The young woman’s voice trembled over the phone. Sitting in her car in Alabama, where abortion is almost totally banned, the 26-year-old mother of two was grappling with an unintended pregnancy.
“I’m like ‘How in the world?’” she said, stifling a sob. “I already have two children, and I cannot. I can’t. I just can’t go through with it.”
She wanted an abortion, she said, but was afraid of getting caught and didn’t know what to expect from the process. “Growing up, I never really thought about actually doing something like this,” she said.
On the other end of the line, at home on a quiet residential street in Delaware, Debra Lynch, a nurse practitioner who runs a service prescribing abortion pills, spoke calmly.
“It’s completely valid to be scared,” she said from her desk in a home office filled with plants and shelves of medication. “And that’s why we want you to call us, even if you’re calling just to say: ‘I’m scared. I need to hear somebody tell me that what’s going on right now is normal, and it’s OK.’”
During the 25-minute conversation, Ms. Lynch asked the woman about her health history and pregnancy and assessed that she was medically eligible for abortion medications that can be taken in the first 12 weeks of pregnancy: mifepristone, which blocks a hormone necessary for pregnancy development, and misoprostol, taken 24 to 48 hours later, which causes contractions so pregnancy tissue can be expelled.
She carefully explained how to take them and mentioned that after the second medication, there would be cramping and bleeding that could continue for days.
Ms. Lynch’s husband, Jay, packaged the pills into a plain white envelope and labeled it with the Alabama address, as well as their service’s name and return address. A mail carrier picked it up from their mailbox. Included was a handwritten note on paper decorated with flowers: “We are here for you if you need us. You are not alone. Feel free to reach out anytime, no matter what you need.”
Ms. Lynch is one of about several dozen providers in the country taking legal risks by prescribing and sending pills to patients in states with abortion bans. Many providers are based in states with shield laws, intended to offer them protection by preventing authorities there from cooperating with out-of-state officials who try to prosecute or sue them for serving people in their states.
About 20 states have adopted some type of abortion shield law since the Supreme Court overturned the national right to abortion in 2022. Eight explicitly protect telemedicine abortion prescribers who send medication to patients in any state. Delaware’s shield law isn’t as explicit, and there are different views on the scope of its protection, some legal experts said. Ms. Lynch said lawyers advised her that Delaware’s laws appear to protect prescribers who mail pills to any state, but she recently decided to move to one of the eight states with the clearest protections.
The mailing of abortion pills has become a major issue for anti-abortion activists. In a lawsuit against the Food and Drug Administration, three Republican state attorneys general are seeking to reinstate rules requiring patients to obtain pills from providers in person. And abortion opponents are pressing for other state and federal actions to curtail the sending of abortion medication into states with bans.
“It is violating not only our pro-life laws but our homicide laws,” said John Seago, president of Texas Right to Life.
He added: “We’re really shocked that there’s been a widespread embrace of this. And so for Texas, we’ve established it’s immoral, it’s unethical. We want to stop it.”
Shield laws have become a key abortion-rights strategy, and each month, prescribers are sending medication to about 10,000 patients in states with bans. But the laws are beginning to be tested as authorities in states that outlaw abortion bring legal action against such prescribers, a confrontation many expect to reach the Supreme Court.
The first cases — a criminal indictment in Louisiana and a civil suit by the Texas attorney general — involve a New York doctor accused of sending abortion pills to those states. New York officials have refused to cooperate, invoking that state’s shield law. But the cases have transformed the risk for abortion providers from theoretical to real.
Given the stakes, most prescribers sending pills to states with bans keep their names and other identifying information out of public view. Ms. Lynch was willing to be named, saying that to “step forward and identify who you are as an actual real live human” might help some women needing abortions feel less fearful.
She allowed The New York Times to spend a day with her as she had phone consultations with patients. (The Alabama woman and others allowed The Times to listen; to protect their identity, The Times agreed not to name the patients.)
The visit offered a rare look at the work of one unconventional prescriber and the delicate and complex circumstances women seeking abortions may experience.
Ms. Lynch operates the service, called Her Safe Harbor, with three other volunteer licensed prescribers and Mr. Lynch, who handles various operational responsibilities and formerly worked for Delaware’s health and social services department. The service, which started last June, also provides contraceptive pills and treatment for gynecological infections. The Lynches said the service ships several hundred packages a month, mailing to any address patients request, including a general store in a Midwestern town.
