.S. Food and Drug Administration in 2000, but it is under legal challenges in court and legislatures across the country are attempting to restrict access to the drug. On Friday night, Wyoming’s governor signed into law a ban on medication-induced abortions. ?A lawsuit challenging the FDA’s approval process for mifepristone is ongoing in Texas, where a federal judge could order the agency to revoke its approval after more than two decades. Other states are attempting to restrict access by threatening legal action against retail pharmacies and any other suppliers of the drug.?

An email notification is sent when the package ships, with detailed instructions about how to take the medication, the potential risks involved, side effects and pain management and when to seek medical attention. The email also includes resources for hotlines with people available for emotional support or to provide answers to medical questions.

The package itself includes a box with one mifepristone pill and four misoprostol pills, and a separate package contains 12 misoprostol pills. The combination box is enough for pregnancies that are less than 12 weeks’ gestation, while the 12 pills are designed for pregnancies of more than 12 weeks.

By email, Gomperts told States Newsroom her organization is receiving more than 1,000 emails per day from individuals looking for help. Many of them also cannot afford the full price of the drugs. In February, Gomperts said 57% of those who paid for the drugs were able to pay less than 50 euros, or about $53.

“It is important to continue this work because the people we help cannot travel to other states to get a safe abortion,” Gomperts said.

Alabama has already threatened prosecution under different law for taking abortion pills?

Gomperts grew up in the Netherlands and became passionate about providing abortion care during her work for Greenpeace, according to the New York Times. She has worked to provide abortions for women in countries around the world, including Spain, Morocco, Guatemala and Ireland, when the country still had a strict abortion ban.

Christine Ryan, legal director of the Global Justice Center, is from Ireland and told States Newsroom she still lived there when the abortion ban was in place. It was repealed in 2018 after the high-profile case of a woman who died from a septic infection after she was denied abortion care during a miscarriage.

Ryan said witnessing those events and following Gomperts’ work is what made her decide to get involved in reproductive rights.

“Rebecca Gomperts has been like a guardian angel to women worldwide for decades,” Ryan said.

Gomperts used the same “workaround” to send the drugs to Irish women when it was banned, Ryan said, since she is based in another country.

Fourteen states across U.S. have abortion bans in place, nine of which do not include exceptions for cases of rape or incest. The bans do not have criminal penalties in place for the pregnant person, and while Texas, Oklahoma and Idaho have civil enforcement laws that allow family members or the pregnant person to sue medical providers for their role in an abortion, the suits cannot be brought against the pregnant person.

That has not stopped some states from threatening to prosecute individuals for taking abortion pills under different existing statutes. In January, Alabama Attorney General Steve Marshall said the state could prosecute people under a chemical endangerment law that has been used to prosecute women who use illegal substances during pregnancy. It’s unclear if that law would apply to mifepristone and misoprostol, which are legal drugs approved by the FDA. The U.S. Department of Justice also issued an opinion in December stating the mailing of the drugs to a particular jurisdiction is not sufficient basis for “concluding that the sender intends them to be used unlawfully.”??

The Wyoming Legislature also passed a ban on medication abortion in March, which Gov. Mark Gordon signed Friday.

Although Politico and the New York Times reported this month that Walgreens confirmed it would not sell the medication in up to 20 states where attorneys general had threatened legal repercussions for doing so, a Walgreens spokesman told States Newsroom in a statement, “We want to be very clear about what our position has always been: Walgreens plans to dispense Mifepristone in any jurisdiction where it is legally permissible to do so. Once we are certified by the FDA, we will dispense this medication consistent with federal and state laws.‘’

While that will make it difficult for individuals to receive mifepristone from a pharmacy, Ryan said it won’t be as easy to enforce bans on mailed pills.?“The authorities in (states with abortion bans) — who are they going to try to prosecute in terms of the mailing of these pills?” Ryan said.

Idaho anti-abortion activist: We need penalties for sending ‘human pesticide’ to women

Brandi Swindell, founder and president of anti-abortion clinic Stanton Healthcare, told States Newsroom she thinks the mailing of abortion pills is a major problem that she called “creepy” and said reminds her of a drug cartel.

“We have these — not only out-of-state — but out of country groups that are pimping a human pesticide that could have very serious ramifications on a woman physically and emotionally, can impact her mental health, her physical well-being,” Swindell said. “And they are coming into states where we have clear abortion laws, where we have gone through the legal process, the legislative process. … And they’re going to try to sell and pimp these drugs preying on women that are in a potential crisis or unexpected pregnancy situation, a vulnerable situation.”

Idaho has a near-total ban on abortions at any stage of pregnancy, with affirmative court defenses to save the pregnant person’s life and for rape and incest if a police report is provided. Swindell said she is working with state lawmakers in Idaho, where Stanton Healthcare is based, to seek an opinion from Idaho Attorney General Raúl Labrador’s office about whether the state’s abortion ban includes medication abortion.

“There needs to be clarification and enforcement that any organization or individual that is involved in promoting, selling or profiting from attempting to skirt Idaho’s law to dispense and sell and profit from the abortion pill, that those entities need to be held accountable,” Swindell said.

If Labrador’s office concludes the method is not included in Idaho’s law, Swindell said there needs to be legislation introduced as soon as possible to strengthen the existing law before the Idaho Legislature adjourns for the year, which could happen in the next few weeks.

“We’re passionately working to make sure that chemical abortions are banned,” Swindell said. “We want to make this a major issue in the 2024 presidential race.”

Self-managed abortions at home make pregnant people feel safer, legal advocate says?

The drug’s use has become much more common in abortions across the country in the past three years. According to the Guttmacher Institute, as of December, medication abortion made up about 54% of all abortions performed in the United States.

Part of that may be people taking advantage of those legal workarounds with the mail, but Ryan said some pregnant people find home management of an abortion to be empowering and it offers a stronger sense of safety.

“You’ve had clinics suffering so much violence in the clinic setting, and having to deal with protesters, and the difficulties in arranging transport and financing transport, whereas managing pregnancy in someone’s own home is a safe place,” Ryan said. “Also having access to a clinician over the phone and online is something that has shown to be quite powerful.”

While providers and patients across the United States wait on a ruling from a federal judge in Texas about the U.S. Food and Drug Administration’s approval of mifepristone, advocates want to stress that options like Aid Access will still be available no matter the outcome of the court case.

Dr. Jennifer Lincoln, an obstetrician-gynecologist who practices in Portland and the executive director of an advocacy organization called Mayday Health, said if state laws become more stringent around policing abortion medication, Aid Access and other internationally based options will become more important.

“The best thing you can do is inform yourself and pass the message along that you’ll still be able to get these medications,” Lincoln told States Newsroom. “It requires a few more hoops, but you’ll still be able to get it.”

Ryan doesn’t worry about organizations like Aid Access being affected by whatever happens in U.S. courts, but she is worried about state- and county-level prosecutors trying to target people who use the pills at home.

“What I do really see as a particularly challenging (fact) that activists and patients have to deal with in the U.S. that wasn’t as pertinent somewhere like Ireland, or even in Mexico and Argentina, is the level of surveillance that exists and the power and zeal of the criminal legal system,” Ryan said. “It is a phenomenon that is very much overlapping with the human rights crisis to create this extremely challenging environment for people to exist in.”

States Newsroom National Reproductive Rights Reporter Sofia Resnick contributed to this report.