Underground fight...

A hidden abortion crew prepares to confront a post-Roe America

Driven underground during the pandemic, online abortion providers say they’ll keep supplying pills and services even if the Supreme Court approves state bans.

By DARIUS TAHIR

The Supreme Court’s decision to review Mississippi’s stringent restrictions on abortion — putting Roe vs. Wade under its roughest stress test yet — is being seen as a call to action for the nation’s community of underground abortion activists.

And they make it clear they’re prepared to defy any laws banning abortion.

The community had spent the pandemic dealing with the “abortionpocalypse” — a wave of red state restrictions on procedures to terminate pregnancies — by recruiting new members and online providers, adding new privacy features that could shield them from law enforcement and organizing. And now, with the court’s decision to hear the Mississippi case in its upcoming term, they’re confronting a new threat.

“Even though our work is legal and we're not doing anything wrong, we operate under the assumption what we do could become illegal at any time,” said a member of one group, the Mountain Access Brigade, of their new work on privacy-supporting technology. The member spoke under condition of anonymity to discuss confidential plans. The underground community of support groups has been adding services to advise women about how to use abortion pills or how to arrange rides for women interested in getting an abortion in-person.

The pandemic gave activists “a real view of what a South without access would look like,” said Robin Marty, an activist with the Yellowhammer Fund, another activist group. Marty recently came out with an update to her book “Handbook for Post-Roe America,” which describes to readers how they can prepare — from obtaining pills online to organizing politically — for a country with statewide bans on abortion.

“People have so much fatigue when it comes to, ‘This is the worst. No, now this is even worse. Oh wait, this is even worse than that’,” she said.

For decades, the worst for the pro-abortion-rights activist community was a Supreme Court decision to overrule the 1973 holding in Roe v. Wade, without which many states in the South and some in the West would likely enact bans on abortions. But new technology has complicated those issues, raising the possibility that a robust underground operation could continue to provide abortion pills to women seeking to terminate pregnancies at home.

Even before the Covid-19 lockdown prompted advocates to strengthen their networks, many patients were already self-managing their own abortions. One 2010 survey from the Guttmacher Institute found 2.6 percent of women saying they’d done so — a figure that many activists believe was understated at the time and has almost certainly grown as pills have become increasingly available.

Many patients are turning to online groups, some quite large: Aid Access, one of the most prominent online abortion providers, said it receives requests from almost 30,000 women per year.

And online groups say demand boomed during the pandemic. Aid Access’ requests jumped 27 percent from March 20 to April 11 last year, according to a paper in Obstetrics & Gynecology.

“We can handle more requests when needed,” said Rebecca Gomperts, Aid Access’ co-founder. In addition, patients can utilize a large, decentralized network of additional online pharmacies and providers, small and large.

In the event of an adverse Supreme Court decision, experts and activists say, it’s hard to predict how much supply could expand to meet patients’ needs in a post-Roe landscape. But the new restrictions on abortions imposed by states during the pandemic — combined with many women’s reluctance to get care in person for fear of contracting the virus — gave them a taste of how they might approach a post-Roe America.

Fear of contracting the coronavirus in clinics pushed people online, and often — due to federal and state restrictions — to underground services, involving internet forums, small internet groups offering assistance in-person and virtually, and mail deliveries from international pharmacies to out-of-the-way mailboxes.

/r/abortion, a Reddit forum devoted to providing advice about all types of abortion care, gained thousands of readers per month through December of last year, a moderator for the forum said, as readers dealing with canceled appointments tried to find new means of abortion — including online pharmacies that could ship pills from abroad. That trend will continue, the moderator predicted, if the courts allow further restrictions, up to and including the bans that would result if Roe v. Wade were overturned.

Even without a sweeping court ruling, current trends are likely to continue as GOP-controlled states erect ever-more-stringent abortion restrictions — even to the extent of providing “private rights of action” for ordinary citizens to enforce such restrictions against friends and neighbors, as Texas has done. Activists believe the effort to enlist average citizens in the fight against abortion is a direct response to fears that more abortions will be conducted at home, outside the gaze of the law.