Ms. Lynch’s medical guidance follows what most medication abortion providers recommend. But some other steps she takes push the envelope in ways other prescribers do not. Those steps, she said, are intended to reach patients who are especially concerned about privacy or nervous about the abortion process.
She says she believes the risks she is taking pale in comparison to the risks patients take in seeking abortions. “They are the ones who are really being brave, you know?” she said.
A Call From Texas
There were cries of young children in the background as a mother of two in Texas described over the phone how she learned during a routine gynecologist appointment that she was pregnant again. She told Ms. Lynch that she didn’t want her husband to know because he had sometimes been abusive. She asked that the pills be mailed to a friend’s house, where she planned to take them while her husband was at work.
There was another issue though: How would the woman explain to her doctor why she was no longer pregnant? She told Ms. Lynch that she thought that she should visit an emergency room after taking the pills, so a hospital could document that she had a miscarriage. But she was terrified about whether abortion pills or even the nausea medicine that the service sends in the package could be detected with blood tests. She asked if she could tell the hospital not to take blood.
Ms. Lynch told her that standard blood and urine tests don’t detect those medications and advised that saying she was having a miscarriage but didn’t want lab tests could raise suspicion and impede the hospital’s ability to provide the miscarriage documentation she wanted. After the call, she said the woman seemed reassured about what to do.
Many callers are in sensitive circumstances, Ms. Lynch said, including women who have been victims of date rape. She said concern for their safety and privacy was one reason she had adopted some practices that differ from other services.
“It’s not just obfuscation for the sake of obfuscation from law enforcement,” she said. “A lot of times, it’s because it’s a domestic violence situation or a high-risk-for-violence-in-the-home situation, or they live with other people who might out them.”
Women in states with bans have limited options for abortion. They can travel to states with legal abortion, but that can be costly and involve time away from jobs and children. Some obtain pills from informal community networks that don’t have medical professionals or prescription medication.
Many women choose another option: telemedicine abortion services that mail prescribed pills. Such prescribers often assess medical eligibility by reviewing forms that patients complete online, a system many patients consider convenient and efficient.
Ms. Lynch says her service works differently. It is designed for patients in states with abortion bans and restrictions who want to talk with a provider on the phone or who worry that online forms might leave an electronic footprint, she said.
Typically, abortion pill prescribers strictly comply with the laws of the state they’re licensed in, which helps ensure that their state’s shield law will protect them. For example, they carefully obey their state’s requirements about sending the prescriptions with the medication. Ms. Lynch, however, said that to better serve patients who are afraid to receive such documentation, she decided not to put copies of the prescriptions in the packages, although such a practice would trouble the providers who follow the rules.
“One of the main points that we heard from people was that they don’t want a prescription with their name on it,” she said. “So, we had to make a decision: Are we willing to potentially violate a Delaware law with the labeling of the prescriptions in order to remove this barrier that’s a very real barrier for a lot of people?”
Her service keeps prescriptions and other records for patients in paper files offsite, she said. To give patients additional “plausible deniability,” she said, she sends receipts with a medical code for a urinary tract infection consultation, one of the conditions the service treats, along with written information about U.T.I.s. She doesn’t ask patients in states with abortion bans or restrictions to provide identification like a driver’s license.
Ms. Lynch, 56, has had an eclectic career and said she previously worked in geriatrics, chronic disease and other fields. Assisting a community Covid response team in Philadelphia “kind of redirected my career focus on being more social-needs-oriented,” she said. After Roe v. Wade was overturned, she wanted to offer support to women seeking abortions and admired the shield-law providers’ work, she said.
A Queens native, she is voluble and expressive. During the recent visit, she was wearing a long blue floral dress and pink head scarf and was barefoot with a flowery vine tattoo spiraling down one leg. She and Mr. Lynch, a 61-year-old Brooklyn native, have been married for over 30 years and have worked together before, including once running a children’s theater.
During phone consultations, Ms. Lynch’s questions mirror the online forms other services use and her responses generally echo those of other providers. For example, she won’t prescribe abortion pills to women with bleeding disorders or ectopic pregnancies, in which the fertilized egg is outside the uterus and never produces a baby.
