As states banned or restricted abortion this summer, the number of American women ordering abortion pills from overseas jumped significantly — enough to offset most of the drop in legal abortions.
Overall, abortion in the United States declined about 2 percent in the first two full months after the Supreme Court overturned Roe v. Wade, accounting for women who traveled to states where it remained legal or ordered pills from overseas, according to a New York Times analysis of data from two studies released this week.
One of the studies was released Sunday by WeCount, a research project led by the Society of Family planning that is collecting data from abortion providers nationwide. The group, which supports abortion rights, found that the number of legal abortions fell by around 7,000 a month in July and August in states that banned or restricted nearly all abortions, and by another 3,000 a month in states that passed more limited restrictions.
But in states where abortions remained broadly legal, the number of abortions increased by roughly 5,000, the study found, leaving a total drop of 6 percent compared with April.
A separate study, released Tuesday by the medical journal JAMA, found a nearly 120 percent increase in online abortion pill orders from overseas in July and August placed through Aid Access, which operates outside the U.S. health system and is designed to circumvent state abortion bans.
Putting both studies together, there were about 2,000 fewer abortions per month, compared with April, when abortion was legal in every state.
“If the goal is for some people to remain pregnant when they don’t want to be, the goal is being achieved,” said Abigail Aiken, a professor at the University of Texas at Austin and a co-author on the new JAMA paper. “If the goal is to end abortion, it’s not effective.”
People who support abortion restrictions say the new data shows that the recent bans are working. “The results from the WeCount project confirm that pro-life laws save lives,” said Chuck Donovan, president of the Charlotte Lozier Institute, an anti-abortion group.
“It’s important that we don’t conflate the impact of state abortion restrictions with the spread of abortion-by-mail,” he said. “Abortion advocates’ push to get chemical abortion out of the clinic and into the mailbox began long before.”
The two studies provide the most detailed measurement yet of how access to abortion changed after the decision, known as Dobbs v. Jackson Women’s Health Organization. Other research in JAMA shows that bans and restrictions are decreasing access, particularly among those living in the South, and those who are poor, Black or Native American.
At the same time, services like Aid Access have complicated attempts by some state lawmakers to ban abortions entirely. In contrast with illegal abortions before Roe, abortion pills today are safe for most women to take early in pregnancy and at home, a variety of research has found. And they’re available to nearly anyone with an internet connection and a mailing address.
Although some proponents of abortion rights see the pills as an effective workaround to abortion restrictions, others say current options are a poor substitute for formal medical care at a nearby clinic.
“While things are better than the pre-Roe period, I think we’re seeing some similarities, where people who are most vulnerable don’t have specialized knowledge of how to work the system or work the laws to get access to abortion,” said Ushma Upadhyay, a professor of reproductive sciences at the University of California, San Francisco. “Ordering pills illegally is not a solution. And the travel time is just impossible for so many groups of people.”
Some aspects of how the court ruling is affecting abortions nationwide are not yet clear. Monthly data about abortion access has not been collected nationwide before, making it difficult to fully account for seasonal changes in abortion rates. State laws relating to abortion have repeatedly changed, and abortion clinics are opening — and closing — around the country.
There is no way to track whether the pills ordered on Aid Access were taken, or whether the people who ordered them got an abortion another way. Not everyone who requests pills actually receives them, Professor Aiken said. The totals also exclude women who are not pregnant but purchase the pills through Aid Access to have in advance.
But the tally also underestimates the number of abortions in some ways. It does not include people who ordered pills from other overseas websites. Aid Access is the largest such provider, but others have recently started or expanded. The data also excludes women who got an abortion outside the formal health system in another way, such as ingesting herbs or crossing the border to Mexico, where one abortion pill is sold over the counter as an ulcer medicine. They are often clandestine and hard to measure.
“There is a large undercount of people who are self-managing their abortions, absolutely,” said Renee Bracey Sherman, an activist and the founder of We Testify, a group that shares abortion stories, including those of people who managed their own abortions. “Because people are sourcing them in their communities and because they are getting them in lots of different ways.”
The abortion pills are a two-drug combination of mifepristone and misoprostol that stops the development of a fetus and then causes a miscarriage. The process takes a few days. A small share of women who take them do not experience a complete miscarriage, and need follow-up care in a hospital.
The medications have been approved by the Food and Drug Administration and are offered by abortion providers in states where abortion remains legal. In recent years, more women have chosen medication abortion than in-clinic procedures. In December, the F.D.A. allowed abortion pills to be prescribed through telemedicine, without requiring a physical visit to an abortion clinic, though many states forbid it.
Skirting American laws, Aid Access connects patients with European doctors, then mails the pills from Indian pharmacies to patients in the United States.
It is illegal to sell prescription medicine to Americans without a prescription from a doctor licensed in the United States. Between 2000 and 2020, there were at least 61 cases in which people were criminally investigated or charged with managing their own abortions or helping someone do so, according to If/When/How, a legal group that supports reproductive rights.
And since the Dobbs decision, some states have tightened laws regarding medication abortion. They are hard to enforce, though, because the pills come through the mail, and overseas pharmacies are typically outside the jurisdiction of local law enforcement.
“Fortunately, self-managed abortion in 2022 looks really different from what it looked like before Roe, and people have the option of using these safe and effective medications, the same medications we use in a clinic,” said Dr. Daniel Grossman, director of Advancing New Standards in Reproductive Health at the University of California, San Francisco, who also published an article about abortion pills in JAMA on Tuesday. “This is helping to mitigate the harm of the Dobbs decision, but it’s not solving the problem. Some people are being forced into ordering medications online when it’s not their first choice.”
The new paper found that the biggest increase in orders by far was from Louisiana, which is surrounded by states with abortion bans, making the nearest clinic significantly harder to reach.
Orders for pills from Aid Access climbed significantly starting in the spring, when a draft of the Supreme Court decision leaked but before laws had changed in many states. Orders have increased even in states where abortion remains legal. Researchers and providers say that it might be because of increased publicity about the option of ordering pills online and some confusion about the state of the law.
“It’s absolutely becoming more known that abortion pills are a form of abortion that’s safe and effective, and also that telemedicine for abortion is a thing,” said Elisa Wells, co-founder of Plan C, which publishes information on accessing abortion pills. “With each news story and advertising that’s happened, people who didn’t know about it become aware.”
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