“If Roe goes down — we hope it won't — there are always going to be ways to access abortion,” said Elisa Wells, a co-founder of Plan C, an organization that connects users to abortions, including providing information of the quality of medications from online pharmacies. “Plan C included, we're already working on alternative ways to access the pills.”

During the pandemic, help lines were clogged with women are trying to determine how much legal risk they would face if they used abortion pills in ways that violated state restrictions on at-home abortions.

If/When/How, a group providing legal services to abortion patients, said it was answering 10 times the usual number of weekly calls to its help line by the end of the year.

“The questions we receive largely fall into the bucket of general legal rights and the specific legal risks of self-managing abortions with pills,” said Rafa Kidvai, who directs the group’s legal defense fund, a new effort to prevent prosecutors charging patients for conducting at-home abortions.

From the other side of the debate, elevated interest in online access to abortion pills represents a longtime nightmare for anti-abortion activists. Ever since medication abortions were approved by the FDA in the 1990s, anti-abortion figures have warned the drugs could make terminating a pregnancy too convenient and too easy. Then-presidential candidate George W. Bush warned that “making this abortion pill widespread would make abortions more and more common.”

Those warnings persisted just after the pandemic. “If the abortion lobby’s ultimate dream succeeds, however, brick-and-mortar facilities will become obsolete,” wrote Marjorie Dannenfelser, the president of the anti-abortion-rights Susan B. Anthony List in a Townhall column, criticizing abortion-rights activists’ efforts to prioritize abortion care in the stimulus package. Instead, Dannenfelser wrote, the “next frontier” is to use the internet and the mail to ship abortion pills — thereby leveraging new tech and organizations to spread abortion nationwide.

It’s a fear that’s likely to get even stronger. The Biden administration’s Food and Drug Administration recently signaled it’s looking at overturning one of the key restrictions obstructing the distribution of one of the drugs used in a medication abortion regimen, the requirement that only doctors can provide the pills.

It’s an about-face after the Trump administration FDA took action against one of the main online providers, Aid Access, and some of the overseas pharmacies that served them. Social conservatives had strongly lobbied the FDA and Health and Human Services Department to take action against online providers. Now, with the change in the administration, there’s a change in policy.

“They want to make it seem that it’s as unserious as picking up a vitamin from CVS,” said Roger Severino, a prominent social conservative who served as director of HHS’ Office for Civil Rights during the Trump administration. Severino argued the economics of medication abortions are more favorable for abortion providers; and it’s generally cheaper to provide abortions via a pill than through surgery.

Indeed, surgical abortions can cost $400 or $500; medications are potentially quite cheap. Wells said she was inspired to start promoting access when she saw the pills available in Ethiopia for $7. And those low prices are available online, if you look in the right places.

So while pro-abortion-rights activists might use different language, they largely agree medications — which can be shipped by mail directly to a patient — are more convenient and affordable. It’s the “21st century abortion,” Wells said. “There used to be the model of 'how many clinics are across a state?'” Now, doctors or providers can see patients over Zoom and rely on the mail to get pills to patients. It’s a way to “diffuse and expand access.”

But getting that care was a tricky process last year. There were legal restrictions: States erected regulations, and the FDA maintained rules making it difficult to mail the pills.

Then there were disruptions to supply: Many medications were sourced from India, which suspended exports in March 2020. The whole model “was no longer viable,” said Wells.

That’s to say nothing of slowdowns in the mail: not so bad if you’re waiting on a new charger; a big problem if you need medications in a couple weeks.

The two drugs used to terminate a pregnancy can be safely administered up to the 77 days of gestation, according to recommendations from the American Academy of Family Physicians. A move by England’s National Health Service to encourage at-home abortions found no increase in complications. But many conservatives maintain that making the drugs available, outside the direct control of a doctor, would enable women to use them improperly — such as on later-term pregnancies — which could cause potentially dangerous side effects.