Some patients ask what they should do if they want or need to visit an emergency room. Serious complications from medication abortion are rare, and numerous studies have found it to be safe, including when pills are prescribed by telemedicine and mailed. Long before the F.D.A.’s 2021 decision permitting telemedicine abortion, the agency considered the medication safe enough to allow patients to take it at home and not in the presence of a doctor. But some women want a hospital to assess whether their bleeding level is normal or whether all the pregnancy tissue has been passed.
Ms. Lynch, like other abortion providers, counsels that there is no medical reason for women to tell hospitals they have taken abortion pills, and that they can allow hospitals to assume they are miscarrying, which involves the same symptoms and is often treated with the same medications.
Her service often conducts follow-up calls, checking on patients after they take the medication and sometimes for days afterward. On four occasions, she has suggested that a patient visit an emergency room, she said. One woman was dehydrated, and two wondered if they were bleeding excessively. She wanted the fourth to be evaluated because of heavy bleeding. All turned out to be fine and needed no treatment at the hospital, she said.
A ‘Pro-Life’ Caller
After another woman in Texas had a consultation with Ms. Lynch and took the medication, the woman and her husband wanted to check that the process was progressing normally. The patient’s husband called and texted several times a day, sometimes late at night.
The man said they were devout Christians who considered themselves “pro-life” but found themselves in circumstances where abortion was right for them. “It’s not very common that some grew-up-in-the-country Republican from Texas who loves guns changes his mind on things,” he said on one call. “But here we are.”
His wife has endometriosis and had been advised that pregnancy could be dangerous for her, he said. They worried that Texas’ abortion ban made hospitals so afraid that if she miscarried or had pregnancy complications, doctors would have to wait to intervene until her condition became life-threatening.
“If you’re a woman in Texas, and you’re going through complications and a miscarriage,” he said, “it’s going to be difficult for you to find treatment, and that’s not OK. And as a Christian, I understand that these laws stem from Christian values. But the one thing that we never really discuss is a woman’s health.”
Six days after his wife began the medication regimen, he called again, asking if they should be concerned that some bleeding was still occurring.
“No fevers, right?” Ms. Lynch asked.
“No nausea, no fevers,” he said, adding that his wife “keeps bleeding and cramping, but it’s not crazy excessive.”
Ms. Lynch suggested the woman take an additional two misoprostol tablets, noting that some women need more than the initial four tablets to fully expel pregnancy tissue. If bleeding didn’t lessen by the next day, she said, “then I probably would want to get her an ultrasound.”
She quickly explained: “Now, she wouldn’t have to go to the emergency room or anything, because as long as she doesn’t have a fever or any signs of infection or continuous bleeding, it wouldn’t be an emergency. So we could arrange for her to have an ultrasound there, locally, done without it going in her chart, or actually without the provider even having her name or any information.”
Ms. Lynch’s service has contacts for medical practitioners in many states who will provide ultrasounds and other care, she said, absorbing the cost themselves, as long as they aren’t violating that state’s abortion laws.
After the additional misoprostol, the bleeding eased, making an ultrasound unnecessary.
Like several other telemedicine abortion services, Her Safe Harbor typically charges $150 per order but also accepts whatever patients can afford. “Right now, I have like $40 on me, and I realize that’s probably not enough for anything,” the Alabama woman said.
Mr. Lynch, who handles logistics like billing and answering the phone, sent her the medications for free.
The Lynches recently decided to move to New York, which has one of the strongest shield laws. They’ve chosen a rural upstate community, where they can afford property large enough for a small clinic adjacent to their home. Ms. Lynch plans to apply for the necessary state nursing licenses.
To comply with New York’s law, some of her practices would most likely need to change. But she said she appreciated that New York recently added another layer of protection by allowing providers to send patients prescriptions with the medical practice’s name instead of the provider’s name.
She applauded the state’s forceful response to the Texas and Louisiana cases. Gov. Kathy Hochul of New York has refused to extradite the abortion provider, Dr. Margaret Carpenter, to Louisiana, and a county clerk blocked an attempt by Texas to enforce a $113,000 penalty against Dr. Carpenter.
Ms. Lynch said those actions sent a signal that “no matter what, we are going to protect the patients and we are going to protect the provider.”
Susan C. Beachy contributed research.
Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics.
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