“The reason there was an in-person requirement was to make sure you had a qualified doctor” to keep an eye on problems, Severino said

But abortion-rights advocates maintain that those fears are overblown — and some point to the fact that the numbers of self-managed abortions soared during the pandemic with few reports of serious side effects.

Indeed, as lockdowns took hold, improvisations reigned. “We figured out providers in the U.S. could write prescriptions to misoprostol,” Wells said. Misoprostol is one-half of the typical regimen to abort a fetus; taken alone, it’s somewhat less effective than in tandem with mifepristone. “That was a stopgap.”

Even the FDA’s regulations were interpreted by some physicians to allow for at-home abortions in some circumstances. Some doctors decided to send prescriptions by mail — as long as they took control of the dispensing and mailing process.

The efforts by doctors determined to continue providing services in the face of opposition is one facet of what Wells calls “conscientious provisioning” — a trend of doctors and providers pushing the extent of the law to give access to abortions regardless of legal restrictions.

“We’ve had providers saying, these rules are causing me to assault my patients, providing incorrect information to patients,” she said.

Wells said Plan C has talked with some 200 providers. In states where teleabortion — in which a doctor instructs the patient over a video link — is legal, doctors and other providers have helped power a wave of new startups. Companies like Choix or Just The Pill take advantage of some blue states’ suddenly looser restrictions to make abortions more easily available.

The new options — often presented in sleek, trendy graphics closer to a millennial-skewing startup than the typical health care website — attracted a different type of patient than had typically sought abortions online.

Whereas a recent Journal of the American Medical Association article found users of Aid Access were mostly unable to afford in-clinic care in states that imposed extensive restrictions, one New York doctor said her new, online clientele was more affluent. What unites both groups of patients: a desire for privacy away from the stigma of seeking an abortion.

That’s one of the potential advantages of teleabortion, and a reason more patients are likely to turn to underground options, even if Roe v. Wade were left in force. There are online forums, like /r/abortion, providing information and links to internet pharmacies.

There are also “abortion doula” groups, like Mountain Access Brigade, that offer connective services — like rides to clinics or online options — for patients. They’re closely related to a type of activism that Yellowhammer Fund's Marty calls “aunties” — online gatherings of volunteers who group together to support patients seeking abortions, from giving rides to escorting patients into clinics.

They spent the pandemic upgrading their technology, said Katie, a nom de guerre shared by the volunteers of that group.

The group takes “privacy very, very, very seriously, and use technology to that end,” she said, and builds software to manage their business: sharing scheduling and calling duties, or giving very carefully worded advice — not materials or active facilitation — on self-managed abortion.

“It’s funny how legality is often about the words you use and not the actions you take,” she said. “But that is walking the tightrope of what’s left of Roe v Wade.”

Patients can also take advantage of other improvisations: getting pills shipped to postal offices in less-regulated states, for example. For abortion rights activists, the inventiveness is proof that patients will seek out abortions regardless of the legal structure.

The problem, they say, is increasing static from anti-abortion activists. Multiple activists interviewed for this article believe activists are trying to confuse patients on the internet.

For example, a user searching “Plan C” on Google might find results related to Wells’ project to provide access to abortions; but they might also see results from so-called crisis pregnancy centers, groups run by anti-abortion activists that seek to dissuade users from getting an abortion — certainly for long enough so that an abortion can’t be done pharmaceutically or legally.

Some activists are also warning about “infiltration.” Online “auntie” groups are one target, activists believe. Marty’s updated "Handbook" cautions that “Abortion opponents have grown more adept at inserting themselves into these spaces and harassing or derailing patients seeking support.”

Such misinformation is part of the reason why Marty’s become pessimistic. She worries that women in blue states will get more convenient, available abortions — while red states will crack down to a higher degree.

“The FDA will let people get pills mailed to their house, and so people feel more comfortable believing things will get better — despite the fact that half the country still can’t get abortion via telemedicine and many of the rest can’t afford the pills through these services anyway,” she predicted.